Diplopia is the simultaneous perception of two images of a single object that may be displaced vertically, horizontally or diagonally in relation to each other.  Normally it is the result of impaired function of the EOM’s (extraocular muscles) whereby both eyes are still functional but they cannot converge to target the desired object.  Problems with EOM’s can be mechanical, ingestion of toxins or disorders of the cranial nerves.  It is often the first sign of a systemic disease, particularly to a muscular or neurologic process.  Further, it can disrupt a person’s reading, movement or balance.

        The brain naturally guards against double vision.  It can sometimes ignore the image from one eye (referred to as suppression).  The ability to suppress is usually found in childhood, when the brain is still in the stages of development.  Thus, those with childhood strabismus almost never complain of diplopia, as opposed to adults with strabismus almost always do. 

        Finally, there is a distinction between monocular and binocular diplopia.  Monocular is more rare and diplopia can occur with viewing with only one eye, or where the patient perceives more than two images, monocular polyopia.  Binocular diplopia is double vision arising as a result of the misalignment of the two eyes relative to each other.  This particular phenomenon occurs with esotropia or exotropia.  In such a case while the fovea of one eye is directed at the object of regard, the fovea of the other is directed elsewhere, and the image of the object of regard falls on an extra-foveal area of the retina.  Images falling on the fovea are seen as being directly ahead, while those falling on retina outside the fovea may be seen as above, below, right or left or straight ahead depending upon the area of retina stimulated.  Therefore, when the eyes are misaligned, the brain will perceive two images of one target object, as the target object simultaneously stimulates different, non-corresponding, retinal areas in either eye, thus producing double vision.

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       Today atrial fibrillation accounts for 1/3 of the hospitalizations for cardiac rhythm disturbances.  The most common symptoms include dyspnea, palpitations and decreased exercise tolerance.  Patients with A-fib are at increased risk for stroke and more often than not, anticoagulation is recommended.  I have had several of my elderly clients in home health care that have had this disturbance and are on Coumadin therapy.  Although episodes of A-fib can be converted to normal sinus rhythm by pharmaceutical means or electroshock conversion, the natural history of A-fib is one of recurrence, and many times a catheter ablation is necessary to correct the problem.

       Cardiac ablation is a procedure that can correct heart rhythm disturbances and typically involves the use of a catheter; a long, flexible tube inserted in a vein in the groin and threaded to the heart.  It works by destroying tissue in your heart that triggers an abnormal heart rhythm.  Sometimes ablation prevents abnormal electrical signals from traveling through the heart and thus stops the arrhythmia.  Occasionally cardiac ablation is done through open-heart surgery, but using the catheter ablation method is much less invasive and shortens the recovery time.  This procedure is a treatment option for people that have tried medication without success, have had serious side effects from tried medication or have a high risk of complication from their arrhythmia, such as sudden cardiac arrest.

       Ablation usually takes about 3-6 hours, although some cases are longer if there are any complications.  During the procedure, one might feel some minor discomfort when the dye is injected in the catheter or when energy is run through the catheter tips.  Ablations are always performed in the hospital and even on an outpatient basis if there are no complications.  Sedation is given through an intravenous line to help you relax.  Next, they will numb a small area near a vein on the groin, neck or forearm, a needle is inserted in the vein, and a tube called a sheath is placed through the needle.  The catheter that is used for the ablation is threaded to the heart through the sheath. 

       Finally, a dye is injected that will show up on x-ray images so that the doctor can see the part of the heart that needs to be treated.  The catheter has special electrodes at the tips that will be used during the procedure.  Once the abnormal tissue that is causing the arrhythmia is identified, the catheter is aimed at that area.  Lastly, energy will travel through the catheter tips to create a scar or destroy the tissue that triggers the arrhythmia.  The energy used in this ablation may come from radiofrequency (heat), lasers or cryoablation (extreme cold).  Catheter ablation for A-fib is becoming quite popular for patients that are unable to get relief from other means.

I have referred a few of my close friends and they are headed to Las Vegas for training in November and December of this year.  As far as I know they will be training nurses well into next year.  They pay for your flight and for a very nice room in a hotel/casino with free shuttle to the office for training.  Usually you leave on a Sunday and return home on a Saturday (1 week).  Training is also fully paid and your meals are reimbursed shortly after you return home.  What is the job about?  It is reviewing medical records for short, inpatient hospital stays.  I have found it very challenging and every case is totally different!  The nurses are from all over the US and they come from a variety of fields; OR, ER, telemetry, CCU, med/surg, hospice, insurance companies, management, operations, etc.

Just thought I would write one more blog about this exciting opportunity for a home-based registered nurse.  By the way, this is done using high speed Internet and piping right into their Citrix system.  I must say that I feel very fortunate to have found this company during this tough economic time we are all facing.  If you have further questions for me, please leave them in the comment section and I’ll surely get back to you.  As always, thanks for reading AND if you are not a nurse, there are other positions available with this growing organization.

To explain a little bit more about what they do, they are a RAC provider with Medicare and Medicaid Services (CMS) and other commercial payors.  Recovery auditing is an up and coming field of nursing that will continue to grow for years to come.  Better yet, this is a telecommute position; you work with an intelligent and wonderful staff and you have a mentor that helps you succeed!  9 paid holidays plus PTO; holidays start right away, 401K and health benefits start after 4 months.  The pay starts at $50,000 – $55,000 (salaried position).  To my knowledge, they are only hiring full time employees.

The training is marvelous, and yes quite tiring, but well worth the trip to Vegas for learning AND having some fun.  Here is what is covered in the training:

• Welcome and Introduction
• Help Desk
• Citrix User Guide
• Remote User Requirements
• Mere 4 and Mere 3
• Case Studies
• Quality Management Program
• Team Folder
• Medical Terms
• Computer Information – General
• Timesheet – Deltek
• Expense Reporting
• HCM – Clinical
• CMS 101
• Evaluations

There were several states present at this particular training session – Pennsylvania, Iowa (my home state), Nebraska, Florida, Georgia, California, Las Vegas, Missouri, North Carolina, etc.  They are all registered nurses – a great bunch of people to work with and everyone is in the same boat.  I met several really great people – there were 13 in the class; however, I believe they are going to up the attendance to 20 people starting next month.

I am just waiting for my equipment to arrive today, as I start this career officially tomorrow, but you are an employee the minute you walk in for training.  Once again, if you have medical record review experience, think about joining this company before it is too late.  If you have further questions, please leave a comment in the comment section of my blog.  Be certain to use my name, Stephanie Jewett, as the person that referred you.  Although there are locations in Florida and California, all training is done at the headquarters in Las Vegas.  HDI is Medicare’s exclusive Recovery Audit Contractor in Region D (17 states & 3 U.S. territories).  They have served as the National (all 50 states covered) Payment Error Rate Measurement (PERM) contractor for CMS since 2006.  HDI is the industry leader in healthcare claims integrity: fraud, waste, abuse, errors and improper payment identification and recoupment solutions.  Finally, HealthDataInsights reviews over $300 billion in paid claims annually.

In more detail, HPV is a virus of the epithelial cells that are found on the skin and also the vagina, vulva, anus, penis, mouth and throat.  There are around 40 types of HPV and they range in severity.  Some are without health risks and others lead to genital warts and even cancer.  The word papilloma actually refers to the warts that may develop as a result of the virus.  Although intercourse is the most common way of getting HPV, there are other ways to become infected, such as oral sex.  The virus can also be passed through bodily fluids and mucous membranes.  Mucous membranes certainly include genitals, but they also refer to the mouth, nose and throat.  Therefore, there are ways of spreading the virus through the contact of these areas, and not necessarily only by sexual behavior. Kissing, sharing drinks and toothbrushes, and close contact to an infected person’s face can all contribute to the spreading of HPV.  In rare cases, a mother who is infected with HPV can pass the virus onto her newborn during delivery.  The baby may then develop an HPV infection of the genital region or upper respiratory system.

In many instances, symptoms of an HPV infection may never manifest.  Even if you don’t initially develop any signs, symptoms can occur at a later time.  Once you begin to show signs of the infection, you are able to transmit the disease to your sexual partners.  The most common sign of an infection are warts within the genital region.  The warts can appear as cauliflower-like clusters that show within the region of a woman’s vulva, the anal region, on the cervix or in the vagina.  A man may develop signs of warts on the penis, scrotum or around the anus.

Sometimes when a woman gets a pap smear, the results of the test may indicate that there is an abnormality.  In most cases, the abnormalities (meaning cells) will return to normal without any complications.  However, according to the Mayo Clinic, some abnormalities, considered high grade, usually progress to cancers of the cervix, vagina or vulva.  Other symptoms of an infection can include common warts, which appear on the hands, feet, elbows, wrists and face.  Lesions can also appear on the tongue, tonsils, upper roof of your mouth, larynx and nose.

To protect yourself from HPV, take simple prevention methods.  If sexually active, always use a condom.  Try to maintain a monogamous relationship, or limit the amount of sexual partners.  With common warts, you can prevent the spread of warts by trying not to pick at the warts or biting your nails.  If you have warts on your feet, keep your feet clean. Always wear clean socks, and keep your feet dry.  If you are pregnant and have an HPV infection, your doctor may recommend removal of the warts prior to your child’s delivery.  Finally, protect yourself AND others by getting your daughter or son the vaccine Gardasil.  To learn more about this important vaccine, consult a physician or visit the Gardasil website at:  hpvinfo.com

I found my best resource for this topic was ClinicalTrials.gov. ClinicalTrials.gov currently reports there are 110,353 active trials with locations in 174 countries.  That is unbelievable!  Their website broke down the different types of clinical trials, which are:

Treatment trials test experimental treatments, new combinations of drugs, or new approaches to surgery or radiation therapy.

Prevention trials look for better ways to prevent disease in people who have never had the disease or to prevent a disease from returning. These approaches may include medicines, vaccines, vitamins, minerals, or lifestyle changes.

Diagnostic trials are conducted to find better tests or procedures for diagnosing a particular disease or condition.

Screening trials test the best way to detect certain diseases or health conditions.

Quality of Life trials (or Supportive Care trials) explore ways to improve comfort and the quality of life for individuals with a chronic illness.

In addition to the different types of trials, there are four specific phases that have a different purpose to help scientists answer different questions.  In Phase I trials, researchers test an experimental drug or treatment in a small group of people (20-80) for the first time to evaluate its safety, determine a safe dosage range, and identify side effects.  In Phase II trials, the experimental study drug or treatment is given to a larger group of people (100-300) to see if it is effective and to further evaluate its safety.  In Phase III trials, the experimental study drug or treatment is given to large groups of people (1,000-3,000) to confirm its effectiveness, monitor side effects, compare it to commonly used treatments, and collect information that will allow the experimental drug or treatment to be used safely.  Finally, in Phase IV trials, post marketing studies delineate additional information including the drug’s risks, benefits and optimal use.

Before starting a clinical trial on a patient, it is imperative to have an informed consent.  This process involves learning the key facts about a clinical trial before deciding whether or not to participate.  It is also a continuing process throughout the study to provide information for participants.  To help someone decide whether or not to participate, the doctors and nurses involved in the trial explain the details of the study.  If the participant’s native language is not English, translation assistance can be provided.  Then the research team provides an informed consent document that includes details about the study, such as its purpose, duration, required procedures and key contacts.  Risks and potential benefits are explained in the informed consent document.  The participant then decides whether or not to sign the document.  It is important to note that an informed consent is not a contract, and the participant may withdraw from the trial at any time.  All clinical trials are based on a study plan, referred to as a protocol.  The plan is carefully designed to safeguard the health of the participants as well as answer specific research questions.  A protocol describes what types of people may participate in the trial; the schedule of tests, procedures, medications, and dosages; and the length of the study.  While in a clinical trial, participants following a protocol are seen regularly by the research staff to monitor their health and to determine the safety and effectiveness of their treatment.

In this article, we are going to cover some of the most important questions to ask if you are contemplating participating in a clinical trial and what the benefits might be as well as the risks.  The questions each participant needs to ask are as follows:

• What is the purpose of the study?
• Who is going to be in the study?
• Why do researchers believe the experimental treatment being tested may be effective? Has it been tested before?
• What kinds of tests and experimental treatments are involved?
• How do the possible risks, side effects, and benefits in the study compare with my current treatment?
• How might this trial affect my daily life?
• How long will the trial last?
• Will hospitalization be required?
• Who will pay for the experimental treatment?
• Will I be reimbursed for other expenses?
• What type of long-term follow up care is part of this study?
• How will I know that the experimental treatment is working? Will results of the trials be provided to me?
• Who will be in charge of my care?

The benefits of participating in a clinical trial include gaining access to new research treatments before they are widely available, obtaining expert medical care at leading health care facilities during the trial, helping others by contributing to medical research and, most important, playing an active role in one’s own health care.  The risks, on the other hand, include unpleasant, serious or even life-threatening side effects to experimental treatments, the experimental treatment may not be effective for the participant and the protocol may require more of a person’s time and attention than would a non-protocol treatment.  For instance, more trips to the study site, more treatments, hospital stays or complex dosage requirements.

Clinical trials really are important, but they are a very complex part of research as well.  Ideas for clinical trials usually come from researchers.  After researchers test new therapies or procedures in the laboratory and in animal studies, the experimental treatments with the most promising laboratory results are moved into clinical trials.  During a trial, more and more information is gained about an experimental treatment, its risks and how well it may or may not work.  Clinical trials are sponsored or funded by a variety of organizations or individuals such as physicians, medical institutions, foundations, voluntary groups and pharmaceutical companies, in addition to federal agencies such as the National Institutes of Health (NIH), the Department of Defense (DOD), and the Department of Veterans Affairs (VA).  Trials can take place in a variety of locations, such as hospitals, universities, doctors’ offices or community clinics.

As a field, nursing has seen an explosion in growth in recent years. The aging of the American population has led the Bureau of Labor and Statistics to predict job growth to increase by 22 percent by 2018, far out-stripping the national average. For many, the good pay and job security (which is even better than that of other popular fields, such as medical transcription) of nursing have made it an ideal career path, and nursing schools have blossomed across the country. However, each school has its own unique advantages and disadvantages and a number of factors should be considered before you select a school.

What Type of Nurse Do You Want to Be?

There are three main types of nurses: registered nurses (RNs), licensed practical nurses (LPNs) and advanced practice nurses (APNs). Each works in the medical profession, often in hospitals, but the educational route for each is different, as are the career prospects for each.

It is possible to become a registered nurse through either an associate degree (ADN) or a bachelor’s degree (BSN) program in nursing or by training through a recognized hospital diploma program. It generally takes four to five years to attain a BSN, while ADN programs take two to three years. Diploma programs through hospitals generally take three years to complete.

RNs fulfill the typical nursing role, performing basic medical procedures, working with doctors and caring for patients. While ADN and diploma programs offer a shorter timeline to becoming an RN, they offer fewer advancement opportunities and chances at specialization. Individuals with a BSN typically find that they have a wider variety of jobs to choose from, and many go on to become APNs.

APNs have attained a master’s degree in nursing. Their practice is more specialized, with many APNs serving as clinical nurse specialists, nurse anesthetists, nurse practitioners and nurse-midwives. These nurses have specialized in medicine and often treat patients. They can diagnose illnesses and write prescriptions and oftentimes serve in the same capacity as a general physician.

LPNs, also known as licensed vocational nurses, have less training than RNs. Most training programs for LPNs last about a year and are offered by technical schools and community colleges. While LPNs interact with patients on a regular basis and perform many basic medical functions, they do not perform tests or other medical procedures, although they will assist doctors and RNs during procedures. However, since advancement opportunities are limited for most LPNs, many colleges offer LPN to RN programs for those who have achieved certification as an LPN but wish to become licensed as an RN.

Program Accreditation

The most important aspect to look for from a program, after you have identified which type of nurse you wish to become, is its accreditation. If the program you attend is not accredited, you could find yourself barred from taking the state’s nursing test or attaining a license in the field. This is especially important if you are looking at for-profit colleges and online nursing programs, as many do not offer the appropriate accreditation.

The National League for Nursing Accrediting Commission, Inc. (NLNAC) is the most common accrediting commission for ADN and Diploma programs. Thus, before you decide on any of these programs, it is a good idea to go to their web site (listed below in the References section) and search their directory for the programs in which you are interested. It will tell you when the school was accredited, what, if any, actions have been taken against it and will provide you with a point of contact at the school.

For those interested in achieving a BSN, a master’s in nursing or a doctorate of clinical nursing (most commonly achieved by those interested in teaching other nurses), the Commission on Collegiate Nursing Education (CCNE) is an independent accrediting agency commissioned by the U.S. Department of Education. In addition to accrediting bachelor’s and graduate programs, CCNE also accredits nursing residency programs. These institutions are both recognized throughout the country for their accrediting capacities, ensuring that you can work in any state provided you pass that state’s licensing test.

Real World Experience

While all accredited programs will offer real world clinical experience, the amount can vary by program. However, a teaching hospital should be part of your educational program, which will provide you with plenty of opportunities to learn. For instance, the University of North Florida offers a nursing program that has a community-based component, meaning students will be learning through hands-on training throughout their time at the school. Take the time to get as much real world experience as you can, as this will pay dividends in the future.

For those interested in pursuing a master’s degree or becoming an APN, university nursing programs typically offer these advanced programs as part of their curriculum. Some also offer doctoral programs at teaching hospitals. Visiting the Web site of the university’s program will reveal a great deal about their teaching philosophy, as will requesting to sit in on a class, to review syllabi and to talk to students.

Nurse Residency Programs

A new trend at some hospitals is to place new nurses into a nurse residency program. Basically, this is a 12-week long course in which new nurses will work with veterans to learn the often pressure-filled and confusing ins-and-outs of being a nurse. Therefore, once you have graduated from your nursing program and are on your way to being an RN, you might consider one of these programs as they have shown promise for easing the transition into what can be a hectic work life.

Regardless of what path you choose to take to become a nurse, it is essential that you do your homework first. Don’t sign up for a program simply because it is inexpensive or convenient. For instance, online programs might sound convenient but very few are actually accredited. You should always check the Web site of the school to which you are applying and the independent accreditation Web site to ensure everything matches up. In the end, remember that each path into nursing can lead to a different one and education never stops in the rapidly evolving field of health care. A good nurse is one who has learned to adapt to these changes, and the first step to becoming a good nurse is in finding the program that will help you to realize your career goals.

          Bronchial (or tracheal) sounds are heard on the chest at sites which are close to large airways.  In contrast to vesicular sounds, they are relatively louder in expiration than inspiration.  This type of breath sound is heard best over the trachea, but they can also be heard on the back, between the scapulae and at the lung apices especially on the right.  Vesicular sounds are the most common sounds heard over the chest.  They are present at sites that are at a distance from large airways.  The vesicular sound is a soft sound that has been compared to that of wind blowing through trees.  It is louder in inspiration than expiration.  The vesicular sound is commonly decreased in chronic obstructive lung disease.  It is also decreased over sites of pneumonia in the early stages of the illness.  It is usually, but not always, decreased or absent in conditions where the ventilation to an area of the lung is impaired, for example, in pneumothorax, misplaced endotracheal tube or mucus plugging.

          When we refer to the term adventitious breath sounds, we mean extra or additional sounds that are heard over normal breath sounds.  There are several types of abnormal breath sounds, but the three most common are rales (crackles), rhonchi and wheezing.  Rales, or crackles, are caused by fluid in the small airways or atelectasis. Crackles are referred to as discontinuous sounds; they are intermittent, nonmusical and brief.  Crackles may be heard on inspiration or expiration.  These sounds are often associated with inflammation or infection of the small bronchi, bronchioles and alveoli. Crackles that don’t clear after a cough may indicate pulmonary edema or fluid in the alveoli due to heart failure or adult respiratory distress syndrome (ARDS).  Wheezes are sounds that are heard continuously during inspiration or expiration, or during both inspiration and expiration.  They are caused by air moving through airways narrowed by constriction or swelling of the airway or partial airway obstruction. 

          Wheezes that are relatively high pitched and have a shrill or squeaking quality may be referred to as sibilant rhonchi.  They are often heard continuously through both inspiration and expiration and have a musical quality.  These wheezes occur when airways are narrowed, such as may occur during an acute asthmatic attack.  Wheezes that are lower-pitched sounds with a snoring or moaning quality may be referred to as sonorous rhonchi.  Secretions in large airways, such as occurs with bronchitis, may produce these sounds; they may clear somewhat with coughing.  Rhonchi are continuous adventitious breath sounds detected by auscultation.  Although rhonchi are usually louder and lower pitched than crackles (more like a hoarse moan or a deep snore) they may be described as rattling, bubbling, rumbling or musical.

          In sum, the detection of adventitious sounds is an important part of the respiratory examination, often leading to a diagnosis of cardiac and pulmonary conditions.  It is important as caregivers that we differentiate these most important lung sounds and chart them accordingly.  We, as nurses, need to note that absent or decreased sounds can mean air or fluid in or around the lungs (pneumonia, heart failure or pleural effusion), increased thickness of the chest wall, over-inflation of a part of the lungs (emphysema) or reduced airflow to part of the lungs.  Further, we should be aware that several other conditions can cause abnormal or decreased breath sounds, including acute bronchitis, asthma, bronchiectasis, chronic bronchitis, interstitial lung disease, foreign body obstruction of the airway, pulmonary edema and tracheobronchitis.

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While not heavily studied or well-known, Meniere’s disease can be a debilitating, painful, and dangerous condition of the inner ear.  Named after 19th century French physician Prosper Meniere who studied the inner ear, it is a chronic condition most often found with varying symptoms in people in their 40s and 50s but not unheard of in other age groups, even children.

Maria Rainier

While symptoms may be relieved via various treatment methods, this chronic condition can leave lasting marks on one’s life if left untreated.

Causes and Symptoms

Although physicians don’t know for sure what causes Meniere’s disease, the most obvious hint is the presence of an abnormal volume of fluid in the inner ear. 

In detail, the inner ear is made up of a cluster of cavities and passages appropriately dubbed a labyrinth, split into two types: bony (the outside of the inner ear which is made of bone) and membranous (a soft area of membrane).  Therein lies endolymph, a fluid, which must remain at a certain volume, pressure, and chemical composition in order for the hair-like sensors nearby to function.

Several factors may change the volume, pressure, and/or composition of this fluid, thereby provoking an episode of Meniere’s.  These include, usually in some combination:

Improper fluid drainage due to blockage or anatomic variations.

Abnormal immune response

Head trauma

Viral infection

Allergies

Genetic predisposition

Usually, causes like these work in combination with others to cause one or several symptoms of the disease.

Recurring episodes of vertigo.  (Vertigo being spinning, dizzy sensation caused by a vestibular system dysfunction in the inner ear.)  These can last spontaneously, without seeming provocation, and last from 20 minutes to 24 hours.  Severe instances of vertigo may prompt nausea and vomiting.

Loss of hearing.  This may vary from episode to episode, but untreated cases may result in permanent hearing loss.

Tinnitus.  A person experiencing tinnitus will hear a ringing, buzzing, hissing, roaring, or whistling sound in an ear when no such sound is actually present.

Aural fullness, meaning pressure in the ear.

These symptoms may occur in clusters with long or short periods of mild to no symptoms between them.  Since they occur without warning, those with Meniere’s disease are at risk of falling on hard surfaces due to vertigo or accidents while operating heavy machinery or a vehicle, not to mention permanent hearing loss. 

If you experience any symptoms of Meniere’s disease, make an appointment with a doctor.  Treatments include but are not limited to:

Dietary manipulations (most often a low sodium diet with alcohol and caffeine restriction)

Diuretics

Anti-vertigo drugs

Anti-anxiety drugs

Steroids

Anti-histamines

Nutritional supplements

In severe cases, surgery remains a drastic but viable option.  Although potentially debilitating, there is no reason to become house-bound with Meniere’s disease.  Many people life healthful, meaningful lives with the disease.  You may even know some of them: Alan B. Shepard (the first American astronaut), basketball player and NHL forward Steve Francis and Mattias RItola, and possibly Marilyn Monroe and Charles Darwin.

Bio: Maria Rainier is a freelance writer and blog junkie. She is currently a resident blogger at First in Education and performs research surrounding online degrees. In her spare time, she enjoys square-foot gardening, swimming, and avoiding her laptop.