alleyCare Nurse1ST EDITION I SPRING 2010

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ValleyCare Nurse Table of ContentsFrom the Chief Nursing Officer… 1

Jessica Jordan RN, BSN, MS

ValleyCare Nursing Mission, Vision and Definition 2

Meet the Advanced Practice Nursing Council 3

Advanced Practice Council Mission Statement

Advanced Practice Nurses Biographies

ValleyCare Shared Governance Councils 8

Janine Pinks NP, PA-C, MSN

Nursing Program Partnership 10

Kim Cristobal RN, MSN and Karen Lounsbury DNP, RN-BC

Las Positas College Student Health Center 13

Dayna Cerruti-Barbero RN, PHN, MSN, FNP

The Birth of the Mobile Health Program 14

Berndette Revak RN, MSN, CIC

Is That a Tick? Lyme Disease 18

Brian Edwards RN, BSN, CEN

Is it an Emergency? Caring for the patient with Aortic Dissection 23

Janine Pinks NP, PA-C, MSN

Guatemala, Medical Mission: The Gift of Giving 27

Maria Castillo, Surgical Technician

In Recognition of Employees who are Pursuing Higher Education 30

Nurses who are certified

Laverne Rose Nurse of the Year 33

!

From the Chief Nursing OfficerJessica Jordan, RN, BSN, MA

Vice President and Chief Nursing Officer

! Hello and welcome to the first issue of the ValleyCare Nurse! This publication was the brainchild of our

newly developed Advanced Practice Nurse Council as they sought to find ways to mentor and inspire their nursing

colleagues. You will be learning more about these extraordinary advanced practice nurses

as you read through this publication.

! Nurses Week, 2010, finds ValleyCare Nurses better than ever! Our work over the

past year has lead to improvements in Clinical Pertinence, Fall Reduction, Pressure Ulcer

Prevention, Ventilator Associated Pneumonia Prevention and Central Line Blood Stream

Infection Prevention to name a few. We also have seen increases in our Core Measures

and Patient Satisfaction scores. We have seen many more nurses become certified in their

specialty areas and also have seen more nurses return to school for higher degrees. ValleyCare is so proud of our first

Doctoral Nurse, Karen Lounsbury, who has inspired at least two other nurses to follow her path to the Doctoral level.

Please look carefully for the names of all of our certified nurses and be sure to congratulate them for putting in the

extra time and effort to be the best that they can be in their specialty area.

! This year’s theme for Nursing Week is a “Culture of Caring”. This was inspired by the Patient Satisfaction

campaign that is happening in our Medical-Surgical and Critical Care areas. I believe that ValleyCare Nurses show

how much they care each and every day; not just in the emotional sense but also in the sense that they care to be clini-

cally competent, academically inquisitive, financially responsible, and supportive colleagues to the entire interdisci-

plinary team. We are a diverse group from many extremely different specialized areas but we all have a common goal

and that is to provide the best possible care to our patients, their families and also to each other.

! ValleyCare Nursing Division continues on our journey to excellence by pursuing Magnet status. We have

developed a Shared Decision Making Model which includes not only Unit Based Councils but also several Nursing

Division Wide Councils: Nurse Quality, Nurse Practice, Nurse Research, Professional Development, Advanced Prac-

tice and Nursing Operations. All the members of the council work hard to provide nurses at ValleyCare an environ-

ment that is conducive to autonomous, ethical and evidence based professional practice. Please take the time to

learn more about our Magnet Journey by reviewing the nursing intranet module, or better yet, actively serving on

your unit based council. Please enjoy this publication and the Nurses’ Week activities knowing that each and every

one of you is a valued member of our great team of Nurses. Thank you for your dedication, your care and compas-

sion, and your commitment to excellence. Sincerely, Jessica

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ValleyCare Mission, Vision, Philosophy and Definition of Nursing

Mission

The Department of Nursing Strives to far exceed each patient’s expectations for quality healthcare through delivery of safe, clinically outstanding and compassionate care.

Vision

The ValleyCare Department of Nursing is an internationally recognized provider of clinical and service excellence.

Philosophy

The Nursing Department is organized to provide the optimal achievable quality of nursing care, and to maintain the optimal professional conduct and practices of its members.

It is our Philosophy that nursing is an autonomous and patient centered care process that advocates:

The ill regain health, The healthy maintain health, Those who cannot be cured to maximize their potentials, Those who are dying to live as fully as possible until their death.

Nursing undertakes these tasks by exercising autonomous judgment and applying knowledge to the solutions of problems, and by evaluating its actions. Nursing furthermore, accepts the responsibility and accountability in an en-vironment of just culture for the results of its actions.

Professional nurses at ValleyCare Health System are responsible and accountable for their practice to themselves, to the profession, to the hospital and to the public.

Definition

Using a partly compensatory nursing system, ValleyCare Health System defines Nursing as:

The delivery of patient-centered nursing care based on Dorothea Orem’s Self-Care Model that utilizes a combination of features including supportive-educative nursing. We believe Nursing Care requirements are specific to variations in human structure and functioning during the various stages of the life cycle.

Our Nursing practice is guided by the California Nurse Practice Act, Title XXII, Title XVI, ANA Standards of Care in conjunction with our community and hospital standard that are delineated in our policy and procedure Manual.

We provide Nursing Care with knowledge of spiritual and cultural diversity between social groups and understand the significance of people’s cultural orientations and their contacts and communications with others.

We are responsible for the provision of nursing to individuals or multi-person units within defined types of nursing situations. The scope of Nursing Services span the life cycle of fetal, neonatal, pediatric, adult, senior and geriatric, including those who are ill, disabled or debilitated.

We are able to reduce patients’ emotional pain and physical discomfort and pain by effecting conditions that increase patients’ comfort and satisfaction within nurse-patient relationship. We master the valid and reliable techniques for nursing diagnosis and prescription; for meeting the therapeutic self-care demands of individuals with various mixes of universal, developmental and health-deviation self-care requisites.

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Meet the Advanced Practice Nursing Council

Mission Statement

The Advanced Practice (AP) Council of ValleyCare Health System represents the interests of advanced practitioners

within the health system. The purpose of the AP Council is to promote the visibility, viability, and unity of all ad-

vanced practitioners. The council will foster professional excellence and educational advancement with the ultimate

aim of providing quality health care that is both accessible and cost-effective to our patient population. The AP

Council provides a forum to facilitate the involvement of advanced practitioners in research, education, quality im-

provement, professional development, and clinical growth.

Rosafel Adriano MSN, FNP:

Graduated Cum Laude from De Anza College with her Associate Degree in Nursing 12

years ago, and received her BSN-MSN degree with area of concentration on International

Family Nurse Practitioner at Cal State University, Los Angeles 7 years ago. As part of a

Health Profession service-learning course in her Master's Program, Rosafel developed

patient education materials and screening tools for colon cancer patients for the Asian

Pacific Health Care Venture organization in LA County. Furthermore, she contributed

to an editorial column in the California Examiner to further promote awareness on the

prevalence of colon cancer in the Asian community. She is currently certified through the

American Academy of Nurse Practitioner. She worked at St. Joseph Hospital, Orange County, Surgical Post-Op unit

as a staff nurse while fulfilling her Master's Degree. After earning her MSN degree, she has worked as family nurse

practitioner for a private family practice in Newport Beach and in Hayward, CA. She is now the lead supervising NP of

the outpatient clinics in ValleyCare Health System.

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Erin Bashaw RN, MSN, PHN, DNP Candidate

Erin has been in nursing for six years. She has a Master's in Nursing Administration, a

Bachelor’s in Nursing Science, a Bachelor’s in Health Science, is a licensed Public

Health Nurse and is completing her Doctorate in Nursing Practice at University of San

Francisco. She works full-time at ValleyCare in Pleasanton as a Med/Surg RN, Hospital

Supervisor and Infection Control RN. She also teaches for Ohlone College two days a

week in the nursing program in the clinical setting. She is passionate about creating

health for the masses, making prevention affordable and teaching nurses to be front-line

leaders of the healthcare industry.

Dayna Cerruti-Barbero MSN, FNP

Dayna started her nursing career in 1994 during the Summer of her undergraduate pro-

gram as a student nurse. She has been a Family Nurse Practitioner for the last 10 years,

finishing graduate school as a Sigma Theta Tau Honor Society Member. Over the last

sixteen years, her diverse nursing experience has included everything from inpatient

HIV/AIDS, Transplant and IICU, First Assist in Neurosurgery, practicing as a Derma-

tology Nurse Practitioner, to now practicing as a Family Nurse Practitioner at the Las

Positas College Student Health Center in her role as the Health and Wellness Center

Program Coordinator. At Las Positas College, she found her passion focusing on educa-

tion and disease prevention. By empowering students, she hopes to help foster educated health choices and to im-

plement healthy lifestyle behaviors.

Brian Edwards RN, BSN, CEN, FNP Candidate

Brian started his healthcare career in June 1995 by mopping the floors and taking out

trash at ValleyCare Health System. He graciously accepted a position in Environmental

Services while he was attending college for a prospective Administration of Justice de-

gree. Soon after, Brian developed an interest in caring for people while working as a jani-

tor in the hospital setting. Brian began his Emergency Department career in 1996 while

working as a Registrar. Shortly thereafter, he began working in patient care as an Emer-

gency Department Technician / EMT. While attending classes to fulfill his registered

nursing Associates Degree requirements, Brian continued to work as an ED Tech. Once

degree requirements were met in 2001, he started his RN career in the ED. He obtained his Bachelor of Science in

Nursing (BSN) in 2004, and began working for the Emergency Department Management team as a Charge Nurse. In

2006, Brian accepted the position of Emergency Department Manager and one year later advanced to Director of

Emergency Services. Brian is currently working as the Director of Emergency Services and Respiratory Therapy,

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and is a member of the PICC (peripherally inserted central catheter) insertion team at ValleyCare Health System. He

is gladly finishing up his graduate training and will fulfill his requirements for a Master of Science in nursing degree

and licensure as a Nurse Practitioner in May 2010. ValleyCare Health System is the perfect place for Brian and he

looks forward to many years to come with this organization. He feels honored to be a part of such a wonderful institu-

tion!

Farnoosh Ebadat MSN, FNP

Farnoosh received her RN and MSN degree through an extended program at SFSU in

2003. She started her career as a RN in an Emergency Room. While working full time,

she went back to SFSU to attend their NP program. She received her post Master De-

gree as a FNP in 2007. She accepted her first job as a FNP by working part time in a fam-

ily practice office and part time with a Psychiatrist. After working for a year, she got an

offer in an out-patient setting at Las Positas/Chabot College. Currently, she is a full

time FNP rotating through Las Positas College Health Center, Chabot College Health

Center and the MHU.

Karen Lounsbury, DNP,

Karen is the Manager of Staff Development and Nursing Education at ValleyCare Health

System. Karen graduated from Chabot College with an Associate of Arts in Nursing in

1979. She worked in Med/Surg at Dixie Medical Center in St. George Utah for one and

half years and transferred into the Critical Care Unit. In 1989, Karen was hired as a staff

nurse in the Valley Memorial CCU and became a nursing supervisor from 1995-2003. In

1993, Karen completed a BSN at San Jose State University and in 2003, she completed a

MSN in Nursing Education at California State University, Dominguez Hills. In 2009

she completed her Doctor of Nursing Practice in the Leadership track at the University

of San Francisco. Karen also holds adjunct faculty positions at Chabot College and University of San Francisco.

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Angelina Leong Chau MSN, FNP-C

Angelina is currently working as a Family Nurse Practitioner (FNP) at the ValleyCare

Mobile Health Unit and Chabot College Student Health Center. Prior to being a Family

Nurse Practitioner, she was a registered nurse in the emergency room. She obtained her

Master of Science in Nursing-Family Nurse Practitioner from Samuel Merritt University,

Oakland, and is currently pursuing her Doctor of Nursing Practice degree at Duke Uni-

versity, North Carolina.

Janine Pinks NP, PA-C, MSN

Janine has a diverse professional background with 21 years of nursing experience. She

has worked in several areas of nursing including the emergency room and neonatal inten-

sive care. The last 16 years she has specialized in adult open heart surgery and the last

seven years has worked as an advanced practitioner. She is skilled at first assisting, vein

harvesting, patient assessment, diagnosis and treatment of the CV surgery patient. She

earned her Master of Science in Nursing at the University of California, Sacramento, and

her FNP/PA Certification at California State University, Davis.

Bernie Revak RN, MSN, CIC

Bernie has 30 years of nursing experience, working primarily at ValleyCare. She has

worked in almost all areas of nursing and the hospital including Billing/Auditing Com-

pliance, Critical Care, Ambulatory Surgery/PACU, Labor & Delivery/Maternal Child/

Pediatrics, Public & Community Health, and Infection Control. As a Pediatric Adjunct

Faculty for the Chabot College-ValleyCare Nursing Program, Bernie taught students

primary pediatric nursing skills at Children’s Hospital Oakland and ValleyCare. Bernie

developed the ValleyCare Mobile Health Unit (MHU) program from a Master's project to

fruition serving the underserved in the Tri-Valley community. She developed the busi-

ness plan, designed the unit, sought and received financial support from both the community and grant supporters.

Bernie equipped the MHU to provide basic medical care as well a disaster relief response unit. She earned her Asso-

ciate of Arts in Nursing from Chabot College, a Bachelor of Science in Nursing from California State University,

Dominguez Hills, and her Master of Science in Nursing with a focus in Nursing Administration from California State

University, Dominguez Hills. Bernie is the nurse manager for Infection Control, Public Health, and Outpatient Clin-

ics. She is board certified in Infection Control and Prevention.

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MaryJo Schaarschmidt, MSN, CPNP, CNS, RNC-NIC,

MaryJo earned her BSN from the University of San Francisco 25 years ago as she was

commissioned as an officer in the Army Nurse Corps. After spending many years in

Washington DC at Walter Reed Army Medical Center caring for neonates and children

triaged with life threatening diagnoses and needing to be air transported back to the

states, she returned home to California. While earning her MSN at UC San Francisco

she helped to close the old Childrens Hospital at Stanford and open the doors of Packard

Children's Hospital at Stanford University working as a CNS. She earned her CPNP at

Indiana University Purdue University while helping to build and open St Vincent Chil-

dren’s Hospital. During these past 7 years at ValleyCare, as CNS for the NICU and Pediatrics, she helped with the

NICU renovation and pediatric partnership with UCSF. Her 20 years as an Advanced Practice Nurse have allowed

her to stay at the bedside while continually pushing for process improvement, increased patient safety, mentoring,

staff education, and program development.

Staci Valdix RN, MS, FNP:

Staci graduated from Samuel Merritt School of Nursing. She began her career over 20

years ago, in the Intensive Care and Open Heart Unit at Samuel Merritt Hospital (now

know as Summit/Alta Bates). She got her Master in Nursing/ Family Nurse Practitioner

Certificate from Sonoma State University. She has worked for a private cardiologist,

Cardiac Rehabilitation, Cardiac Education and presently coordinating the Congestive

Heart Failure inpatient program for the hospital.

Naomi Williams RN, MSN, PNP

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ValleyCare Shared Governance CouncilsJanine Pinks, NP, PA-C, MSN

! As employees, nurses must structure their practice within rules imposed by their employers in the form of

policies and procedures. This has a profound effect on how nurses deliver patient care. The scope and amount of re-

sources made available by the employing organization further influences their practice. Fortunately, administrators

and managers, who are frequently also nurses, help create these policies. However, the nurses who actually deliver

care are often absent from the policy-making processes and structures. Nursing shared governance emerged as one

way to give these clinical nurses equal footing with administration and to allow them to participate in the decision-

making processes that affect their practice. Shared governance is defined as an organizational model through which

nurses control their practice as well as influence administrative areas.

! The nursing staff at ValleyCare health System participates in eight councils. These councils are the vehicles

that gather administration and nursing staff together to share in decision making regarding nursing practice. The

shared governance at ValleyCare legitimizes nurses’ control over practice, and encourages the interdisciplinary

communication necessary to provide patients with quality health care.

The Eight Councils

Coordinating Council is responsible for coordinating, integrating, monitoring and communicating the activities of

the other councils. Membership is comprised of the chairs of the other four councils, The Director of Nursing Educa-

tion, the Vice President of Nursing and the Chief Operating Officer.

Research Council is Chaired by Shelly Barnhill, RNC, BSN, MA, a clinical educator for staff development. The re-

search council advocates and supports clinical research and the use of evidence-based nursing practice. It offers staff

a variety of activities to build research skills and support evidence-based practice. One sponsored activity includes

classes taught by UCSF, guiding nurses through a research project. Membership consists of advanced practitioners,

master’s prepared staff and staff nurses.

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Professional Development Council is chaired by Mary Kay Dunn, RN, MSN Perioperative Educator for surgical

services. This council assesses the educational needs of staff to promote and coordinate professional development

and education using the Benner Model. Membership is comprised of the institution’s clinical educators and staff

nurses

Advanced Practice Council is chaired by Janine Pinks, NP, PA-C, MSN a PA for Cardiovascular Surgery Services.

This council represents the interests of the advanced practitioner within the Health Care System through visibility

and unity of its members. Advanced practitioner is defined as: A Nurse Practitioner, Clinical Nurse Specialist, Certi-

fied Nurse-Midwife, Certified Registered Nurse Anesthetist, Doctor of Nurse Practice and Physician Assistant. It

promotes professional excellence and educational advancement with the goal of providing quality healthcare that is

both accessible and cost-effective to our patient population. The council encourages the advance practitioner to be a

mentor and resource to nurses and other health care professionals. Membership consists of all advanced practitio-

ners in the healthcare system and the Vice President of nursing services.

Nurse Practice Council is chaired by Jeanette Kitt, RN, BSN a Clinical Educator for staff development. This council

is responsible for implementing and maintaining standards of clinical practice and patient care consistent with evi-

denced based practice and regulatory agency requirements. Membership includes a minimum of one staff nurse from

each nursing unit.

Nurse Quality Council is chaired by Karen Lounsbury, RN, DNP, the Manager of Nursing Education. The Nurse

Quality Council oversees patient satisfaction, facilitates performance improvement measures and participates in peer

review. Membership includes at least one staff nurse from each nursing unit.

Nursing Operations Council is chaired by Jessica Jordan RN, BSN, MS the Vice President of Nursing Services.

This council approves the final policies and procedures, supports the council structures, reviews hospital based

committee reports and acts as a resource for staff.

Unit Based Nursing Councils focus on unit based quality and practice. It serves as a means of communication be-

tween unit staff and other councils. They address issues and concerns related to patient care, staff competency, and

nursing accountability. Memberships consist of staff members in each department.

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Nursing Program PartnershipVHA 2009 Team Collaboration AwardChabot College and ValleyCare Health System

KIM CRISTOBAL RN, MSN; KAREN LOUNSBURY, DNP, RN-BC

! When the nursing shortage was at its peak, in 2003, ValleyCare Health System in Livermore and Pleasanton

formed a partnership with the Chabot College Nursing Program in Hayward, California. In 2003, the Medical Surgi-

cal nursing units at ValleyCare had many open nursing positions and were

relying on both long-term travelers and day registry staff to provide patient

care. Some hospitals in the Bay Area imported foreign nurses to fill their

openings. Rather than take nurses from other countries experiencing their

own nursing shortages, ValleyCare decided to “grow their own nurses.”

ValleyCare Health System is a not for profit community health care system;

it is consistent with the hospital Mission and Vision to draw nurses who

live in and contribute to the community.

! The Nursing Program Director at Chabot College, Dr. Nancy

Cowan, and Vice President of Nursing Services at ValleyCare Health Sys-

tem, Jessica Jordan, met for several months planning this venture prior to

its inception. A Steering Committee was formed that included the Chan-

cellor of the Chabot Las Positas College District, the College Presidents from both Chabot and Las Positas, the Dean

of the Health Professions Department, 2 ValleyCare Health System Board members, the Nursing Program Director,

the Dean of Academic Services, the Vice President of Nursing Services at ValleyCare and faculty from Chabot Col-

lege. The Boards of Directors at ValleyCare Health System, Chabot College and Las Positas College and the Chabot

College Faculty Association had to approve the joint venture before it could proceed.

! Funds were secured for classroom construction, equipment installation and instructors at the Chabot Col-

lege Nursing ValleyCare site in Livermore. Two classrooms were equipped with state of the art teleconferencing

equipment. A skills lab, computer lab, library and a simulation lab were added at the ValleyCare extension site. A

Guild was formed of retired ValleyCare nurses to provide support and mentoring for the new nursing students. From

the onset, social activities on the ValleyCare campus included welcome luncheons or desserts, holiday activities, and

receptions prior to graduation. The nursing students are provided information about ValleyCare positions available

while they are in school and after graduation.

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Jessica Jordan and Dr. Nancy Cowan

! The partnership also increased capacity for pre-nursing students at Las Positas College in Livermore. The

partnership funded Las Positas College with equipment and staff for a Microbiology Lab and provides additional sec-

tions of Anatomy and Physiology. This increased the number of students able to take highly impacted prerequisites

for the Chabot

Nursing Program.

! Initially this

partnership in-

creased their exist-

ing enrollment by 10

students per year,

from 40 to 50. In

2006, the Valley-

Care cohort added

20 students to the

class, bringing the

total up to 60 stu-

dents. The closest

nursing school east

of the Tri-Valley is

Delta Community

College in Stock-

ton, California. This

partnership has cre-

ated an alternative

for students seeking a nursing program in the Tri-Valley area. With the teleconferenced classes and Skills Lab, nurs-

ing students are able to meet the requirements of the nursing program without a commute. The students experience

most of their clinical placements at ValleyCare Medical Center, using the skill of currently employed ValleyCare RNs

as clinical instructors.

! This has truly been a partnership between administrators, faculty and nursing departments at both sites. Cur-

rently, with 20 students in the ValleyCare cohort and 40 in the Hayward group, close collaboration is required for

this dual campus system to be successful. Since lectures are teleconferenced to distant locations, students are proc-

tored at the distant site classrooms. An administrative assistant, a part time proctor and a skills lab instructor all assist

the faculty at the distance site in Livermore. Exams and skills check- offs must be administered in a consistent manner

at both locations.

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Classes of 2010 and 2011

ValleyCare Extension of Chabot College of Nursing

! The Chabot-ValleyCare Partnership has been a resounding success. At the California Board of Registered

Nursing Site Visit in 2006, the Chabot College Nursing Program and ValleyCare Health System satellite received

commendations as an exemplary example of an academic-service partnership. As a result of this partnership, 5 classes

of nursing students graduated resulting in an additional 80 new nurses in the workforce. ValleyCare has been able to

hire 50-85 percent of the graduates who graduated as a result of the partnership. All the Medical Surgical positions

are currently filled allowing experienced Medical Surgical nurses to undergo additional training and move into Criti-

cal Care, Labor and Delivery and Emergency Department positions.

! In 2009, ValleyCare provided one of the few New Graduate RN Residency programs when many San Fran-

cisco Bay Area hospitals were not hiring new grads or offering New Graduate programs. ValleyCare interviewed 30

New Graduate RNs and hired 12 RNs.

! The Chabot College-ValleyCare partnership continues to grow and improve. ValleyCare is now working with

Dr. Nancy Cowan at Chabot in a partnership with California State University East Bay to encourage Associate De-

gree nurses to continue their education and receive Bachelor’s Degrees.

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Las Positas College Student Health CenterDayna Cerruti-Barbero RN, MSN, PHN, FNP

Committed to Empowering and Caring for Students…One at a time…

! College Health? Yes it is true, through a community partnership, ValleyCare has been providing college

health services at Las Positas College for over the last 10 years. In fact, ValleyCare provides health services to both

Las Positas and Chabot College. The ValleyCare Health System and the Las Positas College Student Health and

Wellness Center partnership was establish in 1998. Under the medical direction of Dr. Robert Santos, this small sat-

ellite clinic has continued to grow and change with this amazing, diverse, and innovative community college, where

you will find the Nurse Practitioner operated clinic to be full and thriving. The Health and Wellness Center is a com-

plete integrative health program with its funding provided by the Student Health Fee. The program includes medical

care, mental health services, wellness counseling and campus outreach.

! ValleyCare offers a full range of Medical Services to all registered students. The Nurse Practitioner visit is

free of charge and extended services including laboratory testing, diagnostic imaging, and immunizations are deeply

discounted. The Health and Wellness Center is staffed with a ValleyCare Nurse Practitioner, Medical Assistant, and

Front Office Clerical support.

! Being one of the first integrated medical and mental health college clinics nationally, the Health Center offers

free mental health services including psychotherapy, referrals, and a crisis intervention response team. The Valley-

Care medical team works closely with the Las Positas College Mental Health staff consisting of a Marriage Family

Therapist, a Marriage Family Therapy Intern, and a Veteran’s counselor.

! ValleyCare’s commitment as the community leader for wellness and prevention is thriving at our campus.

The program advocates for a healthy campus community and we have partnered with health educators and students in

our mission to “empower students to adopt a healthy lifestyle”. The program coordinator’s academic health calendar

guides campus events including; weekly outreach, health fairs, bone marrow & blood drives, as well as, guest speak-

ing for various classrooms, clubs, and professional groups. So, the next time you are up at Las Positas College, come

visit our ValleyCare College Health Center. I guarantee you will be impressed! We are committed to student success

by caring for the mind, body, and spirits of our students, which empowers them to make educated health choices by

fostering a healthy lifestyle, one student at a time.

" " " 13

The Birth of a Mobile Health Program Bernadette Revak, RN, MSN,

! Uninsured individuals utilize the emergency room (ER) for primary, non-emergent care due to lack of re-

sources and inaccessibility to a primary care provider. Mobile medical care is growing in the United States at a re-

markable rate in response to the need for convenient, accessible, and affordable healthcare services. The nurse ad-

ministrator can integrate the organizational mission of assuming the leadership role for the health of the community

by developing and implementing a mobile health care program with a goal to serve the uninsured, underinsured in

effort to improve community health and decrease inappropriate utilization of emergency room services.

! The numbers of uninsured persons in the United States are growing at a phenomenal pace. In 2005, 46.1

million Americans under the age of 65 lacked health insurance, which was an increase of 1.3 million from 2004 (Kai-

ser Commission on Medicaid and the Uninsured, 2006). Nationally, California has one of the highest uninsured

population rates with greater than 21% without coverage being middle age and the numbers continue to rise with 6.6

million people reported in 2003 (Garamendi, 2005). Hospital emergency rooms have become a safety net to provide

healthcare services to the uninsured and working poor with the enactment of the Emergency Medical Treatment and

Active Labor Act (EMTALA) in 1986 (Centers for Medicare and Medicaid Services, n.d.). EMTALA mandates a

medical screening and treatment for all patients, regardless of their ability to pay.

! Many of the uninsured have no place to turn for medical care other than the ER. These uninsured patients are

three to four times more at risk for a serious medical problem due to lack of access to care because they do not par-" " " 14

ticipate in preventative programs (Bloom & Tonthat, 2002). California public hospitals represent only six percent of

the hospitals in the state and provide $1.6 billion in uncompensated care annually (Garamendi, 2005). Studies of ER

utilization reveal that patients without a usual source of care are more likely to use the ER for non-urgent care (Co-

hen & Bloom, 2005; Bloom & Tonthat, 2002). Using the ER for non-emergent care significantly factors into the

overcrowding issue and can notably impact a hospital’s ability to provide emergency care to the community by ex-

hausting the financial resources of the institution (Begley, Vojvodic, Seo, & Burau, 2006). The story commonly

heard in the news is another hospital is closing its emergency room doors due to financial hardship.

! ValleyCare, the primary sponsor for the Mobile Health Program, experienced a 14.6% increase in ER visits

from 2003-2005. Community benefits for the vulnerable populations receiving medical care, health training and

education at the hospital exceeded one million dollars in 2005, which was an increase of 7% from 2000 (ValleyCare

Health System, 2006). A community based mobile health center could prove valuable in reducing non-urgent ER

patient visits, resulting in valuable ER resources more readily available for emergencies and a reduction of incre-

mental expenses needed to address overcrowding.

! Developing a plan to improve utilization of emergency services and health care access for the health of the

rural communities would bring the mission and vision of the organization to fruition. The mission specifically states

to assume the leadership role for health of the communities (ValleyCare, 2000). There are many reasons that exist

for looking outside the facility walls of a healthcare organization, one of which is to provide convenient, accessible,

and affordable healthcare services. A mobile health van provides the venue to accomplish these leadership goals of

social change with improved healthcare access to the underserved populations in the community, which includes sen-

ior citizens, school-aged population, and the uninsured.

! In our healthcare system today, options for particular communities are largely affected by economics and law.

Creating change is difficult and the nurse executive leadership is critical in creating said change. This transforma-

tional leadership style positively affects how people accept change and a measurement of their support is demon-

strated by the level of commitment to the project (Leach, 2005). The nursing profession has a long history of provid-

ing holistic, community-based healthcare to disadvantaged and underserved populations. Nurse leaders must lead by

example, as change agents, in creating a desirable future for healthcare delivery.

! Involvement in shaping healthcare policy is an expected outcome for the leadership standard of advanced

nursing practice as outlined by American Nurses Association (2004). To best develop new program policy, a com-

prehensive needs assessment is critical in developing an operational plan to conduct health promotion, screening,

prevention, and educational services.

! The combined estimated population of the Tri-Valley is more than 233,000 persons (Alameda County,

2006). For three of the four cities within the Tri-Valley area, ValleyCare is the sole provider of acute care services.

The people of the Tri-Valley come from diverse educational and cultural backgrounds. The Tri-Valley has a wide

" " " 15

economic spectrum ranging from the impoverished to the wealthy. The one city in greatest need of this mobile health

program, population of 80,000, has 20% of the households with an earned income of less than $30,000 in 1999, as

compared to 28% in Alameda County as a whole (Alameda County, 2001). There are numerous wineries, champion-

ship golf courses, and luxury homes in this same city. Unfortunately, this area has not been found to have a credible

need for county health funding to assist in the expansion of emergency services because of the higher income charac-

ter portrayed in the valley. Unbeknownst to many residents of the Tri-Valley area, 12% to 14% of the children qualify

for state and federal aid (Alameda County, 2001).

! Mobile care can be an entry point for health care services by linking the patient to a provider establishing a

“provider home” for future health care. Obtaining the support of the communities to be served is a crucial compo-

nent for the implementation of a program. The Rotary Foundation in the area was looking for a large “hands on”

community service project, partnering with an existing organization (Livermore Rotary, n.d.). The organization was

approached by the nurse administrator and hospital Vice President regarding partnering in providing mobile health

services to the communities and an agreement was reached.

! Evidence from research studies on outreach mobile clinics nationwide supported the decision to move for-

ward in developing this program. In one study, conducted over seven years, revealed a greater utilization by homeless

persons of outpatient services from the mobile medical units (MMUs) than inpatient ER services (Nakonezny &

Ojeda, 2005). In another randomized, prospective study, the utilization of mobile clinic services to improve patient

compliance to a diabetes intervention/management program was evaluated. The overall response rate to the mobile

interventional clinic exceeded 70% of patients with poorly controlled diabetes mellitus compared to 35% in the con-

ventional clinic (Maislos & Weisman, 2004). And lastly, in Maryland, the Governor’s Wellmobile Program was

launched in 1994 to provide accessible care to uninsured and underinsured population (Heller & Goldwater, 2004).

Many of the citizens that receive care from this program would have had no other access to healthcare other than the

ER. Mobile health programs have proven successful across the nation and can have a significant effect on the accessi-

bility of healthcare services to the underserved population.

! Rogers (1995) refers to the social system as a set of interconnected units working together to problem solve a

common goal. In developing new approaches to community health, the Diffusion of Innovations theory can be used

to expose theories and successful interventions on a wider-scale. It can help to ensure the impact on health promo-

tion and disease prevention is realized through the dissemination of new ideas and social practices to the general

public to improve public health.

! Along with federal and private agencies, each state also has a say in regulating its health care providers. The

California Department of Health Services (CDHS) serves to protect and improve the health of all Californians

through access to quality care (CDHS, 2006). The California Health and Safety codes that specifically govern the

operation of a mobile health clinic are 1765.101 -1765.175 (Legislative Counsel of California, n.d.).

" " " 16

! The purpose of standardized procedures is to define the scope of practice of the family nurse practitioner

(FNP) for the Mobile Health Clinic in order to meet the legal requirements for the provision of health care by nurse

practitioners. These standardized procedures are developed through collaboration among nurse practitioners, physi-

cians and administrators in the organized health care system to provide assurance of the best healthcare possible and

based on the guidelines established by the California Board of Registered Nursing (2004). Standardized procedures

consist of general policies and health care management standardized procedures. The health care management stan-

dardized procedures delineate the medical functions requiring a standardized procedures and, using policies and

protocols, define the circumstances and requirements for their implementation by the nurse practitioner (California

Board of Registered Nursing, 2004).

! In August 2007 the Mobile Health Unit received licensing from the Department of Health Services and be-

gan a regular schedule of clinic sites visits through the tri-valley community. Information regarding the services avail-

able is disseminated through the local school districts, community venues (e.g. senior centers, libraries, etc.), and

through local health providers. As of February 2010, the program has provided medical care, immunizations, screen-

ings, referral services, and health education for over 4,302 clients/patients.

Mission: To improve the health care of Tri-Valley communities by providing accessible, culturally sensitive

outpatient primary care to the uninsured and underserved population

MHU program :

•Serves Tri-Valley’s low-income residents, 30% of school age children are uninsured and only 14% qualify for state

and federal aid.

• Livermore reports: 20% of households report incomes under $30,000 per year

•Unable to access primary health care

•Reduces the number of non-urgent ER visits

•Encourages health screening services including laboratory testing

•Preventative and Health Promotion educational services

This mobile health program is designed to enhance the healthcare system by improving the community health, in-

creasing public awareness, and providing access to healthcare services to those who encounter barriers. By connect-

ing the patient to a primary provider, regular access to medical care is established. In providing this service to the

community, the healthcare organization will have a reduction in uncompensated care, improved ER utilization, and a

healthier community.

" " " 17

Is That a Tick? Lyme Disease Brian Edwards RN, BSN, CEN

Lyme disease is a tick-borne infectious disease caused by

the spirochete orrelia burgdorferi (B. burgdorferi). This disease

is transmitted to humans by the bite an infected tick. (Buttaro, et

al. 2007). Lyme disease (LD) is quite a robust and complex ill-

ness to manage. Dr. Epps (2001), states in his article,“Lyme dis-

ease is, by far, the most common vector-borne disease in the

United States. It as researched in another article that, “16,455

cases were reported in 1996; and the actual incidence may be 10-

fold higher” (Gardner, 1998). According to the Centers for Dis-

ease Control & Prevention (CDC) website, recent published data

reveals that “During 2003-2005, CDC received reports of 64,382 Lyme disease cases from 46 states and the

District of Columbia”; and South Dakota, Colorado, and Hawaii were the only states to have zero reported

cases of LD in 2007. (Centers for Disease Control, & Prevention, 2007). With over 20,000 new cases of LD

reported per year, it is fundamental for healthcare providers to have accurate identification of disease mani-

festations, coupled with evidence-based approaches to therapy to effectively manage this illness (Epps,

2001). This disease is a growing, serious public health problem in certain areas of the United States and can

negatively impact a community in many ways; however Lyme disease cannot be transmitted from human to

human and is absolutely a preventable, communicable disease. The public, especially in higher risk areas,

needs to be better educated on the disease and it’s ramifications. “Lyme hysteria” can cause many emer-

gency rooms and clinics to be overwhelmed with individuals seeking medical treatment for inappropriate

reasons, especially during the warmer part of the year when there is higher risk of exposure. The CDC

(2007) reports, “Reducing exposure to ticks is the best defense against Lyme disease.”

The highest risk factor for LD is being exposed to an environment that is abundant with the ticks that

are able to carry and transmit the spirochete. Meletis et al. (2009) states in their article that the B. burgdor-

feri is transmitted to humans primarily by the black-legged tick or deer tick, Ixodes scapularis, on the east " " " 18

coast. The primary vector on the west coast is the western black-legged tick known as Ixodes pacificus (Me-

letis, et al. 2009). After looking at the LD distribution map for the United States, it is quite evident that the

majority of infections happen in the midwest and northeastern regions (Centers for Disease Control, & Pre-

vention, 2007). Ticks like to live in an environment that is rich in shade with wooded areas. These ticks can

be found in tall grass, Spanish moss, bushes, low tree branches, and sometimes even lawns and gardens (Pe-

lotes Island, n.d.). Humans at greatest risk of getting infected by LD would be individuals who live or spend

time around or near shady, wooded areas during the warm weather period of the year; usually April through

September. This is when ticks are most active and most likely to come in contact with humans (Recognizing

and avoiding, 2009). People who enjoy the outdoors, such as campers and hikers are at greater risk.

A study was conducted by Glass, et al. (1995) with the objective of developing a geographical sys-

tem used to identify and locate residential environmental risk factors for Lyme disease. Their study results

revealed that residence in forested areas, on specific soils, and in two regions of the county they were study-

ing were associated with elevated risk of getting Lyme disease. They also reported that residence in highly

developed regions was protective (Glass, et al. 1995). In conclusion of their study, they reported “combining

a geographic information system with epidemiologic methods can be used to rapidly identify risk factors of

zoonotic disease over large areas” (Glass, et al. 1995). The evidence reveals that shady, wooded areas are

prone to have ticks lurking during warm weather; consequently the risk of getting LD in these areas is much

higher.

There are 3 different stages of Lyme disease, all with distinct symptoms associated with each junc-

ture. The stages are (1) early localized infection or localized disease, (2) early disseminated infection, and

(3) late disseminated infection or chronic disease. Most individuals are allergic to the tick saliva and de-

velop a “bull’s-eye” appearing rash known as erythema migrans, usually within 1 week to 1 month after be-

ing bitten by an infected tick. Approximately 75% of infected humans will develop this circular rash and

may develop additional eruptions of these lesions in other areas of the body after several days (Meletis, et al.

2009). Of the clients who do not get the rash, the first sign of bacterial infection can be symptoms of the

second or third stage of LD (Meletis, et al. 2009). During the second stage of infection, the patient can de-

velop symptoms of weakness, fatigue, fever, chills, enlarged lymph nodes, headache, myalgias, and arthral-

gias. Meletis, et al. (2009) report that, “usually only one or a few joints become affected, most commonly

the knees”, and “neurologic symptoms such as presentation of facial muscle paralysis (Bell’s palsy), periph-

eral neuropathy, meningitis, severe headaches, and neck stiffness may occur.” In their book, Buttaro, et al.

(2007) wrote that during this stage, “the most common abnormality noted is a nonspecific ST-T wave

change, but any conduction abnormality, including complete heart block, can occur.” The third and final

stage of Lyme disease can occur months to years after the initial infection in patients who were not treated

" " " 19

due to the disease being unrecognized, not treated appropriately with antibiotics from the beginning, or in

individuals whose treatment didn’t eliminate the infection entirely. In 2009 Meletis, et al. discussed ap-

proximately 60% of clients with untreated LD infection will begin to have intermittent arthritis and severe

joint pain/swelling; and chronic arthritis develops in 10-20% of untreated patients (Meletis, et al. 2009). Fi-

bromyalgia, chronic pain syndrome, and chronic fatigue are other manifestations of Lyme disease in later

stages. In Stricker & Johnson’s (2009) article about chronic Lyme disease, they state that the Infectious Dis-

eases Society of America (IDSA) believes, “chronic infection with the Lyme spirochete is rare or nonexist-

ent, and the concept of chronic Lyme disease rests on ‘faith-based’ opinion rather than ‘evidence-based’ sci-

ence” (Stricker & Johnson, 2008). Another outlook published in 2007, in the New England Journal of Medi-

cine reiterates the belief that chronic LD doesn’t exist, and even if it does, the risks of prolonged antibiotic

therapy outweigh any benefits (Feder, et al. 2007).

Recognizing the presence of erythema migrans in itself is a sufficient finding for early diagnosis of

Lyme disease. If symptoms are manifesting signs of LD, a healthcare provider does have laboratory options.

In most instances, the clinician will order a blood test called an enzyme-linked immunosorbent assay

(ELISA) to check for presence of antibodies to the spirochete B. burgdoferi (Epps, 2001). The specificity of

the ELISA test should then be confirmed by way of the Western blot (WB) test for B. burgdoferi, where an-

tibodies of the immunoglobulin (Ig) M and IgG classes are being searched. The WB test for Lyme disease is

a very specific lab test and if positive, the patient is most likely infected with the organism. So you are

probably wondering why a provider shouldn’t simply order this test first, rather than the ELISA. Well, ac-

cording to the CDC website for LD, they do not recommend testing blood by Western blot without first test-

ing it by ELISA due to the fact that doing so increases the potential for false positive results (Centers for

Disease Control, & Prevention, 2007). These false positive results can lead to patients being unnecessarily

treated for Lyme disease rather than getting the correct treatment for the root-cause of their illness. A study

conducted in 1993 by Dressler, et al. also confirmed and concluded that Western blotting can be used to in-

crease the specificity of serologic testing in Lyme disease. Other diagnostic tests that can detect LD are the

polymerase chain reaction (PCR) test, and the Lyme urine antigen test. The CDC, (2007) urges that the test

accuracies and clinical usefulness have not been adequately established and generally do not recommend

these tests to be done. Buttaro, et al. (2007), also agree with the CDC and write in their text, “their availabil-

ity and utility are not yet established; and the Lyme urine antigen test has given unreliable results and should

not be used in the diagnosis of Lyme disease.” It is also encouraged by the CDC, (2007) to adhere to the

recommended two-step process when testing blood for evidence of Lyme disease.

The treatment of LD can certainly be a complex challenge for healthcare providers and completely

depends on the patient history and clinical manifestations. The usual treatment for LD is a course of antibi-

" " " 20

otic therapy. The decision on what antibiotic selection and course best fits a given situation, again, lies di-

rectly on the clinical expression, history, and the organ system involvement (Epps, 2001). In this same arti-

cle, Dr. Epps gives a good example of this situation. More aggressive intravenous (IV) antibiotic therapy

would be recommended for a client with central nervous system (CNS) involvement or someone with com-

plete heart block, while an early localized eruption of the disease usually will respond quite well to a course

of oral antibiotic therapy (Epps, 2001). For treatment of the adult patients in primary care with most of the

symptoms of LD, minus the true CNS manifestations, the antibiotic treatment of choice is with the oral

route of administration. Doxycycline 100 mg b.i.d. for 10-12 days is sufficient to treat erythema migrans,

myalgias, arthralgias, and mild heart block (Buttaro, et al., 2007). Other antibiotics include amoxicillin

500mg b.i.d. for 2-3 weeks and cefuroxime axetil 500mg b.i.d. for 2-3 weeks (Treatment of lyme disease,

2005). The oral antibiotic therapy of agents mentioned in the prior sentence is generally 28 days for patients

presenting with arthritis. Buttaro, et al. (2007) also states in their text that the longer courses of antibiotic

therapy are indicated for later or more severe manifestations of the disease. Bell palsy can also be treated

with all antibiotic therapies mentioned above. For pediatric dosing, the drugs of choice are, (1) amoxicillin

250mg t.i.d. or 25-30 mg/kg/day in three divided doses for 2-4 weeks; or (2) cefuroxime axetil 125mg or 30

mg/kg b.i.d. for 2-4 weeks. All pediatric treatments and dosing of medication are all driven by age, weight,

history, clinical presentation, and organ involvement as stated earlier. Third-generation cephalasporins given

IV such as ceftriaxone or cefotaxime are the drugs of choice for clients with CNS involvement, or serious

cardiac manifestations. If there is a true allergy to cephalosporins, treatment with chloramphenicol has been

recommended (Buttaro, et al., 2007).

Patient and family education in the prevention of LD includes avoiding the risk areas where ticks are

most likely to be lurking. If these heavily wooded, shady, and grassy areas cannot be avoided, it is recom-

mended that long pants and long-sleeved shirts be worn along with a hat to avoid exposure to a tick. Keep-

ing lawns mowed and brush trimmed will also help keep ticks away. While hiking, it is recommended to

stay on trails and not venture into the wooded area. Insect repellent containing DEET is a versatile and ef-

fective repellent for use in the support of avoiding ticks, subsequently evading LD. Inspection of the body

for any ticks after being exposed to an environment which is at risk of having LD is extremely important.

According to an article in the Pediatric journal, people should be instructed on how to inspect themselves

and their children’s bodies and clothing daily after possible tick exposure due to the fact that the bacterium

that causes LD has a prolonged duration of transmission, usually > 48 hours and immediate removal of the

tick can greatly reduce the chances of infection (Committee on infectious diseases, 2000).

As with all debilitating illnesses there comes along the fact that there might be some psyhosocial is-

sues involved. Cavert (2007) points out in her article 3 main psychosocial issues associated with LD, which

" " " 21

are: (1) guilt, (2) isolation/desertion, and (3) validation of the person. A person might feel guilty and helpless

due to the fact that they are too sick to care for their children, return to work, enjoy sex, and have fun with

family and friends (Cavery, 2007). They may have difficulties feeling validated as a person due having lack

of family and friend support for their chronic symptoms.

Once a clinician can successfully make a diagnosis of Lyme disease, it is quite appropriate to have

this illness managed in a primary care setting. There are a small percentage of people who do not respond

well to treatment and continue to have problems. These individuals most likely responded poorly to the

therapy because they never had Lyme disease at all and received the wrong treatment for their illness, had

Lyme disease and another infection simultaneously and were only treated for Lyme disease, contracted a

new illness unrelated to Lyme disease but with similar symptoms, and have again been bitten by the tick that

causes Lyme disease (Infectious Diseases Society of America, 2009). When management of symptoms be-

come complex and prolonged, referral to the appropriate specialist for the particular organ system being af-

fected is indicated, especially if LD testing comes up negative.

In conclusion, this student has gathered that healthcare providers along with the community need to

have improved education on the identification, prevention, and treatment of Lyme disease.

ReferencesButtaro, T. M., Trybulski, J. , Bailey, P. P., & Sandberg-Cook, J. (2007). Primary Care: A collaborative practice (3rd ed.). St. Louis:

MosbyCavert, K., (2007). Psychosocial issues of lyme disease. Melissa Kaplan’s Lyme Disease. Retrieved September 25, 2009 from

http://www.anapsid.org/lyme/psychosocial.htmlCenters for Disease Control, & Prevention., (2007). Lyme disease - United States, 2003-2005. MMWR Weekly 56(23), 573-576Committee on Infectious Diseases. (2000). Prevention of lyme disease. Pediatrics 105(1), 142-147Dressler, F., Whalen, J.A., Reinhardt, B.N., & Steere, A.C., (1993). Western blotting in the serodiagnosis of lyme disease. The Journal

of Infectious Diseases, 167(2), 392-400Epps, S.C., (2001, August 1). Lyme disease: Current therapies and prevention. Retrieved September 22, 2009 from

http://www.medscape.com/viewarticle/410183 Feder, H.M., Johnson, B.J., O’Connell, S., Shapiro, E.D., Steere, A.C., Wormser, G.P., (2007). Ad hoc international lyme disease

group. A critical appraisal of ‘chronic lyme disease’. New England Journal of Medicine 357, 1422-1430Diseases Society of America (2009). Frequently asked questions about lyme disease. Retrieved September 25, 2009 from

http://www.idsociety.org/lymediseasefacts.htmGardner, P., (1998). Lyme disease vaccines. Annals of Internal Medicine 129(7), 583-584Glass, G.E., Schwartz, B.S., Morgan, J.M., Johnson, D.T., Noy, P.M. & Israel, E., (1995). Environmental risk factors for lyme disease

identified with geographic information systems. American Journal of Public Health 85(7), 944-948Meletis, C., Zabriskie, N., & Rountree, R. (2009). Identifying and treating lyme disease. Alternative and Complimentary Therapies

15(1), 17-23Pelotes Island Nature Preserve (n.d.). Ticks and Lyme Disease Know How to Keep Yourself Safe. Retrieved September 22, 2009, from

http:/!/!pelotes.jea.com/!AnimalFact/!ticksafety.htmRecognizing and avoiding tick-borne illness. (2009, June). Harvard Women's Health Watch 16(10), 4-6Stricker, R.B., Johnson, L. (2008). Chronic lyme disease and the “axis of evil”. Future Microbiology 3(6), 621-624Treatment of lyme disease. (2005, May). The Medical Letter on Drugs and Therapeutics 47(1209), 41-43

" " " 22

Is it an Emergency?Caring for the Patient with Aortic Dissection

Janine Pinks NP, PA-C, MSN

Introduction

Aortic dissection is a medical emergency that can present at any medical facility throughout the country. The pa-

tient’s presenting symptoms can make it difficult to diagnose, but prompt diagnosis is the key to successful interven-

tion.

This article will discuss aortic dissection. It will give an overview of the basic anatomy of the aorta, terminology of

aortic dissection, and diagnosis and treatment of the patient with an aortic dissection.

Anatomy of the aorta

! The portion of the aorta in the chest is called the thoracic aorta. It begins at the level of the heart and extends

upwards in the anterior chest (aortic root and ascending thoracic aorta), next passes from front to back under the

neck (aortic arch), and then descends in the posterior chest adjacent to the spine (descending thoracic aorta). Finally,

the aorta continues through the abdomen (abdominal aorta), where at last it splits into two smaller branches (com-

mon iliac arteries) that supply the circulation to the lower extremities.

Definition

! Aortic dissection is defined as separation of the layers within the aortic wall. Tears in the intimal layer result

in the propagation of dissection (proximally or distally) secondary to blood entering the intima-media space. Disrup-

tion of the aortic intima and a variable depth of the media permit the force of aortic blood flow to be redirected from

the true lumen into a dissection plane within the media creating a false lumen. This is often a lethal event, but may

result in a chronic condition with an aneurismal dilatation of the dissected aorta and a potential for rupture.

! Aortic dissection can be diagnosed premortem or postmortem because many patients die before presentation

to the emergency department (ED) or before diagnosis is made in the ED. It is felt that 50% of all patients suffering

from an acute aortic dissection are dead within 48 hours of onset. Aortic dissection occurs in approximately 2 out of

every 10,000 people. It can affect anyone, but is most often seen in men aged 40 to 70. Aortic dissection is more

common in males than in females, with a male-to-female ratio of 2:1. The condition commonly occurs in persons in

the sixth and seventh decades of life. Patients with Marfan syndrome present earlier, usually in the third and fourth

" " " 23

decades of life. The exact cause is unknown, but risks include arthersclerosis (hardening of the arteries) and high

blood pressure. Other risk factors and conditions associated with the development of aortic dissection include:

•Bicuspid aortic valve

•Coarctation (narrowing) of the aorta

•Connective tissue disorders

•Ehlers-Danlos syndrome

•Heart surgery or cardiac cath procedures

•Marfan Syndrom

•Pregnancy

•Pseudoxanthoma elasticum

•Vascular inflammation due to conditions such as arteritis and

syphilis

Trauma is an uncommon cause of aortic dissection; blunt

forces typically result in a hematoma or transsection rather

than dissection.

Classification

Classification systems for aortic dissection have been critical

strategies for diagnosis and the subsequent management of

the patient. Several systems exist, but the two most important

variables necessary to categorize patients are the location and

timing of the dissection.

Acute dissection is used to describe a dissection within two

weeks of an event. Sub acute is used to describe a dissection

between 2weeks to 2 months, and chronic is used to describe

a dissection greater then 2 months.

The two classification systems most frequently used to describe the location of an aortic dissection are the DeBakey

and Stanford system. Dr. DeBakey and coworkers classified aortic dissection into 3 types; not just where the tear

originates, but what part of the aorta is involved in the dissection. Whereas the Stanford system classifies the aortic

" " " 24

dissection in two types; whether the ascending aorta is involved in the dissection or not regardless of the site of ori-

gin. We tend to use the Stanford classification here at ValleyCare:

" " " 25

Symptoms

Patients with acute aortic dissection present with the sudden onset of severe and tearing chest pain, although this de-

scription is not universal. Some patients present with only mild pain, often mistaken for a symptom of musculoskele-

tal conditions located in the thorax, groin, or back. Some patients present with no pain. The pain is usually localized

to the front or back of the chest, often the interscapular region, and typically migrates with propagation of the dissec-

tion. The pain of aortic dissection is typically distinguished from the pain of acute myocardial infarction by its abrupt

onset, although the presentations of the two conditions overlap to some degree and are easily confused. Aortic dis-

section can be presumed in patients with symptoms and signs suggestive of myocardial infarction but without classic

ECG findings.

Treatment

! Treatment is usually based on the type of dissection. A type A dissection is always a surgical emergency be-

cause the ascending aorta is involved. If it is not surgically repaired the dissection will continue down into the heart

which may result in death from wall rupture, hemopericardium and tamponade, occlusion of the coronary ostia with

myocardial infarction, or severe aortic insufficiency. This is considered an open heart surgery and done with the pa-

tient on the heart lung machine. One of the most difficult and critical open heart surgeries done here.

A type B aortic dissection (descending thoracic aorta) is best treated with medication if the patient is clinicaly stable.

It is usually medically managed by reducing the person's blood pressure with beta-blockers (an esmolol drip is the

most common). The risks do not outweigh the benefits of a surgical repair, because the patient is at a very high risk

for kidney failure and paralysis from a surgical repair. If a surgical repair is eminent because it continues to leak, he

could be transferred to Stanford or UCSF (this would be ideal). If too unstable to transfer we may try to stent it, if not

successful we will open (usually done on the heart lung machine if open surgical repair), but as stated before the risks

do not outweigh the benefits and outcomes usually aren't good.

Conclusion

Aortic dissection is a medical emergency and here at ValleyCare we have had several presenting to our ED since our

open heart surgery program started. Prompt diagnosis is the key to successful treatment and good patient outcomes.

" " " 26

GuatemalaMedical Mission: The Gift of Giving

Maria Castillo, Surgical Technician

A beautiful country rich in cul-

ture with amazing landscapes

and biodiversity…Cities and

towns surrounded by volca-

noes, deep jungles, and pris-

tine waters…Views that from

any vantage point are breath-

taking.

! Even with all the natural beauty Guatemala has to offer, you have look past it all and into its people in order to

realize that over half the population (56%) is living in poverty, and almost 40% of the population are indigenous na-

tives who are very poor. The native people who live across the vast terrain, some in very isolated villages, may have

never seen a doctor or see one very irregularly. Ailments that are regularly taken care of in the United States are put

off in Guatemala, where health care can be considered a luxury many can not afford. The elderly with cataracts wait

until they are nearly blind to seek medical care. Women requiring hysterectomies wait until the fibroids are as large

as softballs. Dental care is another luxury many bypass.

! I have been a surgical technician in the Bay Area for over 10 years. In 2005, I was privileged to be invited to

join the Hospital De La Familia (HDLF) organization on my very first mission. HDLF is an organization that was

started by a California developer and a priest from Nuevo Progresso, Guatemala in 1973 to provide medical and surgi-

cal care to the people of Guatemala. I was inspired by their humanitarian work and honored to be asked to join the

team, so of course I jumped at the chance. I saw it as an extension of my desire to help people, but little did I know

that I had just embarked on a life changing adventure.

! On my first trip early November of 2005, I headed out to the San Francisco airport to meet up with a group of

doctors, nurses and surgical technicians, most of whom I had never met. What I found there was a group of people

with a common purpose, who were warm and inviting, happy to welcome a newcomer such as me. This trip was al-

most cancelled because of a hurricane that ripped through Central America and caused devastation in the countryside

" " " 27

due to mudslides. Roads leading to the village of Nuevo Progresso and the HDLF hospital were affected and some

were impassable. When the weather cleared and the roads were repaired, the mission was back on.

! Af-

ter a 7-hour

flight to the

capital of

Guatemala

City, we em-

barked on an

8-hour bumpy

bus ride on

what they call

a chicken bus;

not because it

carries chick-

ens but be-

cause many

are too

chicken to ride it. The bus was escorted by the military to ensure our safe arrival to Nuevo Progresso, located about

50 miles south of the Mexican border on a hilltop in the middle of the jungle. As we arrived, we were greeted by fire-

crackers, dancing children and delicious food. The joy and gratitude was apparent in the eyes of the local villagers

and we hadn’t even gotten to work yet! After briefly settling into our designated rooms, everyone walked over to the

hospital and quickly got to work unloading the boxes of supplies and medications to prepare for the next day when

the surgeries would start.

! At 6am the next morning, I looked down and out of my window, which faced the street between our rooms

and the hospital. The site of hundreds of people lined up quietly waiting to be cared for served to reflect the immense

need for health services felt by many across the country. Some were elderly and being lead by the hands of a younger

family member, while others carried babies tied to their backs. Heading out to breakfast as I walked through the

crowd, many people expressed their gratitude by reaching out to give me their blessing; some in dialects I had never

heard. By the time I made it across the street I was already overwhelmed with emotion and teary eyed.

! After breakfast the work began. We did surgery after surgery. Hernias, hysterectomies, and open cholecys-

tectomies. We repaired cleft lips and palates, treated burn injuries and removed strange looking growths that I had

never seen before. Our patients were always thankful and never complained, and even the smallest of children sat very

still as IV’s were put in. At the time, we had three surgical beds in one large operating room. The first couple of days

" " " 28

HDLF Team

were strange trying to get use to the fact that there were other surgeries going on just an arms length away. In another

room the eye team was

busy caring for well

over a hundred patients

a day. They performed

cataract surgeries and

fitted patients for

glasses that were do-

nated and brought over

from the United States.

In the Nutrition Cen-

ter, babies and small

children were being

nursed back to health.

! We were all

able to keep this pace

up for 10 exhausting but very satisfying days. In the end, with the help of the amazing Guatemalan doctors that are

there year-round, we had treated over 1,500 patients. As the mission came to an end, I had a chance to reflect on my

experience and what I found was that I had been accepted into a family. It was another type of family but a family

none-the-less. This family gets together every couple of years to give their time, skill, compassion and provide medi-

cal care for those that otherwise would not receive medical treatment. I had experienced healthcare at it’s finest by

men and women who love what they do, and donate their vacations to give the gift of better health and a better quality

of life. I had finally found my passion.

! There are 8 groups within the HDLF organization making trips out to Nuevo Progresso. 1 group goes every 3

months and every group has its turn every other year. Since my first trip in 2005, I have been invited to return twice:

in 2007 and again last year in 2009. The hospital has improved, the operating room has been expanded and there are

now four operating room tables. The Eye Clinic was moved to a larger building with updated equipment, and the Nu-

trition Center has also moved and as a result can now hold more patients.

! It seems like with every trip, I have a harder time coming back knowing that we are leaving behind many pa-

tients that are in need. However, the knowledge that another group will soon be there to take our place quickly puts

my mind at ease. I am very thankful to all those that have allowed me to be part of such a wonderful family of caring

medical professionals. Although I will not be able to make it on the 2011 trip, I know I will be welcomed back in the

future.

" " " 29

Operating Room

Recognizing Nurses Pursuing Advanced Degrees and Nurses Who are Certified

Nurses Attending SchoolNurses Attending SchoolNurses Attending SchoolNAME UNIT DEGREE PURSUING

Bashaw, Erin Nursing DNP

Biaggi, Wendy 2 West Unit clerk AA in Nursing

Bowers, Lani 2 West BSN

Castillo, Maria Surgery pre-reqs nursing

Chan, Bev SNF BSN

Chau, Angelina OP Clinics DNP

Cobery, Nancy Surgery MSN

Daco, Angelina CCU BSN

Degoey, Chrisitne 3 West unit clerk AA in Nursing

Echeme, Victor CAN pre-reqs nursing

Edwards, Brian ED MSN/FNP

Falcon, Carol Surgery BSN

Friedman, Cindy PAS dept AA in Nursing

Angelina Leong Chau FNP-Mobile Health Unit DNP

Fisher, Juliette 2 West BSN

Forschen, Kiun Surgery MSN

Forte, Kristina ED MSN/FNP

Frazer, Samatha SNF pre-reqs nursing

Jensen, Cherie SNF BS in Health Care Administration

Hermoso, Tifffany CCU MBA/MSN/Healthcare Management degrees

Kennedy, Amada ED BSN

Kiely, Cathy 2 North MSN

Lopez, Elizabeth PAS dept BSN

Machado, Kimberly ED MSN/FNP

Maier, Christiane Mat/Child MSN/APN

Martin, Lisa 2 North BSN

McCorkle, Jeanne Pre-Op BSN

Mireles, Lisa 3W pre-reqs nursing

Montez, Deborah Admiting dept pre-reqs nursing

Montez, Megan 2N/1W unit clerk pre-reqs nursing

Monahan, Shelley CCU BSN

Moreland, Rick Surgery Pre-reqs physician assistant

Osuja, Nelly CAN LVN

Padda, Seema CCU BSN

Pancoast, Heather 2N/1W unit clerk pre-reqs nursing

Payne, Jessica 2 West CAN AA in Nursing

Ray, Amanda Surgery pre-reqs nursing

Rezendes, Tricia 3 West unit clerk Nursing

" " " 30

Rillston, Jennifer 2 West BSN

Sarmiento, Michelle PAS dept Nursing

Solovskoy, Nicole 1West/2N unit clerk Nursing

Spitaleri, Alison Lifestyles Rx pre-reqs nursing

Shurko, Carole 2 West BSN

Stewart, Laura Legends BSN

Turner, Laureen Pre-Op MSN

Velaquez, Laura Clerk pre-reqs nursing

Vallejo, Ben Surgery pre-reqs nursing

Wagner, Mitch Surgery Pre-reqs physician assistant

Warren, Glenda 2 North BSN

Williams, Gina UC BSN

Yee, Karen 2 West BSN

Nursing CertificationsNursing CertificationsNursing CertificationsNAME UNIT CERTIFICATIONS

Adriano, Rosafel OP Clincs FNP-C

Arana, Paula Surgery CNOR

Bangal, Nena CCU CCRN

Barbero-Cerruti, Dayna OP Clincs PHN/FNP

Barnhill, Shelley Staff Development RNC-OB/C-EFM

Bean, Sandra Mat/Child RNC

Bencik, Eileen Cardiac Rehab RNC

Benett, Linda Cath Lab CCRN

Berg, Jennifer Nursing Administration CWOCN

Bernardo, Araceli Mat/Child RNC

Breen, Eric Emergency Department CEN

Bowles, Julie Mat/Child RNC

Brooks, Elena 2 North RNC

Brown, Martha Peri-Op Services CPAN

Bundros, Daphne OP Clincs FNP-C

Butler, Karen PACU CPAN

Candee, Debra CCU CCRN/CSC

Cando, Alejandro CCU CCRN

Carson, Rachel ONC

Cabalsi, Julia CCU CCRN

Cason-Flores, Rachel Bariatrics OBC/CBN

Cerruti, Teresa Mat/Child RNC

Chadwick, Brea CEN

Chan, Beverly SNF RNC

Chau, Angelina OP Clincs NP/FNP-C

Chau, Joy Surgery CNOR

Chen, Stephanie CCU CCRN

Clark, Kathleen ED IBCLC

Coronel, Emmylou CCU CCRN

Cristobol, Kim Staff Development CCRN

Daco, Angelina CCU CCTN

Davis, Missy Cath Lab CCRN

Dubray, Elena Mat/Child RNC

Dumlao, Raymond Med/Surg RNC

Dynek, Karen Cath Lab CCRN/ACC/CCA/PHN

Ebadat, Farnoosh OP Clincs FNP-C

Edwards, Brian ED CEN

Falcon, Carol Surgery CNOR

" " " 31

Feifarek, Judy Mat/Child RNC

Flores, Paula Pre-Op IBCLC

Giddens, Carolyn Social Services CPUR/CCM

Glasgow, Lisa CCU CCRN

Gray, Lori 2 North ONC

Haidet, Theresa Legends PHN

Halvorsen, Marge Surgery CNOR

Hanamura, Jancie PACU CPAN/CCRN

Hardiman, Nina PACU CCRN

Hawkinson, Graham ER Tech Paramedic Cert.

Holland, Bette Surgery CNOR

Hurlock, Carolyn Mat/Child RNC

Janzen, Marilyn CM/UR/SS CPUR

Jensen, Cherie SNF RNC, RAC-CT (Certified Resident Assessment Coordinator)

Johnson, Carol 2 North RNC/ONS

Jordan, Jessica Nursing Administration CIC

Jose, Christine Surgery CNOR

Kitt, Jeanette Staff Development CCRN/CNRN

Krause, Judy Mat/Child IBCLC

Laney, Karen 2 North ONC/OCN

LaSalle, Sherry CCU Med/Surg/Certificate Human Services

Lendi, MaryEllen Mat/Child RNC

Levy, Joanie Case Management ACSW

Lindley, Susie Mat/Child IBCLC

Lounsbury, Karen Staff DevelopmentCNL/RN-BC/Nursing Professional Develop-

ment

Machado, Kimberly ED CEN

Maier, Christiane Mat/Child RNC

Marez, Jennifer NICU RNC

Manley, Lola Diabetes Center CDE

Martin, Carol ED CEN, DABFN(diplomat american bd forensic nsg)

Martin, Lisa 2 North ONC/RNC

Martinelli, Jennifer 2 North ONC

Matheson, MaryJo PACU CPAN

McCorkle, Jeanne Pre-Op CAPA

Meyer, Joyce Mat/Child RNC

Montemayor, Doreen QM CPHQ

Nabozny, Danielle Mat/Child RNC

Northrop, Nancy PACU CPAN

Noriestra, Geraldine Mat/Child RNC

Norton, Carolyn Surgery CNOR

Nuzzo, Michelle Mat/Child RNC

Ogee, Linda ED CEN

Ornelas, Suzanne Mat/Child RNC

Padda, Seema CCU CCRN

Patrone, Tina Mat/Child RNC

Pedroso, Romana Surgery CNOR

Perkins, Kristen Mat/Child IBCLC

Pinks, Janine Surgery NPC/PAC

Pilkington, Susan CCU CCRN

Prishtina, Mary Library OCN

Reed, Judy QM CPHQ

Revak, Bernie IC/MOU PHN/CIC

Rivera, Ron Cath Lab CCRN

Rosas, Anel 2 North ONC

" " " 32

Ruiz, Lori QM CPHQ

Rutter, Tammy 2 North ONC

Schaarschmidt, MaryJo Mat/Child CPNP/CNS/RNC

Shelnut, Tracy SNF RNC

Shurko, Carole Med/Surg Med/Surg

Silva, Annette Cardiac Rehab RNC

Stanley, Sheela 2 west ONS

Stewart, Shannon 3 West RN-BC

Stidwell, Kathi ED SANE-A

Stowers, Patti Surgery CPAN

Schwartz, Marge Mat/Child RNC

Tjoe, Yuke Mat/Child CWOCN

Todd, Evelyn Mat/Child RNC

Torrey, Sandra Med/Surg ONS

Valdix, Staci Cardiology FNP/Public Health

Valencia, Michelle 2 North ONC

Villapondo, Grace Mat/Child RNC

Warren, Glenda 2 North ONC

Welch, Michelle 2 North ONC

Weinacht, Darian CCU CCRN< CEN

Williams, Naomi Mat/Child PNP

Williams, Susan OP Clincs FNP

Yau-Chan, Phyllis CCU CCRNZielske, Garnet Case Management CCM

Note: If you are pursuing an advanced degree or have been certified, and you are not listed above please contact

Margie Eggers. We want to keep an accurate account count of our dedicated staff’s accomplishments.

Note: If you are pursuing an advanced degree or have been certified, and you are not listed above please contact

Margie Eggers. We want to keep an accurate account count of our dedicated staff’s accomplishments.

Note: If you are pursuing an advanced degree or have been certified, and you are not listed above please contact

Margie Eggers. We want to keep an accurate account count of our dedicated staff’s accomplishments.

Laverne Rose Nurse of the Year15 years of recognizing excellence.Mary K. Dunn RN, MSN

! Every year, since 1996, ValleyCare has awarded one of its nurses with the

honor of the Laverne Rose Nurse of the Year Award. The award is named after

Laverne Rose who was the charge nurse of the Medical Surgical Units for many

years. Laverne exemplified the compassion and skill that ValleyCare looks for in

the awardies. The nominees are nurses who exhibit the following qualities: Pro-

fessionalism and participation in professional affiliations; Dedication and advo-

cacy to their patients and profession; Exemplary clinical skills, and Outstanding

mentoring abilities. The award is presented at Nurses day each year. 2010 will

mark the 15th annual Laverne Rose Award. Thanks to all the awardies and nomi-

nees who shine in their field, and provide excellent, compassionate care everyday.

alleyCare Nurse1ST EDITION I SPRING 2010

2003

2008 2002

2005

1998

2004

2007

2001

20061996

2000

2009

" " " 33

Jean Johnston is fondly remembered as ValleyCare’s

wound care nurse and liaison between acute care and home

care setting, during the early 1990’s. She was described

as an angel by all who came in contact with her, and she

truly was. She touched and inspired many in her career at

VCMC. Jean was kind, compassionate, and the ultimate

professional. She cared deeply about her profession, her

patients, and her colleagues. Clinically Jean acted as chair

person for the wound care committee. She always used her keen assessment skills

while utilizing the most advanced interventions and products for treating patients. Jean

inspired us all; she exemplified the best of what nursing can be. Jean was VCMC’s first

recipient of the Nurse of the Year award, receiving the award in 1996. ValleyCare chose

an excellent first Nurse of the Year, because Jean provided such a worthy model for the

candidates of future years to follow.

IN MEMORIUM

Prepared by MagCloud for mary dunn. Get more at mdunn.magcloud.com.