Sleep concerns in children and young people with cerebral palsy in their home setting.

AIMS: The aims were to identify in-home concerns about sleep in children and young people with cerebral palsy (CP) across age and Gross Motor Function Classification Scale (GMFCS) levels. METHODS: This was a retrospective review of clinical notes of 154 children and young people with CP, aged 1-18 years (M = 7.8; standard deviation = 5.4) who received a home-based sleep service. Reported concerns were synthesised, for analysis according to age groups (1-5, 6-13, 14-18) and GMFCS levels. RESULTS: Sixteen factors of concern were derived from the home-based assessment reports. Most children and young people had multiple factors of concern. These varied across age groups and GMFCS levels. Body position was of concern across all age groups, for over 90% at GMFCS levels IV and V, and for 10% at GMFCS level I. Settling routines were of concern for more than 90% at GMFCS levels I and II, but for less than 50% at GMFCS levels IV and V. Settling routines were of concern to over 65% of those under 6 years but less than 25% of those over 14 years. Conversely, pain and pressure care concerned less than 10% of children under 6, and more than 35% of those over 14 years. CONCLUSIONS: Concerns about sleep vary across ages and GMFCS levels of children and young people with CP. Concerns relate to impairment of body structure and function, activity, environment, and personal supports. Multi-disciplinary, home-based assessment and interventions are recommended to address these concerns.

Functional links between thermoregulation and sleep in children with neurodevelopmental and chronic health conditions.

The bi-directional relationship between sleep and wake is recognized as important for all children. It is particularly consequential for children who have neurodevelopmental disorders (NDDs) or health conditions which challenge their sleep and biological rhythms, and their ability to maintain rhythms of participation in everyday activities. There are many studies which report the diverse reasons for disruption to sleep in these populations. Predominantly, there is focus on respiratory, pharmaceutical, and behavioral approaches to management. There is, however, little exploration and explanation of the important effects of body thermoregulation on children's sleep-wake patterns, and associated behaviors. Circadian patterns of sleep-wake are dependent on patterns of body temperature change, large enough to induce sleep preparedness but remaining within a range to avoid sleep disturbances when active thermoregulatory responses against heat or cold are elicited (to maintain thermoneutrality). Additionally, the subjective notion of thermal comfort (which coincides with the objective concept of thermoneutrality) is of interest as part of general comfort and associated behavioral responses for sleep onset and maintenance. Children's thermoregulation and thermal comfort are affected by diverse biological functions, as well as their participation in everyday activities, within their everyday environments. Hence, the aforementioned populations are additionally vulnerable to disruption of their thermoregulatory system and their capacity for balance of sleep and wakefulness. The purpose of this paper is to present hitherto overlooked information, for consideration by researchers and clinicians toward determining assessment and intervention approaches to support children's thermoregulation functions and promote their subjective thermal comfort, for improved regulation of their sleep and wake functions.

Skin Temperatures of Back or Neck Are Better Than Abdomen for Indication of Average Proximal Skin Temperature During Sleep of School-Aged Children.

PURPOSE: The tight association between sleep, body temperature regulation, and patterns of skin temperature change highlights the necessity for accurate and valid assessment of skin temperatures during sleep. With increased interest in this functional relationship in infants and children, it is important to identify where to best measure proximal skin temperature and whether it is possible to reduce the number of sites of measures, in order to limit the experimental effects in natural settings. Thus, the aim of this study was to determine the most suitable single skin temperature sites for representation of average proximal skin temperature during sleep of school aged children. METHODS: Statistical analyses were applied to skin temperature data of 22 children, aged 6 to 12 years, measured over four consecutive school nights in their home settings, to compare single site measures of abdomen, back, neck, forehead and subclavicular skin temperatures (local temperatures) with average proximal skin temperatures. RESULTS: Abdomen and forehead skin temperatures were significantly different (respectively higher and lower) to the other local proximal temperatures and to average proximal skin temperatures. Moreover, the time pattern of forehead temperature was very different from that of the other local temperatures. CONCLUSIONS: Local forehead and abdomen skin temperatures are least suitable as single site representations of average proximal skin temperatures in school aged children when considering both the level and the time course pattern of the temperature across the night. Conversely, back and neck temperatures provide most fitting representation of average proximal skin temperatures.

Typology of high users of health services among a rural medicaid population.

OBJECTIVES: To identify a typology for high system users among a rural Medicaid population that could assist policy makers and providers in better and more efficiently serving this population. DESIGN AND SAMPLE: Exploratory secondary data analysis of a large integrated Medicaid database in a western state. Five hundred and thirty-nine Medicaid recipients receiving 2 or more state services and receiving 10 or more unique medications. MEASURES: Data analysis examining health care use, medication use, and demographic characteristics using SAS to identify patterns of use of services in the population. Results were confirmed with a statewide sample of 2,287 Medicaid users. RESULTS: 3 characteristics-(1) use of 36 or more health care services in a year; (2) no gap in health care service use over the entire year; and (3) use of >12 health care services in 1 month-describe high-risk groups of Medicaid users. CONCLUSIONS: Public health nurses, particularly as case managers and program planners, can look at service use patterns through client histories and their own agency records, in order to identify high-risk groups who may benefit the most from programs that address their support, education, and coordination of health care needs.

Patterns and reliability of children's skin temperature prior to and during sleep in the home setting.

The relationship between patterns of change in skin temperature and sleep is well recognized. In particular, there is a rapid rise in distal skin temperature (Tdistal) and slower rise in proximal skin temperature (Tproximal) prior to sleep onset. The difference between Tdistal and Tproximal is known as the distal-proximal gradient (DPG). Rise in DPG is known as a measure of distal vasodilation, which contributes to the drop in core body temperature (Tcore) that is important to sleep onset and maintenance. Patterns of change in skin temperature before and during sleep are reported for neonates, infants, adults and elderly, however they are not known for school aged children. Therefore, the current observational study aimed to determine the patterns and reliability of skin temperatures (Tskin) and DPG in relation to sleep of school aged children in their home settings. Participants (22 children, aged 6-12) completed the Children's Sleep Habits Questionnaire and used Thermochron iButtons and actigraphy for four school nights in their typical sleep settings. There were evident patterns of Tskin change before and during sleep. In particular, Tdistal was lower but rose more rapidly than Tproximal after reported bedtime and prior to sleep onset. This reflected a timely rise in DPG, and shows that distal vasodilation precedes sleep onset in school aged children. The measures of Tskin and sleep were practical for children in their home settings, and the observed patterns were consistent across consecutive school nights. Environmental and behavioural strategies that manage skin temperature before and during sleep should be explored for their potential as valuable components of treatment of childhood insomnia.

Substance use and abuse in trauma: implications for care.

Trauma long has been associated with substance use and abuse. Caring for trauma patients who are intoxicated, withdrawing, or otherwise experiencing the negative outcomes of their substance use is difficult under the best of circumstances. The burden of this association can be described in many terms, from economic consequences, to health outcomes, to personal problems. Evidence indicates that untreated substance-associated trauma carries with it extended hospital stays, diminished quality of life, repeat emergency department use, and significant mortality and morbidity. No matter how one examines the burden of the association between substance use and trauma, one is left with the awareness that nurses can improve patient care through better screening, assessment, intervention, an evaluation. Because of the complex nature of the association between substance use and trauma, nursing care for these patients is difficult. Fig. 1 provides an overview of the factors to consider when planning care for these patients. Nurses need to focus on issues of temporality, directionality, and correlates of care as they plan for the needs of their patients. Only with careful considerations of these factors can the nurse clarify the confounding clinical presentation of the trauma overlaid on substance use. Evidence supports the need for all trauma patients to be screened for substance use and for those who have positive screens to receive early intervention. Although there is almost universal awarenes of the of the association between substance use and trauma and of the value of screening, screening rates for trauma patients are surprisingly low. Screening for substance use followed by BMI intervention is cost effective and should be implemented routinely. The high prevalence of substance-associated trauma, coupled with the heterogeneous nature of that association, warrants more study, particularly nursing research, to determine best-care practices. More research is needed to increase the understanding of patterns of use, etiologic models, and effective clinical care strategies. The need for this research is heightened by the awareness that substance-associated trauma is preventable, and the risk is modifiable. Nurses, everyday, are faced with the daunting challenge of meeting the health needs of trauma patients who have associated substance use. More research is needed to help nurses separate out the confounding health needs of these complex patients. That work has begun, and it assuredly will continue to support the need for high-quality nursing interventions to improve the health of trauma patients.

Treatment practices and barriers for depression and anxiety by primary care advanced practice nurses in Wyoming.

PURPOSE: The aim of this study was to investigate barriers to treatment and screening related to depression and anxiety and the diagnostic and treatment practices of primary care advanced practice nurses (APNs) in the state of Wyoming. DATA SOURCES: Every primary care APN in Wyoming received a mailed questionnaire asking them about treatment barriers, screening and treatment practices, and attitudes toward depression and anxiety. CONCLUSIONS: Wyoming APNs in primary care routinely identify, evaluate, and treat patients with both depression and anxiety. APNs generally felt positive about treating these patients, although they reported that their patients encounter a number of financial barriers in accessing treatment. Routine screening practices for depression and anxiety were relatively low among the APNs, and they used a wide variety of interventions for these patients. IMPLICATIONS FOR PRACTICE: The findings identify a lack of standardized approaches to assessment, referral, and treatment, especially pharmacologic intervention, and may indicate the need for alterations in the educational preparation of primary providers in order to improve clinical outcomes of treatment for depression and anxiety.

Uniting the family of psychiatric nurses: commonalities and divergences in the nursing lives we lead.

We have created a new column that will focus on the state of psychiatric nursing around the world and on the increasingly important need for all of us, the family of psychiatric nurses, to begin to explore more deeply, and strengthen in more focused ways, the ties that bind all of us. We begin with an article that presents an international perspective on psychiatric illness and mental health promotion and ends by identifying common concerns often shared by the world's psychiatric nurses. Susan McCabe has a unique ability to blend the hard-core facts with a compassionate and intelligent point of view that is compelling and understandable. She is currently an associate professor at the Fay W. Whitney School of Nursing, University of Wyoming. She is an international speaker who presented at many international venues including the Sigma Theta Tau International Nursing Research Conference in the Virgin Islands in 2003 and the International Conference for Mental Health Nurses in Malta in 2002, a gathering that explored and discussed global issues of mental illness and psychiatric nursing. She is also frequently a keynote speaker or presenter at numerous psychiatric nursing conferences and has published extensively in several refereed journals and book chapters. She has expressed a deep desire for other psychiatric nurses to add their voices to hers and to comment and dialogue about our practice lives via the journal.

EMDR: implications of the use of reprocessing therapy in nursing practice.

TOPIC: Eye movement desensitization and reprocessing (EMDR). PURPOSE: To examine the available evidence base for EMDR treatment in psychiatric nursing practice. SOURCES: Evidenced-based research findings, published case and anecdotal reports, and primary source documents on the development of the treatment method. CONCLUSIONS: EMDR use remains controversial. Although it is safe, little is known regarding the mechanism of action of any therapeutic effect; more rigorous empirical establishment of efficacy is needed.

Complementary herbal and alternative drugs in clinical practice.

TOPIC: Complementary and alternative medicine agents (CAMs). PURPOSE: To summarize the current empirical data about the major CAMs purporting to have psychotherapeutic value. SOURCES OF INFORMATION: Extant literature. CONCLUSIONS: Available evidence indicates that CAMs, while generally safe, are not risk free. While CAM use grows, nurses and other health professionals have a limited knowledge base about the action, side effects, and interactions of common CAM agents. Nurses need to increase their knowledge base about CAMs in order to help patients in decision making regarding the use of these agents to treat common psychiatric symptoms.

Advances in the pharmacological treatment of bipolar affective disorders.

TOPIC: Advances in the psychopharmacologic treatment of bipolar affective disorders (BPAD). PURPOSE: To increase advanced practice nurses' ability to match prescribing practices with known etiological factors and the neurobiology of this complex set of disorders. SOURCES: Published literature. CONCLUSIONS: A wide array of pharmacological agents exist that can be useful to manage BPAD symptoms. APRNs play a critical role in helping patients and their families to use these drugs effectively.