December 2021 • Volume 31 • Number 1
2 Nevada LAST in Nation for
Number of Nurses - Impacting the
Healthcare of Nevadans
3 Meet the current and newlyelected
NNA Board of Directors
4 NNA is excited to provide our
RNF readers with this FREE CEU
11 Real Talk About Burnout
THE OFFICIAL PUBLICATION OF THE NEVADA NURSES ASSOCIATION
The Nevada Nurses Association is a constituent member of the American Nurses Association
Quarterly publication direct mailed to approximately 1,000 RNs and LPNs and
delivered electronically via email to 40,000 RNs and LPNs in Nevada
The President’s Message
What is a Nurse’s Ethical Obligation Regarding
COVID-19 Vaccines and Misinformation?
12 Travel Nursing: The World is Now
16 Nevada has Two New Fellows in
the American Academy of Nursing
17 Nursing Fellow Designation
18 Shining Stars Student Event &
18 Time Management
23 What COVID has Taught Me
10 Research & EBP Corner
12 Nurses in the News
13 Antimicrobial Stewardship –
14 NNA Environmental Health
20 Nevada Nurses Foundation
Mary D. Bondmass,
Ph.D., RN, CNE
As of the writing of this
message, we are about to
enter the winter months
and a predicted fifth wave
of COVID-19 in the United
States (CDC, November 2021).
This next wave and some
of the previous COVID-19 surges are being fueled
by misinformation informing unvaccinated persons.
Because most current COVID-19 cases, hospitalizations,
and deaths are from the unvaccinated, one might argue
that another way of stating the previous sentence
would be that unvaccinated people are responsible
for the continuation of the COVID-19 pandemic in our
country. What then, if any, is the ethical obligation
of a nurse regarding COVID-19 vaccinations and
misinformation, given that approximately 30% of
healthcare workers remain unvaccinated through mid-
September 2021 (Reses et al., 2021).
Looking to the leaders from our professional
organization regarding the question posted in this
message may provide some answers. In November
of this year, eight leading nursing organizations,
coordinated by the National State Boards of Nursing
(NCSBN), published a policy brief related to COVID-19
misinformation that nurses may spread about
COVID-19 (NCSBN, 2021). Misinformation is defined in
the brief as "distorted facts, inaccurate or misleading
information not grounded in the peer-reviewed
scientific literature and counter to information being
disseminated by the Centers for Disease Control
and Prevention (CDC) and the Food and Drug
Administration (FDA)" (NCSBN, 2021).
The purpose of this policy brief was “to help inform
and educate boards of nursing, nurses, and the public
about the need for healthcare professionals to uphold
the highest standards of ethics when it comes to
representing their profession” (NCSBN, 2021).
The American Association of Colleges of Nurses
(AACN), was quoted in an interview about the
brief stating, "Nurses are expected to be 'prepared
to practice from an evidence base; promote safe,
quality patient care; use clinical/critical reasoning to
address simple to complex situations; [and] assume
accountability for one's own and delegated nursing
care" (Robbins, 2021). Echoing AACN's sentiment, Liz
Stokes, JD, RN, the Director of the American Nurses
Association (ANA) Center for Ethics and Human Rights
and an expert contributor to the policy brief, indicated
that the policy “elevates the message not only for
nurses but to the public to instill trust and to promote
optimal public health," (Robbins, 2021). Additionally,
nurses can look to the ANA's Code of Ethics for
Nurses (ANA, 2015), which implies that nurses uphold
the truth and the highest scientific standards when
disseminating information about COVID-19 or any
other health-related condition or situation. Moreover,
this policy brief indicates that nurses are professionally
accountable for the information they provide the
public. In addition to causing harm to the public's
health, misinformation by nurses may place their license
and career in jeopardy (NCSBN, 2021).
What is a Nurse’s Ethical Obligation...continued on page 3
current resident or
Mark Your Calendars
• April 2, 2022 - 8th Annual Big Hat “Kentucky
Derby” High Tea
• January 28-29, 2022 - Rural & Frontier Nursing Symposium
Page 2 • Nevada RNformation December 2021, January, February 2022
NNA Mission Statement
The Nevada Nurses Association promotes professional nursing practice through
continuing education, community service, nursing leadership, and legislative
activities to advocate for improved health and high quality health care for citizens of
NNA State Board of Directors
Mary D. Bondmass, PhD, RN, CNE Mary.email@example.com ..............President
Nicki Aaker, MSN, MPH, RN, CNOR, PHCNS-BC firstname.lastname@example.org .......Vice President
Glenn Hagerstrom, PhD, APRN, FNP-BC, CNE email@example.com .........Treasurer
Veloma Wolfe, RN .............................................. Secretary
Arvin Operario, MBA, BSN, RN ..............................Director at Large
Michelle L. Bookout, RN, BSN, MSN, DNP .....................Director at Large
Norman Wright, RN, BSN, MS firstname.lastname@example.org ...................Director at Large
Bernadette Longo, PhD, RN, FAAN ..........................President District 1
Margaret Covelli, DPN, RN Margaret.email@example.com ..........President, District 3
Managing Editor, Linda Bowman, RN, RNFormation@nvnurses.org
Mary D. Bondmass, PhD, RN, CNE
Tracey Long PhD, APRN-BC
Lisa Pacheco, MSN, RN
Bernadette Longo, PhD, RN, FAAN
Vicki Walker DNP, BS RN
Are you interested in submitting an article for publication in RNFormation?
Please send it in a Word document to us at RNFormation@nvnurses.org. Our
Editorial Board will review the article and notify you whether it has been
accepted for publication.
If you wish to contact the author of an article published in RNFormation,
please email us and we will be happy to forward your comments.
Arthur L. Davis
Publishing Agency, Inc.
Nevada LAST in Nation for
Number of Nurses - Impacting the
Healthcare of Nevadans
Lisa Marie Pacheco, MSN, RN, NEA-BC
President, Nevada Hispanic Nurses Association
Nurses are the trusted heartbeat of healthcare. They are the caregiver at your
bedside, showing up in the middle of the night to help your ill family member on
hospice, the one that gives the delicate mixture of compassion and chemotherapy
to your loved one, the one that holds your hand as you go into the operating room,
reassuring you we are there for you.
As a registered nurse for over 30 years, I have been from the bedside to the
board room and many places in between. I know from experience the value of
nurses, the education required, the delicate balance of compassion and science, and
the passion of nurses. I also know that to ensure safe, quality patient care, there
must be enough nurses to care for the patients in Nevada. The nurses caring for
Nevadans in this critical time are physically tired, mentally and emotionally burnt out,
and nearing or at retirement age.
According to the Becker Hospital Review, Nevada ranks LAST in the number of
nurses with 605 nurses per 100,000 people. Nevada needs at least 900 nurses per
100,000 citizens to begin moving forward.
Across the nation, the pandemic of 2020 had nurses realizing their vulnerability
to the disease as the hospitals they worked at were filling with COVID patients.
Hospitals also realized their impending financial crisis in facing COVID. Early
retirement was offered, and we lost over 400 Nevada nurses at one hospital. Other
hospitals report the number retiring from their ranks doesn't match the number of
new hires. The loss of these nurses only compounded the shortage issues, as nurses
were still desperately needed for all the COVID patients.
In addition, we cannot overlook the loss of knowledge. If each nurse had at least
20 years of experience, that would equal over 8,000 years of experience gone! It
is this experience that saves lives. The experienced nurse is the one that trains and
supports novice nurses as they enter the profession. These types of mass exodus of
nurses compound the shortage and ultimately impact patient care.
Often those impacted the most do not realize the nursing shortage is touching
their health. The public is most likely not aware of the nursing shortage, although they
have become more aware during the pandemic. Nevertheless, they most likely do not
understand the extent of the issue. It is important to know that the stated number of
hospital beds available are not the physical beds available for patients. It is a count of
how many beds they can provide staff for. What kind of staff do they need? Nurses.
Many retired nurses leave nursing altogether, and others do not return to fulltime
employment in Nevada. This and similar actions exacerbate the nursing
shortage in Nevada.
When nurses already have too many patients to care for safely, the frustration
and fear of caring for more patients is extraordinarily stressful. This is a heavy
weight to carry for 12-hour shifts. The physical and mental stress on nurses leads to
burnout, nurses leaving, and a vicious cycle of short staffing.
Nursing was behind the eight-ball before the pandemic. The lack of nurses is
not new and has impacted public health in many ways. The fewer nurses there are,
the less impact there can be in inpatient care, clinic visits, school health education,
chronic disease intervention and prevention, and much more.
There are many complex reasons that the nursing shortage continues to grow in
Nevada. The impact is interspersed with increased residents, an aging population, and
the many issues that impact the number of nurses remaining and entering the workforce.
There must be a positive intervention, or Nevada residents will pay a high price. The price
they pay will be with their precious health and possibly their lives. An adequate supply of
nurses is essential to healthy communities, and Nevada deserves only the best.
We must investigate and resolve the exodus of registered nurses in Nevada. The
public has branded nurses, heroes; even heroes can use some help.
It’s time to do the best work of your life!
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December 2021, January, February 2022 Nevada RNformation • Page 3
Meet the current and newly-elected
NNA Board of Directors
Mary D. Bondmass, PhD, RN,
CNE, MSN, BSN
Nicki Aaker, MSN, MPH, RN
Director at Large
Norman Wright, RN, BSN, MS
Director at Large
Michelle L. Bookout, RN, BSN,
What is a Nurse’s Ethical Obligation...continued from page 1
The Nevada Nurses Association, as a Constituent
and State Nurses Association of ANA, is in solidarity
with the eight professional nursing organizations
leading the fight again COVID-19 misinformation.
To conclude and answer the question of our ethical
obligation to dispel misinformation about COVID-19
vaccinations, I say 'yes' and challenge all nurses to arm
themselves with facts from credible scientific resources,
especially when counseling the public or even our
fellow nurses. Additionally, I refer the reader to the
references cited here and also to the article in this issue
by my colleague, Norm Wright, NNA Director at Large,
for the facts about COVID-19 and the need to increase
the numbers of vaccinated persons, if we are to stop
the continuation of this horrific pandemic.
Wishing you all a happy and healthy holiday season;
I am sincerely yours,
President, Nevada Nurses Association
Glenn Hagerstrom, PhD, APRN,
Veloma Wolfe, RN
President District 1
Bernadette Longo, PhD, RN,
President District 3
Margaret Covelli, DNP, RN
American Nurses Association [ANA]. (2015). Code of ethics
for nurses. https://www.nursingworld.org/practicepolicy/nursing-excellence/ethics/code-of-ethics-fornurses/coe-view-only/
American Nurses Association [ANA] (2021). COVID vaccine
facts for nurses. https://covidvaccinefacts4nurses.org/
CDC (November 17, 2021). https://www.cdc.gov/
National Council of State Boards of Nursing [NCSBN],
(November 16 2021). Policy statement: Dissemination
of non-scientific and misleading COVID-19 Information
by nurses. PolicyBriefDisseminationofCOVID19Info.pdf
Reses, H.E., Jones, E. S., Richardson, D.B., Cate, K.M.,
Walker, D. W, & Shapiro, C. N. (2021). COVID-19
vaccination coverage among hospital-based healthcare
personnel reported through the Department of Health
and Human Services Unified Hospital Data Surveillance
System, United States, January 20, 2021-September
15, 2021. American Journal of Infection Control, 49,
pp 1554 – 1557. https://www.ajicjournal.org/article/
Robbins, R. (November 18, 2021). Leading nurses’ groups
unite to combat COVID misinformation. Medscape
Medical News (November 2021). https://www.
Director at Large
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Page 4 • Nevada RNformation December 2021, January, February 2022
NNA is excited to provide our RNF readers with this
FREE CEU course!
Authored by: Tracey Long PhD, MS, MSN, RN,
APRN-BC, CDE, CNE, CHUC, COI, CCRN
NNA Course #001 Polypharmacy Problems and
Section 1: The Problems of Polypharmacy
Section 2: Adverse Effects of Overmedication
Risk for Falls
Section 3: Pharmacokinetics
Section 4: Screening Strategies
The ARMOR Tool
Section 5: Improving Medication Management
Reducing Inappropriate Prescribing
Avoiding Adverse Events and Reactions
Section 6: Implications for Healthcare Professionals
Section 7: Resources and References
Section 8: Post-Test
Polypharmacy: Problems and Solutions
(Image Source: wiki commons images url:
1.0 contact hours
Author: Tracey Long PhD, MS, MSN, RN, APRN-BC,
CDE, CNE, CHUC, COI, CCRN
Course Summary: This course discusses the
problems of polypharmacy, especially seen in the
elderly. Pharmacodynamics will be explained in context
to the aging body. It includes an introduction to
Beer’s criteria, which is used to identify inappropriate
medications for older adults. Measures to improve
safe medication management and adherence will be
When you finish this course, you will be able to:
• Identify the problem of polypharmacy and
summarize the risks of multiple medications.
• Distinguish between pharmacokinetics and
• Explain Beers criteria and additional screening
strategies to identify inappropriate medications
for older adults.
• Identify adverse results of polypharmacy.
• List ways of improving medication management
and avoiding polypharmacy.
(Image Source: https://jeffreysterlingmd.files.
Introduction Case Scenario
Walter, 78-year-old Caucasian male didn’t sound
like himself on the phone while visiting with his son.
As a widow he lives alone after raising his five children
with his wife. In his retirement years he generally
sits home watching TV and reading. His medical
conditions include COPD, diabetes, neuropathy,
hypertension, hypothyroidism, hyperlipidemia, obesity,
and depression. He receives medications for each
of these diseases in addition to over-the-counter
vitamin supplements and herbal remedies a friend
told him about, which total over 12 medications
daily. His primary care provider (PCP) recently added
a new medication for hypertension. In addition to
his PCP, he sees a nephrologist, a cardiologist, and a
pulmonologist. As his vision has worsened so has his
memory of which medications he has already taken
for the day. While talking to his son, the son noticed
his father’s speech was slurred and he couldn’t stay
up with the conversation. Later after work, the son
drove to his father’s home and brought him to the
emergency department at the local hospital. Hours
later in the emergency department, and after multiple
tests, it was determined he had taken too many
medications over the past week and had induced
delirium. Unfortunately, this scenario is all too
common in the United States, especially in the geriatric
population. Nurses need to be aware of the dangers of
polypharmacy, the need for medication reconciliation
at each visit, and proper patient education regarding
Section 1: The Problems of Polypharmacy
The concurrent use of several drugs, defined as
polypharmacy, is a serious and often fatal issue.
Polypharmacy is the use of five or more daily
medications, including over-the-counter (OTC)
medications, dietary supplements, and herbal
remedies. Polypharmacy includes prescribing
more medication than is clinically indicated, using
inappropriate medications, and using the correct
medication for an inappropriate length of time
(Masnoon, et al, 2017; Pazan, et al, 2021, AHRQ, 2015).
Research shows polypharmcy of five or more drugs
creates more potential adverse drug reactions (ADRs),
also called adverse drug effects, as the medications
interact with each other. Increased complications from
comorbidities also impact the combination of various
medications that each is each is trying to treat (AHRQ,
2015; Sirois, et al, 2017). Other challenges include
medical illiteracy, which may lead to nonadherence to
the treatment regimen and prescription instructions,
which may become more confusing to understand
as each medication may have a different schedule.
Medication management is an even greater challenge
for the older adult due to decreasing vision and
dexterity, comorbid conditions, often multiple
caregivers and physicians involved, barriers to financial
ability to pay for medications, nonadherence, declining
metabolism and often memory decline. It is estimated
that nearly half of older adults are taking one or more
mediations that are not clinically necessary. More than
90% of those 65 or older use at least one medication
per week, 58% take five or more, and 12% use ten or
more (Sirois, et al, 2019). Medication errors cause 10-
30% of all hospitalizations annually in older patients
(Parameswaran, 2016). Not only does polypharmacy
create preventable healthcare costs, but significantly
increases morbidity and mortality. It is estimated almost
one third of older home health care patients are taking
a medication that is considered inappropriate for older
people (Cadenas, et al, 2021).
Home medication management systems range
from the careful and methodical to the random
and arbitrary. Elders who have difficulty opening
medication bottles may utilize the “candy dish”
method—dumping multiple medications into one
bowl and fishing out the appropriate medication at the
scheduled time. Some older adults store medications in
shopping bags or shoeboxes while others carefully fill
medication dividers weeks in advance. As the number
of older adults increase, health professionals need to
spend more time evaluating medication management
in the home setting.
The rate of growth in the number and proportion
of older adults is unprecedented in the history of the
United States. Two factors—longer life spans and the
large cohort of aging baby boomers—will combine to
double the population aged 65 and older in the next
twenty-five years. By 2050 the population of age 65
and older is estimated jump to 16% compared to the
9% in 2020 (CDC, 2020). Globally the proportion of
elderly adults is 10.5% and is projected to rise to 1.5
billion people aged 65 and older (CDC, 2020). Proper
use of medications is critical to proper and costeffective
chronic disease management.
Improved medical care and prevention efforts have
contributed to dramatic increases in life expectancy
in the United States over the past century. These
factors have caused a major shift in the leading
causes of death, from infectious diseases and acute
illnesses to chronic diseases and degenerative
illnesses. The incidence of chronic disease increases
with advancing age, causing Medicare expenditures
to rise proportionally. Currently, about 92% of older
Americans are living with at least one chronic condition
and 77% suffer from at least two diseases. (NCOA,
2016). Elders who have developed multiple chronic
diseases will therefore be at greater risk of being
prescribed additional medicine as part of the treatment.
The cost of providing healthcare for an older
American is three to five times greater than the cost
for someone younger than 65. By 2030 the nation’s
healthcare spending is projected to increase by 33%
(CMS, 2019). A large portion of medical expense is
attributable to medication-related problems, which cost
the United States 300,000 lives and $3.6 a year (CDC,
2021). The elderly are at risk because of their high rate
of medication use.
Polypharmacy significantly increases the chance for
medication non-adherence, medication errors, and
drug-drug, drug-food, and drug-disease interactions.
The risk for adverse drug reactions (ADRs) increases as
the number of medications increases. The older adult
who has cognitive impairment, who is living alone, or
who is seeing multiple prescribers, is especially at risk.
In addition, normal changes of aging alter the effect of
medications, so that medications that are appropriate
for younger people may be contraindicated in older
adults due to a lower muscle mass, slower renal
clearance and intestinal absorption.
In the United States, nearly 30% of all hospital
admissions are older adults who have not taken their
medications properly. The classes of drugs most
commonly associated with adverse drug reactions in
older adults include diuretics, warfarin, nonsteroidal
anti-inflammatory drugs (NSAIDs), selective serotonin
reuptake inhibitors (SSRIs), beta blockers, and
angiotensin-converting enzyme inhibitors (ACEI)
(Christensen, et al, 2019; Neuman, et al, 2015).
December 2021, January, February 2022 Nevada RNformation • Page 5
Common Drug Classes Taken in Medicare Patients
• Diuretics (29.5%)
• Opioids (21.9%)
• Nonopioid analgesics
o Gastrointestinal tract
o Respiratory tract
• Steroids (9.7%)
• Ophthalmics (9.6%)
• Thyroid (9.4%)
• Antihistamines (9.2%)
• Hormones (9.1%)
• Anticoagulants (7.0%)
• Muscle relaxants (5.4%)
• Osteoporotic (5.3%)
• Anti-seizure (3.4%)
• Anti-gout (3.2%)
• Anti-neoplastic (2.8%)
• Anti-platelets (1.3%)
• Anti-psychotics (1.2%)
• Alzheimer disease
Apply Your Knowledge:
What could have been done for Walter in our case
scenario to avoid the overdose of polypharmacy and
If you as the healthcare professional interacted
with Walter, it would be helpful to ask for a list of
his medications and what he knows about each
one, including the over-the-counter medications.
Patients should be encouraged to know about all their
medications, what they’re for and what adverse effects
to watch for. For elderly patients, a written list is helpful
and can be created as easily as writing them on a note
card for the patient to keep in their wallet or purse.
Medic-Alert style bracelets should be encouraged,
especially for diabetics.
Case Scenario Continues
Walter’s symptoms of slurred speech, disorientation
and confusion are classic for overmedication. Walter
also experienced drowsiness and slight confusion,
which he mistakenly identified as normal for him
since he is aging. When he woke up from his second
daytime nap, he stumbled to get up to the bathroom
and thought it was just because he was still drowsy.
He had to brace himself against the wall down the hall
to the bathroom and passed it off to being clumsy.
After speaking to his son on the phone he couldn’t
remember what the conversation was about.
Walter was admitted into the hospital to monitor
him for adverse drug effects and medication
adjustments. His hospital bill came to over $5800
for a two-day hospital stay. In collaboration with
the emergency physician, hospitalist and nurses, a
medication reconciliation was completed, and several
medications were discontinued. He was discharged
with instructions to follow up with his primary care
physician. At the follow-up, the primary care physician
realized that the patient had been taking additional
medications he was unaware of that were prescribed
by other doctors. The patient had been taking
medications from various doctors and each physician
was unaware of the additional treatments. Walter
didn’t know what each medication was for and stated,
“my doctors know all about that.”
Section 2: Adverse Effects of Overmedication
Healthcare providers need to be alert to the
potential for polypharmacy and its complications. It is
essential to identify risk factors in the patients we treat
in order to manage medications appropriately.
Polypharmacy increases the risk of potentially
inappropriate prescriptions, cognitive disorders,
falls, hip fractures, depression, and incontinence.
Inappropriate medications complicate polypharmacy
because many of the drugs classified as potentially
inappropriate are associated with adverse drug
reactions (ADRs), some offer little or no advantage over
other, safer drugs, and some have a long half-life in
older patients (Soler and Barreto, 2019).
Risk Factors for Adverse Effects from
Characteristic(s) indicating high risk
Over 75 years of age
Living alone or with an elderly
Taking multiple drugs, OTC, social
• Multiple prescribers, such as
physicians, psychiatrists, dentists,
podiatrists, or nurse practitioners
• Multiple medical problems
• Multiple caregivers
• Poor communication between
older patients and health
• Impaired alertness or memory
• Psychiatric problems
• Inability to take medications as
• Appears weak and with impaired
• Needing a walker or cane
Risk for Falls
It has been well-established that polypharmacy is a
risk factor for falls. An estimated 30% of elderly report
falling each year and falls claim the leading cause of
fatal and nonfatal injuries among adults age 65 and
older (Zaniotto, et al, 2020, Gomez, 2015).
Classes of medications that have been linked to
increased fall risk, especially in the elderly include
nonsteroidal anti-inflammatory drugs (NSAIDS),
benzodiazepines, anticholinergics, opioids,
antidepressants and neuroleptics (Zaninotto, et
al, 2020). It is recommended that each of these
medications begin at low-dose entry levels and titrate
upward slowly as needed. Careful monitoring should
be done within the first 2 weeks of drug therapy with
benzodiazepines, opoids and antidepressants when the
fall and fracture risk is highest.
Assessment tools have been created and even
screening tools for fall-risk prediction in the elderly
that can be used (Bongue, 2010). The Home Health
Quality Improvement organization has gathered helpful
research and created practice guidelines for medication
management. Less well known is that fall risk can
increase significantly in the days following a medication
change. Short-term risk of single and recurring falls may
triple within two days after a medication change.
Key factors involved that need to be assessed for fall
and fracture risk and include the following:
• Postural hypotension
• Use of sedatives
• Use of at least four prescription medications
• Impairment in arm or leg strength or range of
• Ability to move safely from bed to chair or to the
bathtub or toilet (transfer skills)
Another strategy to decrease fall risk is to complete
a medication reconcilliation at every medical office
visit or hospitalization. It is the process of creating an
updated list of all the current medications a patient
may be receiving and includes the dosage, route, time,
purpose and frequency of the drug. Both generic
and brand names should be identified so as not to
duplicate drugs. Many times a patient may be confused
and be taking the drug twice as often as prescribed
because the names are different even when the drug
is the same. Physicians, Physician Assistants, Nurse
Practitioners, nurses and other health care professionals
should be completing this process upon hospital
admission, discharge, home visits, care plan reviews,
annual comprehensive exams, office visits and any time
the patient is being transferred from one facility to
another or has medication changes.
What can you do for your patients to help assess for
and prevent falls?
According to HHQI, you can use many fall assessment
tools including the Get Up and Go test and fall risk tools
such as the Fall MedQIC Fall Risk form, which answers
questions about past falls, the number of medications
prescribed, physical strength, confusion and orientation
status and more to come up with a number that
quantifies the patient’s fall risk. Download the form at:
Practices/BPIPs/Fall-Prevention-BPIP.aspx Teaching the
patient about the purpose of their medications can also
help them evaluate the medication’s usefulness.
Section 3: Pharmacokinetics and Aging
Pharmacodynamics refers to the effect that the
drug has on the body, and pharmacokinetics is the
way the drug moves through the body of a person.
This includes the separate processes of ingestion,
absorption, distribution, metabolism, and excretion
(ASHP, 2020). Age-related changes in physiology can
render an older adult more sensitive to medications,
making polypharmacy a major issue associated
with adverse drug events (ADEs), and increased
hospitalizations. In the elderly, general intestinal
absorption slows as well as renal and the liver’s ability
to effectively metabolize drugs in the first-pass effect
making drugs potentially more toxic in the body.
Pharmacokinetics is the study of the absorption,
distribution, metabolism, and excretion (ADME) of
drugs. Changes associated with aging affect the
pharmacokinetics of medications. Once taken, a
medication must obtain therapeutic levels in the
bloodstream to exert a clinical action. This section
discusses how normal changes of aging and alterations
due to age-related conditions affect the body’s
response to polypharmacy.
Drugs are administered orally, parenterally, or
topically. Drugs taken orally are absorbed in the
gastrointestinal (GI) tract. Drugs administered
parenterally are absorbed by the vascular circulation,
while topical drugs are absorbed by skin or mucosa.
Incomplete absorption of orally administered drugs
occurs mainly because of lack of absorption from the
gut. If a drug is too hydrophilic (easily absorbed by or
dissolved in water) it will have trouble crossing the cell’s
lipid membrane. If a drug is too lipophilic (fat-soluble)
it will not be soluble enough to cross the water layer
surrounding the cell (Le, 2020).
Following administration of a drug by any route,
some fraction of the unchanged drug will reach the
systemic circulation. The amount of drug reaching the
systemic circulation after administration is referred to as
its bioavailability. In general, absorption is unchanged
in later adulthood; however, there are some important
changes to consider related to aging.
Age-related changes can impede absorption
due to decreased blood flow to the tissues and the
GI tract and changes in gastric pH (Le, 2020). In
most older adults this normative change of aging
has no clinical consequence; however, the use of
certain medications can enhance this effect and alter
absorption significantly. For example, proton pump
inhibitors (PPIs) such as omeprazole lower gastric pH
and can inhibit Vitamin B12 absorption (Marieb, 2016).
Elders should take PPIs for the least time necessary to
ameliorate the condition they are meant to treat. An
older adult taking a PPI for a prolonged period of time
should have periodic monitoring of vitamin B12 or take
Chronic illness and age-related variations in plasma
proteins may also cause significant problems with
CEU Course continued on page 6
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medications that are highly protein bound, such as
phenytoin and levodopa/carbidopa. Blood levels
can vary, especially if food intake and dosing are not
consistent. For example, if phenytoin is taken with a
high-protein meal, less medication is absorbed because
phenytoin binds with the protein in the stomach.
Decreased cardiac output in older adults and those
with chronic conditions may reduce subcutaneous
and intramuscular drug absorption, thus affecting the
pharmacokinetics of injectable medications.
Once a medication is absorbed into the
bloodstream, it is distributed throughout the body and
exerts both desired and undesired effects. Distribution
dynamics can be affected by body weight and body
composition, which changes with age. Distribution of
a medication is also affected by impaired absorption,
which influences its onset, strength, and duration.
In general, as we age, total body water and
muscle mass decrease while percentage of body fat
increases. These changes can lead to drugs having
a longer duration of action and increased effect.
Drugs that were effective may become compounded
and overexceed their therapeutic threshold causing
increased side effects.
Protein binding refers to the amount of
medication bound to albumin in the blood. It is
a theoretical concept that explains variability in
pharmacologic distribution. Medications that are highly
protein-bound have an affinity for albumin. A bound
drug is inactive whereas an unbound drug exerts a
pharmacologic effect. Think of the albumin as hands
that hold onto drug—the more albumin, the more
hands, the less active drug available.
Serum albumin comes from dietary protein and is
often decreased in older adults, creating unique issues
with medications that are highly protein-bound, such
as levodopa, warfarin, and phenytoin. Serum albumin
is decreased 15% to 20% compared to the levels in
healthy younger adults and is perhaps even lower
during times of illness (Cabrerizo, et al, 2015). If an
older adult has low albumin, there are fewer “hands”
to hold the drug and render it inactive, leaving more
drug free and active. This is one reason older adults
need a lower dose of medication than younger adults,
especially if the drug is highly protein bound.
Following absorption across the gut wall, drug
metabolism occurs almost entirely in the liver. Liver
metabolism greatly reduces the bioavailability of
medications through a process called first-pass
elimination, which is the rate at which circulating
drugs are metabolized as they traverse the liver
before they reach the systemic circulation. Firstpass
elimination can inactivate some drugs, thus
requiring alternative routes of administration. The
liver can also excrete the drug into the bile. With age
and chronic illness, liver size and hepatic blood flow
are decreased, therefore, dosing of medications that
are significantly metabolized by the liver should be
adjusted. In addition, alcohol use should be assessed
when prescribing any medications to the elderly as liver
health or disease can modify the drug’s effectiveness.
Age-related changes in renal function are an
important factor in the clearance of drugs from the
body. About two-thirds of the population experiences
a decline in creatinine clearance with aging (Denic,
et al, 2016). This can lead to a prolonged half-life for
many drugs and cause the build-up of toxic levels if the
dose and frequency are not adjusted. Renal impairment
requires dosage adjustment of medications that are
metabolized and excreted by the kidneys. There are
two laboratory values commonly used to estimate renal
function: creatinine clearance and glomerular filtration
rate. Blood urea nitrogen (BUN) and creatinine are
commonly tested together and should be annually for
elderly patients taking over five medications.
Pharmacodynamics is the effect of the medication
on the body (Le, 2020). Increased drug actions not
explained by changes in pharmacokinetics are often listed
as pharmacodynamic actions. For example, receptors
and receptor sites in elders, or in those with longstanding
illness, may be reduced or limited in function,
having the effect of increasing or decreasing sensitivity
to drug action. Patients with diabetes mellitus often have
decreased insulin receptors, which impact overall glucose
levels as well as effects on other medications.
Medication is metabolized according to our
individual enzyme systems, which are related to our
genes and DNA. Some reactions to medications
can be predicted genetically. This is referred to as
pharmacogenetics. Pharmacogenetics studies and
predicts how an individual’s genetic inheritance
affects the body’s response to drugs. Known genetic
variants predict that certain individuals will not respond
to commonly used medications such as statins,
antihypertensives, and SSRIs.
Through the use of pharmacogenetics, more
accurate methods of matching a drug with the
appropriate patient will be available, as well as better
determination of the correct dosage of a certain drug
tailored to the individual. Genetic mapping holds
great promise (and will soon be available as a tool) for
predicting diseases and drug reactions, but it is still too
expensive to be widely available.
Section 4: Screening Strategies to Prevent
One key intervention to decrease the risks of
polypharmacy is to use effective screening tools to
identify the appropriateness and purpose of each
medication prescribed. Several tools exist to help
prescribers, which will be discussed. For nurses, who
are not prescribers, your role still includes medication
safety measures by completing a medication
reconciliation and being aware yourself of the purpose
of each drug and how it may interact with others the
patient is taking.
The ARMOR TOOL
The Armor Tool (Hague, 2009) is an additional
attempt to consolidate recommendations into a
functional and interactive tool easily implemented to
address polypharmacy. It uses the mnemonic device
ARMOR to help “shield” patients from inappropriate
prescription of ineffective and possibly harmful
• A: Assess (medications)
• R: Review (interactions: drug-drug, drug-disease,
• M: Minimize (number of drugs and functional
• O: Optimize (for renal/hepatic clearance)
• R: Reassess (functional/cognitive /clinical status;
compliance) for the purpose of improving
This tool takes into account the patient’s clinical
profile and functional status and seeks to balance
evidence-based practice guidelines for pharmacological
treatment suggestions with altered physiological states.
ARMOR approaches polypharmacy in a systematic and
organized fashion with the goal of restoring and/or
maintaining functional status. The tool also emphasizes
quality of life and patient preferences as key factors to
consider when changing or discontinuing medications.
Implementation of ARMOR has the additional
advantage of utilizing a multidisciplinary approach
including input from physicians, nurses, pharmacists,
physical and occupational therapists, and others, in an
attempt to consider the patient in their fullest dynamic.
It is meant to be used in the geriatric patient who is:
• Receiving nine or more medications
• Seen for an initial assessment
• Being evaluated for falls/behaviors
• Being admitted for rehabilitation
In 1991 Geriatrician Dr. Mark Beers and colleagues
published an expert consensus document that
attempted to establish criteria for identifying
medications that are inappropriate for use in
older adults. The Beers criteria should be used to
identify “potentially inappropriate medications” for
older adults, meaning the risk may outweigh the
benefit. More commonly known as Beers List, it is
a set of guidelines, updated in 2020 for healthcare
professionals to improve the safety of prescription
medications for older adults (AFP, 2020, AGS, 2015).
The American Geriatric Society refined the Beers
list in 2020 of medications by identifying drugs that
• Always be avoided (have serious potential
effects and alternative medications are available)
• Are rarely appropriate
• Have indications for use in older patients but are
A number of studies have identified common
medication culprits, including diphenhydramine,
amitriptyline, and co-administered warfarin and
nonsteroidal anti-inflammatory medications (NSAIDs).
Even common medications have been reviewed by the
Food and Drug Administration (FDA) specifically for
safety in the elderly due to polypharmacy (FDA, 2020).
Clinicians and health care providers must stay alert to
assess for ADRs and further to report them to the FDA.
Additional studies implicated pain relievers,
benzodiazepines, antidepressants, and musculoskeletal
agents as the cause of 61% of the incidents of
inappropriate prescribing. The 2020 Beers criteria also
updated the list of drugs to avoid as those having
classic drug-drug interactions such as alpha-1 blockers
used in combination with loop diuretics, which
increases urinary incontinence and the use of three
or more CNS active drugs should be avoided as it
increases the risk for falls.
Medications Potentially Inappropriate for Older
(Android, Virilon, Testred)
cyproheptadine (Periactin) oxaprozin (Daypro)
ethacrynic acid (Edecrin)
ferrous sulfate (iron)
December 2021, January, February 2022 Nevada RNformation • Page 7
Source: Adapted from Beers List 2020.
Numerous studies have helped produce evidence
based practice standards and guidelines for the
most commonly misused medications. However,
inappropriate prescribing is difficult to manage.
There are many medications on the questionable list,
and research constantly identifies more problematic
medications. In addition, deciding when a medication
is inappropriate because of medical condition, genetic
predisposition, medical illiteracy that may lead a patient
to not understanding how to administer the medication
correctly, or age is a complex task. Recognizing the
serious scope of potential dangers to our elderly
requires being alert to polypharmacy when caring for
prescribed. When financial resources are stretched,
elders may be inclined to extend medications by
creative self-administration strategies.
Elders with low income, those without adequate
prescription drug coverage, and those using high-cost
medications are likely to stretch out their medication
supply by skipping doses or extending the intervals
between doses or cutting the pills in half if possible.
Taking a lower-than-prescribed dose is especially
prevalent in patients with multiple medical conditions
using many medications, those prone to medication
side effects, and people who resist prescribed
treatment due to personal or cultural beliefs.
Additionally, taking the time with the patient
to explore nonpharmacological treatments such as
weight loss, exercise and modifications to the diet to
decrease gastric acid production should be considered.
Unfortunately, often the patient and the clinician
rely on pharmacological interventions as behavior
modification is more challenging and often doesn’t
create quick results.
Recommendations designed to improve medication
management in older adults include the following
• Reduce inappropriate prescribing
• Decrease polypharmacy
• Avoid adverse events
• Maintain functional status
• Drug education
• Simple written instructions
• Dose modification (to reduce frequency and
number of different medications)
• Disease education
• Medication reconciliation and review
• Packaging (use of pill boxes, pill blisters to
identify separate doses)
• Side effect management
• Tailored interventions (versus standardized
• Medication self-monitoring (medication diary
and calendar as reminders to take medications)
• Written calendar
• Disease and symptom monitoring
• Integration of provider care
• Use of alternative therapies rather than rely on
• Use of one pharmacy for all medications
Reducing Inappropriate Prescribing
Prescribers should practice the following measures
• Ask the patient to bring all medications being
taken, both prescribed and OTC, to the primary
CEU Course continued on page 8
Screening strategies include the STOPP and
START methods that guide healthcare professionals
to the right treatments and away from potentially
inappropriate prescriptions, respectively, and the
ARMOR tool, to guide in choosing the correct
Tools to help clinicians in the complex issue of
polypharmacy include START (Screening Tool to Alert
doctors to the Right Treatments) and STOPP (Screening
Tool of Older Persons Potentially Inappropriate
Prescriptions) (Hamilton, 2011). These criteria were
developed to address both errors of omission, which
is failure to use an appropriate drug when indicated,
(ie, use of an ACE Inhibitor in a diabetic patient for
renal protection), and errors of commission, which
is incorrectly prescribing a medication that may cause
STOPP/START addresses common prescribing
patterns seen in older patients, including:
• Use of a loop diuretic (furosemide) for ankle
edema with no clinical evidence of heart failure
• Use of tricyclic antidepressants (amitriptyline,
etc.) in a patient with glaucoma (likely to cause
• Vasodilator drugs (nitroglycerine, various forms)
in a patient with persistent postural hypotension
(> 20 mmHg drop in systolic blood pressure with
position change) increasing the risk of syncope
• Duplication within a drug class (opiates, others)
without first optimizing monotherapy and
Other screening tools to help with decreasing
unneeded medications and avoiding the adverse
effects of polypharmacy include the deprescribing
method, using the Medication Appropriateness Index,
using the Good Palliative-Geriatric Practice algorithm
and Meds 360. Each has a website (listed under
resources) for more information.
Case Scenario Continues
During the hospitalization, a nurse met with Walter
to complete the medication reconciliation and discuss
a plan to avoid overmedication. She provided a pill
box that allowed Walter to put his daily medications
in each section so he could tell when the medications
had been taken. The nurse also offered alternative
methods that could be used including a dry erase note
board of the daily medication times, an alarm system
for a phone as a reminder and an updated printed out
list of the names of the medications and why he was
taking each one. They even took a picture of what the
pill box should look like with all the various colored
medications and the pill bottles so they would have a
visual reminder for each week they filled the boxes. He
also now had an idea of what symptoms to look for in
case of any future accidental drug overdosing.
Section 5: Improving Medication Management
Because older adults frequently manage a plethora
of chronic illnesses with medications, it is critical to
ensure that each medication is essential and taken as
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Page 8 • Nevada RNformation December 2021, January, February 2022
CEU Course continued from page 7
care provider who can evaluate all medications
being taken, especially if there are multiple
physicians prescribing medications
• Discontinue medications found to conflict
with Beers or other criteria unless compelling
evidence exists for continuance
• Reinforce use of a single pharmacy for all
• Follow treatment guidelines for chronic and
acute disorders that affect older adults
• Identify methods for payment other than giving
• Provide Medicare prescription information
• Consider generic drugs
• Use pre-filled drug boxes and regular reminders
to improve adherence
• Use combination drugs or tablets and alternative
• Use one-a-day dosing when possible
• Avoid prescribing medications to counteract the
effects of other medications
• Monitor lab results at regular intervals; Assess
for known toxicities at each visit.
• Screen for drug interactions
• Work with your patient to design a system for
remembering the medication regimen (McGrath,
et al, 2017)
Avoiding Adverse Events and Reactions
An adverse drug event (ADE) is defined as “an
injury resulting from the use of a drug.” Adverse drug
events include “expected adverse drug reactions (or
side effects) as well as events due to errors.” Adverse
drug events due to errors are, by definition, preventable
(Coleman and Pontefract, 2016).
In contrast, an adverse drug reaction (ADR)
is “any response to a drug which is noxious and
unintended, and which occurs at doses normally
used in humans for prophylaxis, diagnosis, or therapy
of disease, or for the modification of physiological
function.” Adverse events can be categorized as fatal,
life-threatening, serious, or significant. Events resulting
in permanent disability include stroke, intracranial
bleeding events, hemorrhagic injury to the eye, and
drug-induced pulmonary injury.
This definition implies that there was no error in the
use of the drug. Examples of an injury include:
• A rash or diarrhea caused by an antibiotic/antiinfective
• Gastrointestinal tract events such as nausea,
vomiting, diarrhea, constipation, and abdominal
• Anaphylaxis (a serious allergic reaction) to
• A major hemorrhage from a blood-thinning
• Kidney failure from aminoglycosides (antibiotics
often administered into veins or muscle to
treat serious bacterial infections) (Coleman and
Pontefract, 2016; NCA, 2016).
The great irony in medicine is of giving a patient a
medication for a disease, and then another medication
for its side effects, and following it with another
medication or two or more to counter those side
effects and the negative viscious cycle continues.
Often, any diagnosis indicating an appropriate use
of these medications is absent, or testing confirming
the ongoing need for medication is omitted. The
practice then becomes one of continuation without
questioning. This practice is perpetuated when the
patient does not have a consistent medical provider or
In elders, lower initial doses should be used and
upward titration done at a slower rate than in younger
patients. Use of a single medication within a class
should be optimized before a second medication from
the same class is added, and the patient should always
be carefully questioned to determine that the desired
effect from a medication is achieved.
Section 6: Implications for Healthcare
Despite risks, medications are often needed
to maintain health and well-being. Clinicians can
help ensure medication safety by keeping current
on medication information, reviewing medications
frequently to verify need, and by educating the patient
and family about safe administration practices.
Clinicians have a professional responsibility to
keep informed about new medications and new
research on medications and their use. Often adverse
effects of medications are not known until many
people use the medications over a period of time.
For example, findings from the Women’s Health
Initiative (WHI) in 2008 revealed that a widely used
exogenous estrogen, thought to be safe and beneficial
to postmenopausal women, actually increased risk
of breast cancer (Heiss et al., 2008). That research
changed the once automatic response to prescribe
estrogen for menopausal women. The Food and
Drug Administration (FDA) continues to issue blackbox
warnings on various drug that prescribers must
keep updated on to avoid unnecessary and potentially
One maxim of geriatric care is that it is often more
effective to remove a medication than to add one.
Be aware that herbals and supplements can
interact with prescribed drugs. Most of the “herbal
antidepressants” are chemically related to MAOIs
(monoamine oxidase inhibitors), a drug class that can
result in a hypertensive crisis if a minimum 2-week
“wash-out” interval is not observed before starting an
SSRI. A “wash-out” interval is the time period to allow
the medication to completely be eliminated from the
body and is related to the half-life of active ingredients
in pharmaceuticals. The half-life varies from medication
Patients continue to believe that herbal medications
are essentially safe and they are unaware that serious
problems can arise when herbals are mixed with other
medications. Always inquire about supplements,
herbals, and OTC medications when obtaining a
medication history. Encourage patients to give this
information to their pharmacists as well. Make certain
every medication has a current indication and is within
the expiration period.
Instruct the patient or family to keep a current
record of medications. This list should be in an easily
accessible place in the home or in the person’s
wallet or purse. When working with an older
adult who is cognitively impaired, ask the family to
designate one caregiver to manage the medications.
This representative should be the only person to
communicate with healthcare providers about changes
Consider health literacy and language competence
when teaching the patient or family. Provide legible
instructions in large font. After giving medication
instructions, ask the patient or family member to repeat
the instructions back to you to ensure comprehension.
Cultural differences may further need to be explored as
to how they perceive the need for medication. Some
cultures have a distrust of Western medicine and may
not fully adhere to the instructions or may supplement
with home remedies such as herbal remedies
that may counteract or compound the prescribed
Section 7: Resources
BEERS Criteria 2020 list https://www.aafp.org/
Deprescribing.org and app: gives a deprescribing
Geriatric Age Specific Self Learning Module for
Clinical Staff: www.geronurseonline.org
Good Palliative-Geriatric Practice algorithm https://
Medication Appropriateness Index https://www.
Meds 360 for Populations by Cureatr https://www.
Pfizer Medication Safety for the Elderly: https://
The Portal of Geriatrics Online Education: https://
U.S. Food and Drug Administration Medicines and
You: A guide for Older Adults https://www.fda.gov/
U.S. Food and Drug Administration Educational
Resources: Ensuring Safe use of Medicine https://www.
ARMOR: An Interdisciplinary Approach
to Drug Safety https://www.youtube.com/
Geriatrics-Polypharmacy in the Elderly: By
Balakrishnan Nair, MD. https://www.youtube.com/
Graham Hughes- Medication Awareness
and Strategies https://www.youtube.com/
Medication Administration for the Elderly https://
Medication Use in Older Adults https://www.
Polypharmacy in An Aging Population: https://www.
Pharmacokinetics and pharmacodynamics https://
Webinar: Polypharmacy: It’s a lot different
than you may think! https://www.youtube.com/
We’re Overmedicating the Elderly https://www.
Agency for Health Research and Quality (AHRQ). (2015).
National Healthcare Quality Report, 2015: Patient Safety.
Retrieved from: http://www.ahrq.gov/qual/nhqr05/
American Family Physician (2020). Beers Criteria for
Inappropriate Medication Use in Older Patients: An
Update from the AGS. Jan 1;101(1):56-57. Retrieved from
American Geriatrics Society (2015). Identifying medications
that older adults should avoid or use with caution: the
2015 American Geriatrics Society updated Beers criteria".
New York: Foundation for Health in Aging. Retrieved
May 28, 2017 from http://www.healthinaging.org/
American Nurses Association. (2015). Continuity of Care:
The Transitional Care Model. Online Journal of Issues in
Nursing. Vol 20 (3). Retrieved from http://nursingworld.
American Society of Health-System Pharmacists (ASHP). 2020.
Introduction to Pharmacokinetics and Pharmacodynamics.
Retrieved from https://www.ashp.org/-/media/store%20
Cabrerizo,S., Cuadrars, D., Gomez-Busto, F., Artaza-Artabe,
I., Marin-Ciancas, F., and Malafarina, V., (2015). Serum
albumin and health in older people: Review and metaanalysis.
Maturitas. May;81(1):17-27. Retrieved from
Cadenas, R., Diez, M., Fernandez, N., Garcia,J., Prevalence and
Associated Factors of Polypharmacy in Nursing Home
Residents: A Cross-Sectional Study. Int. J. Environ. Res.
Public Health. 18(4), 2037. Retrieved from https://www.
Centers for Disease Control and Prevention (CDC). (2021).
Health Expenditures. Retrieved from https://www.cdc.
Centers for Disease Control and Prevention (CDC). (2016).
An Aging World: 2020. International Population
Reports. Retrieved from https://www.census.gov/library/
Centers for Medicare and Medicaid Services (CMS) (2019).
Projected National Health Expenses Projection 2019-
2018. Retrieved from https://www.cms.gov/Research-
Centers for Disease Control and Prevention (CDC). (2016). Fall
and Fall Injuries Among Adults Aged >65 Years-United
States, 2014. CDC Weekly. 65(37);993-998. Retrieved
May 28, 2017 from https://www.cdc.gov/mmwr/
Christensen L.D., Reilev M., Juul-Larsen H.G., Jorgersen
L.M., Kaae S., Andersen O., Pottegard A., Petersen
J. (2019). Use of prescription drugs in the older adult
population—A nationwide pharmacoepidemiological
study. Eur. J. Clin. Pharmacol. 2019;75:1125–1133.
Retrieved from https://pubmed.ncbi.nlm.nih.
Coleman, J., and Pontefract, S., (2016). Adverse Drug
Reactions. Clinical Med (Lond). Oct;16(5): 481-485.
Retrieved from https://www.ncbi.nlm.nih.gov/pmc/
Denic, A., Glassock, R., and Rule, A., (2016). Structural and
functional changes with the aging kidney. Adv Chronic
Kidney Disease. Jan; 23(1): 19-28. Retrieved from https://
Food and Drug Administration (FDA). (2020). Bridging the
Gap-Promoting Safe and Effective Prescription Drug Use
in the Geriatric Patients. Retrieved from https://www.
Gomez, C., Vega-Quiroga, S., Bermejo-Pareja, F., Medrano,
M., Louis E. and Benito-Leon, J. (2015). Polypharmacy
in the Elderly: A Marker of Increased Risk of Mortality
in a Population-Based Prospective Study (NEDICES).
Gerontology. 61(4);301-9. doi: 10.1159/000365328.
Retrieved from https://www.ncbi.nlm.nih.gov/
Hague R. (2009). ARMOR: A tool to evaluate polypharmacy in
elderly persons. Annals of Long Term Care 17(6): 26–30.
Heiss G, et al., for the WHI Investigators. (2008). Health risks
and benefits three years after stopping randomized
treatment with estrogen and progestin. JAMA
Le, J. (2020). Overview of Pharmacokinetics. Merck Manual.
Skaggs School of Pharmacy and Pharmaceutical
Sciences, University of California San Diego. Retrieved
Marieb, E., and Hoehn, K. (2016). Human Anatomy and
Physiology. Pearson Education.
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Masnoon, N., Shakib, S., Kalisch-Ellett, L., Caughey, G. (2017).
What is polypharmacy? A systatic review of definitions.
BMC Geriatrics. 17 (1):230. Retrieved from https://
McGrath, K., Hajjar, E., Kumar, C., Hwang, C., & Salzman,
B., (2017). Deprescribing: A simple method for reducing
polypharmacy. The Journal of Family Practice, 66(7):436-
445. Retrieved from https://pubmed.ncbi.nlm.nih.
National Council on Aging. (2016). Healthy Aging Facts.
Retrieved from https://www.ncoa.org/news/resources-forreporters/get-the-facts/healthy-aging-facts/
Neuman, T., Cubanski, J., Huang, J., and Damico, A. (2015).
The Rising Cost of Living Longer: Analysis of Medicare
Spending by Age for Beneficiaries in Traditional Medicare.
Kaiser Foundation. Retrieved May 27, 2017 from http://
Parameswaran, N. Chalmers, L., Peterson, G., Bereznicki, B.,
Castelino, R., and Bereznicki, L. (2016). Hospitalization in
older patients due to adverse drug reactions- the need for
a prediction tool. Clinical Interventions Aging. 11:497-505.
Retrieved May 27, 2017 from: https://www.ncbi.nlm.nih.
Pazan, F., and Wehling, M. (2021). Polypharmacy in older
adults: a narrative review of definitions, epidemiology
and consequences. Eu Geriatric Medicine June;12(3):
443-452. Retrieved from https://pubmed.ncbi.nlm.nih.
Sirois, C., Laroche, M.,Guenette, L., Kroger, El, Cooper, D., and
Emond, V., (2017). Polytpharmacy in multimorbid older
adults: protocol for a systematic review. Syst Rev. May
19;6(1):104. Retrieved from https://pubmed.ncbi.nlm.nih.
Sirois, C., Domingues, N., Laroche, M.,Guenette, L., Kroger,
E, Cooper, D., and Emond, V., Zongo, a., Lunghi, C.
(2019). Polypharmacy Definitions for Multimorbid Older
Adults Need Stronger Foundations to Guide Research,
Clinical Practice and Public Health. Pharmacy. Aug
29;7(3):126. Retrieved from https://pubmed.ncbi.nlm.nih.
Soler, O., Barreto, J. (2019). Community-level pharmaceutical
interventions to reduce the risks of polypharmacy in the
elderly: overview of systemtic reviews and economic
evaluations. Frontiers in Pharmacology. April 02. Retrieved
Zaninotto, P., Huang, Y.T., Di Gessa, G. et al. Polypharmacy is
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(2020). Retrieved from https://bmcpublichealth.biomedcentral.
Section 8: Post-Test
1. The term polypharmacy describes:
a. Medications that are synthetic rather than
b. Use of more than five or more medications daily.
c. Buying prescription drugs at more than one
d. Getting prescriptions from more than one
2. Risk for adverse drug reactions (ADRs):
a. Decreases with age and experience.
b. Increases in women of childbearing age.
c. Decreases in those who consult multiple
d. Increases as the number of medications
3. What contributes to the adverse drug effects of the
a. Aging, polypharmacy and decreased sensory
and cognitive abilities.
b. Sufficient insurance coverage.
c. Poor transportation to physician visits.
d. Lack of desire to adhere to doctor’s instructions
4. The Beers criteria identify:
a. Medications inappropriate for use in older
b. Practitioners who write too many prescriptions.
c. Caregivers who need education in giving
d. Medications with side effects known to be
5. Inappropriate prescribing is difficult to manage
a. Names of medications are often similar.
b. Patients don’t follow directions.
c. There are so many medications that are
questionable for older adults.
d. There are too few drugs from which to choose.
6. The risk for falls:
a. Lessens in those relaxed through use of antianxiety
b. Is generally related to impulsive behavior.
c. May triple within two days of a medication
d. Is decreased when older adults remain in the
7. One way to improve medication management is to:
a. Reduce the total number of medications to no
more than five.
b. Challenge personal or cultural beliefs that
c. Ensure that the patient is taking medications as
d. Encourage “creative” self-administration.
8. Age-related changes that impact bioavailability of a
a. Decreased blood flow to the digestive tract.
b. Increased oxygen levels in the blood.
c. Decreased subcutaneous fat.
d. Increased absorption in the gut.
9. Pharmacodynamics refers to the:
a. Interaction of multiple medications.
b. Way the body metabolizes the medication.
c. Energy released by a medication.
d. Effect of the medication on the body.
10. When taking a medication history:
a. Focus exclusively on prescription drugs.
b. Make certain every medication has a current
c. Explain that herbals and supplements are not
d. Advise against taking over-the-counter drugs.
Click on the link below to find the answers,
complete the evaluation, and receive your
certificate. Thank you!
Page 10 • Nevada RNformation December 2021, January, February 2022
Research & EBP Corner
Mary Bondmass, Ph.D., RN, CNE
This RNFormation feature presents abstracts of
research and evidence-based practice (EBP) projects
completed or spear-headed by nurses or student nurses
in Nevada. The focus is on new evidence (i.e., research)
or the translation of evidence (i.e., EBP) in Practice,
Education, or Research. Submissions are welcome
and will be reviewed by the RNF editorial board for
publication; for consideration of your work, please send
an abstract submission to email@example.com
In this issue of RNFormation, the focus of Research
and EBP Corner is on the multidiscipline health care
providers who presented evidence in poster format
at UMC’s 4th Annual Research Empowerment Day.
Posters were peer-reviewed, and first, second, and
honorable mention awards were presented. Due to
COVID19, this year's event was virtual, and because it
was recorded, nurses can receive free CE for viewing
all the posters and completing the evaluation. Use this
link https://www.umcsn.com/VirtualPosterDay/ or use
the QR code on the winners-list below to access all
the poster submissions. Posters receiving a First Place
designation in each of the five categories are presented
Completed Clinical Projects
can point you right to that perfect
Free to Nurses
Easy to Use
E-mailed Job Leads
December 2021, January, February 2022 Nevada RNformation • Page 11
Real Talk About Burnout
Bree Becker, MSN, NP-C, RNC-MNN
Reprinted with permission from
Georgia Nursing April 2021 issue
Research & EBP Corner continued on page 12
Recently I was putting my son to bed. We read one
of my favorite children's books, The Giving Tree by
Shel Silverstein. Despite reading this story many times,
I was struck by the visceral sadness of the tale. It’s a
children's story with a simple plot. A boy is climbing a
tree (personified as a woman), and he happily swings
from her branches, devouring her apples and enjoying
all the comfort the tree provides. Readers follow the
boy on his journey through adolescents, adulthood,
and then as a tired elderly man. Throughout his life, the
boy takes, and the tree gives. Whatever his needs are
at each stage of his life, the tree is happy to provide
a piece of herself to help. She gives her branches for
shade, then her wood to help build a house. Finally,
with her resources depleted, she dwindles to a stump.
And even then, she manages to provide a place for the
boy, who is now an elderly man, to sit.
I realized the tree's exhausted state represents how
many nurses feel. For us, The Giving Tree is an all
too familiar story. The depleted tree personifies the
exhaustion and burnout most of us are experiencing
today. I receive daily articles that reference burnout
and company ads that offer a solution specifically for
me. But at the end of the day, the responsibility of
executing the proposed solution falls back on me.
"Here is something else for you to do to help you
with your burnout." Burnout was identified as an issue
decades ago, and is only getting worse. Despite public
awareness, nurses are still being asked to do more
with less. The pandemic highlighted nurses struggle
with the mental and physical toll of the job. Instead
of offering a cliche intervention for burnout, I want to
have a real conversation. Let’s ask hard questions. Let’s
stop pretending we know how to fix a problem that’s
plagued us for decades.
My personal problem with many of the resources
designed to address burnout is that it creates more
work for me. Now don’t get me wrong, I like learning
about yoga and I actually believe things like exercise
and diet have a positive effect on your mental health.
But the reason I feel exhausted as a nurse is not
because I don’t exercise or eat healthy. I have always
adopted a healthy lifestyle even before I was a nurse.
I do think that my healthy lifestyle allowed me to push
myself physically and mentally as a nurse. The long
hours, constant stress, and erratic schedule didn’t catch
up with me for a decade. But I eventually burned out.
And no amount of green smoothies or yoga could cure
me. I found myself becoming overly cynical, feeling like
I was not making an impact, and dreading work.
Burnout is the symptom of a larger disease: it’s the
result of poor processes within institutions and the
larger healthcare system overall. Nurses experienced
burnout long before this pandemic. The pandemic
has only cast a light on an ugly truth most of us have
been aware of for a long time. If burnout is not the
healthcare worker’s problem alone to solve, who is
responsible for solving it?
Here are real problems, I don’t have the answers.
But I know we are too fragile to continue this way.
Last year, I was clueless about the horror the world
was about to experience due to COVID. While I knew
our medical system was broken and that healthcare
workers were being stretched beyond capacity, I didn’t
realize what a pandemic would do to our profession. I
didn’t realize how vulnerable we are. The future is now.
The what-ifs and maybes are reality. We can’t afford to
hobble along anymore. We have to be willing to talk
about the real issues and the first step is asking hard
I know I can’t fix this today and I know I can’t fix this
alone. To me, it’s a fight worth fighting. And maybe,
by the time I retire, nurses won’t suffer the way I’ve
seen my peers suffer over the last decade. And maybe,
unlike The Giving Tree, nurses won’t give until we
are depleted and we will be empowered to care for
ourselves the way we care for others.
Page 12 • Nevada RNformation December 2021, January, February 2022
Research & EBP Corner continued from page 11
Proposed Clinical Projects
The World is Now Open
Tracey Long PhD, RN, APRN-BC, CDE, CNE, CCRN
Nurses in the News
Medical Missions at Home
Tracey Long PhD, RN, APRN-BC, CDE, CNE,
Your passport may be dusty
and hard to find but take
heart. The heart of a nurse
is giving and serving, and
many nurses look forward to
volunteering for international
medical service work known
as medical missions. During
COVID-19, all international
medical missions were generally
cancelled, which frustrated
those with wanderlust. Medical
missions are opportunities for nurses and allied health
professionals to turn and reach outward to those who
have barriers to medical services including those within
our own state of Nevada. The term mission may hint
at a religious purpose, but not all organizations are
founded in a religious purpose. From religious groups
to for-profit and not-for-profit organizations, dozens
of entities need help from nurses. When a worldwide
pandemic halted international travel, nurses still found
ways to offer volunteer medical service work in our
own communities of Nevada.
In Southern Nevada, nursing students and nurses
found service opportunities through Catholic Charities
offering food, clothing items and even flu shots
in stand-alone clinics brought to neighborhoods.
Opportunity Village in Las Vegas, Nevada welcomed
nurses and nursing students to assist their special needs
workers with health clothing drives and hygiene kits.
Three Square used nursing students and nurses from
Chamberlain, Arizona College (AZC) and Nevada State
College to help organize food bags for thousands of
children who are food insecure. Nevada’s Homeless
Connect in Southern Nevada was challenged by not
being able to offer the usual annual event focusing
on homeless resources that usually served over
3000 people in one day during the pandemic, so
they recreated themselves by offering smaller popup
clinics in neighborhoods where homeless are
more concentrated throughout the valley. “I never
realized how many homeless people the City of Las
Vegas has. People think of Las Vegas as a rich city of
entertainment but forgets that as a major metropolitan
city we also have big city problems like homelessness”
stated Susan a nursing student at AZC. “I really felt like
I could connect with the public as I worked with others
in the food pantry as a volunteer public health nurse”
explained Raychel from CSN school of nursing.
If you’re looking for ideas to give back to your
own community in Nevada, one resource is exploring
volunteer opportunities at www.justserve.org where
organizations list their needs and try to match people’s
skills. Positions can be short-term and vary on the
age, gender, skills, and interest of those you want to
serve. There are medical needs but also groups looking
for volunteers to teach English to new immigrants,
organizing community food pantries, reading to
children, serving in soup kitchens and more. And the
best thing about these service opportunities, is that
you don’t even need your passport! For those who are
interested in serving abroad as the world opens again,
contact Dr. Tracey Long about international medical
missions available for 2022 at longforhome@gmail.
Happy New Year
from the Board and Staff of the
Nevada Nurses Association
The best kept secret of travel nursing has been
exposed! Travel nursing has been an option for the past
several decades but with the higher demand for nurses
across the country during COVID-19, nurses have
begun to explore this job alternate at record numbers.
Travel nursing is designed in generally 13-week
contracts in a location other than the nurse’s primary
home city and allows the nurse the opportunity to
travel to a new state, explore new areas, meet new
people, expand their repertoire of work experience,
and offer freedom of choice.
Benefits of travel nursing begin with the higher hourly
rate, which can vary based on specialty, work hours and
unit. As always, critical care nurses will generally earn
the higher hourly wage from $50/hr to $110/hr and are
in high demand across the nation. Hospitals offer travel
nursing positions in every specialty. A popular benefit to
travel nursing is being able to live in a new city shortterm
without a huge commitment to move everything
you own. The freedom of choosing when and where
to work is a strength for travel nurses. The call for
adventure and meeting new people in new places
can be invigorating. Even nurses with children may
choose to become a travel nurse and have control over
home-schooling and offering children a variety of life
experiences. Travel nursing is available for floor nurses,
specialty units, management and even leadership. It
can broaden your perspective and work experience and
advance your career.
Disadvantages of travel nursing can include being
responsible for your own travel, accommodations,
taxes, moving expenses, medical insurance, and
certifications. Having to become oriented to a new
city, hospital facility, and unit can also create physical
and emotional stress but that may be traded with
the excitement of adventure for those who are ready.
A real concern is the possibility of a cancelled or
shortened contract, which may place undue stress for a
stable monthly budget.
Nurses have many dozens of travel companies to
choose from but must be aware of the variations and
details within a contract including housing, bonuses
for signing-on, health benefits and even work settings.
Doing research about the different companies available
is important to confirm exactly what they offer in
the contract before you sign. Health insurance and
retirement benefits vary based on different companies.
Temporary housing is available and can be negotiated
through the travel nursing agent. Companies that
specialize in temporary housing have also grown with
the increased need for traveling healthcare professionals.
Not only can nurses work as a travel nurse, but
other allied healthcare professionals can also work in
travel assignments. Many couples who both work in
healthcare have found adventure and variety as they
both accept contracts together in a new city. Spouses
of travel nurses who can work remote or are retired
can also enjoy the change in venue and scenery. Some
couples even travel in motor homes across the country
to explore our great nation. International travel nursing
is also an option if available, but contracts are less
common as they usually focus on volunteer medical
service trips, tourism or cultural exchanges.
For those interested in learning more about travel
nursing, a unique conference that focuses exclusively
on travel nursing comes to Las Vegas, Nevada each
year in the Fall called TravCon.
A Newbie BootCamp offers a full day of training on
how to become prepared in all you need to know to have
success. For more information go to https://travcon.org/
Topics from the conference address clinical updates,
housing, personal tax and retirement strategies, medical
Spanish, BLS, ACLS certification and a huge expo of
vendors specializing in travel nursing and professionals.
Founders of the conference have been traveling nurses
for decades and the conference has expanded to include
all healthcare professionals looking to work in temporary
travel assignments. Throughout the year, a traveler’s
podcast can educate and excite you about the potential
When you find you are working with a travel nurse
from another state, remember to be kind as they adjust
to the new setting. Demonstrate the spirit of Nevada by
welcoming them and asking them about themselves.
Nurses can learn from each other and improve our own
clinical skills and networking when we embrace the
diversity of others around us, including travel nurses
from our own country.
December 2021, January, February 2022 Nevada RNformation • Page 13
Antimicrobial Stewardship – Infection Prevention
The Greatest Medical Experiment Ever Done – Part 2
Norman Wright, RN, BSN, MS
My first article about Coronavirus was titled,
Coronavirus, Ebola, Zica, Flu and PDRO. It was written
in February 2020 and appeared on page 10 in the May 2020
issue of RNformation.
So much has changed since then, both in our lives, and
how we are combating the virus.
Although initially touted as a cure, Hydroxychloroquine
was not. By December 2020 Monoclonal Antibody Therapy
was shown to reduce deaths, former President Trump was treated and quickly
recovered. Other advances occurred, the latest on November 5, 2021 when
Pfizer applied for emergency use of a pill that claims 89% effectiveness to reduce
hospitalizations and death after infection. (1)
The media quickly latched on to this “news” and it was broadcast widely.
Perhaps this new pill is the cure, perhaps not, but all of these new variables must be
included in; “The Greatest Medical Experiment Ever Done”!
We are still learning new ways to prevent hospitalization and death after
infection, but despite these advances, the 7-day average of daily deaths in the USA
from November 13 to November 19, 2021 was 1,056 deaths a day and most of the
deaths were among the unvaccinated.
Briefly, a medical experiment includes two, or more, different cohorts. One
cohort receives a medication or intervention; others are given a placebo or
no interventions. Most medical experiments include only two variables, but
our experiment encompasses numerous variables, including vaccines, masks,
quarantines, geography, time, variants, and more.
It is common knowledge that three vaccines are available in the USA; Pfizer,
Moderna and the J&J Jansen one-shot, and each has a different level of efficacy.
According to the CDC the fully vaccinated are over 10 times less likely to become
hospitalized or die, but the CDC compiles data from all 50 states. Removing the
geographic variable, let’s explore local data from the Southern Nevada Health
District (SNHD), which has established two cohorts, anyone fully vaccinated with any
of the three vaccines vs. anyone who is not fully vaccinated. Booster shot data is not
There are numerous ways to skew statistics and one way is to use an extended
timeline that includes data accumulated before an intervention, e.g. the vaccines
was available, and by September 2, 2021 anyone over 12 years old who wanted a
vaccination could be vaccinated.
The SNHD documents that, on September 2, 2021, there were 7,642 COVID
cases and 112 deaths in the vaccinated cohort. The unvaccinated cohort had
297,767 documented cases and 5,143 deaths. During the next eleven weeks until
November 18, 2021, - the cumulative number of cases among the vaccinated grew
to 12,898 and deaths increased to a total of 195.
On November 18th the cumulative number of cases among the unvaccinated
cohort was 326,695 and deaths increased to 5,849. As documented above,
treatment options after someone tests positive have improved. However despite
medical advances, during this eleven week timeframe, there were 83 additional
deaths among the vaccinated and 706 in the unvaccinated cohort. Simple
subtraction shows there were 623 more deaths and 23,673 more cases among the
This chart makes the numbers easy to understand.
One does not need to be a statistician to see the unvaccinated are far more likely
to be infected and die. Yet according to Becker’s Hospital Review, as of November
19, 2021 only 54% of Nevadans are fully vaccinated (3) .
The amount of disinformation regarding vaccination is massive ranging from
the COVID vaccines change your DNA; make you magnetic, the vaccine installs
computer tracking chips in us and ballooned the testes of a man living on a
Caribbean island. Addressing these and similar falsehoods is ludicrous, so, let’s focus
in on disinformation that purports the vaccines contain aborted fetal tissue, which is
On December 11, 2020 the Committee on Pro-Life Activities United States
Conference of Catholic Bishops said:
"In view of the gravity of the current pandemic and the lack of availability of
alternative vaccines, the reasons to accept the new COVID-19 vaccines from Pfizer
and Moderna are sufficiently serious to justify their use, despite their remote
connection to morally compromised cell lines. In addition, receiving the COVID-19
vaccine ought to be understood as an act of charity toward the other members
of our community. In this way, being vaccinated safely against COVID-19 should
be considered an act of love of our neighbor and part of our moral responsibility
for the common good."
I encourage anyone who refuses to be vaccinated against COVID based on
religious reasons to read the entire seven page statement (4)
On August 18, 2021 Our Sunday Visitor contained this quote from the Pope,
“Being vaccinated with vaccines authorized by the competent authorities is an act of
love. And contributing to ensure the majority of people are vaccinated is an act of
love — love for oneself, love for one’s family and friends, love for all people,” (5)
The Pope has been COVID vaccinated and he has repeatedly promoted getting
vaccinated with either the Moderna or Pfizer vaccine and received his booster dose
in October (6) . And, yes, getting vaccinated is an act of love.
Adding Additional Variables to our Experiment
COVID-19 not only impacts Nevada, but the entire world. In March 2020 my wife
and I were scheduled to vacation in New Zealand but our trip was cancelled when
New Zealand abruptly closed its borders due to the novel Sars-Cov-2 virus. Since
then I have followed COVID-19 trends in other areas of the world, including New
Zealand and Japan, a country we visited in 2008.
Comparing the United States with these other two nations provides a
unique sample with two cohorts living in the Northern and one in the Southern
Hemisphere, which removes the summer vs. winter variable.
New Zealand immediately declared strict lockdowns, quarantines, and restricted
travel from the beginning. These interventions lasted for an extended amount of
time and were gradually reduced when COVID was contained at minimal to zero
Japan also initiated quarantine and border restrictions and in Japan it is, and has
been, common for people to wear masks when someone feels “off” or thinks they
may be coming down with a cold, or some other illness, but their symptoms are
not yet seriousness enough to stay home from work, or school. The Japanese wear
a mask to protect others and Japan never had to deal with “No Mask Nevada”, or
“It’s My Body, My Choice Not to Wear a Mask” campaigns.
In the United States we are divided into different political and ideology factions.
We are a nation that continues to fight each other, instead of the virus, and the
differences in the number of cases and deaths in Nevada and the United States as a
whole, when compared to Japan and New Zealand, is stunning.
Nevada’s death rate is 2,559 deaths per million people, which is higher than the
United States number of, 2,375 per million. (7)
Compare that with Japan where only 145 deaths per million occurred, which
includes a spike after the Olympics - and with New Zealand, which only had only 5
(five) deaths per million population as of 11/17/2021.
This chart documents the population of each and shows the number of cases,
cases per million, deaths, and deaths per million people. (8)
Cumulative Infections & Deaths on November 17, 2021
The data is indisputable that vaccines and other public health infection
prevention measures protect against contracting Sars-Cov-2 and prevent COVID-19
complications of hospitalization and death if a breakthrough infection occurs. I find
it amazing and disheartening that so many conspiracy theories about COVID and
Circling back to my article, Coronavirus, Ebola, Zica, Flu and PDRO, written in
February, 2020, be reminded that PDRO stands for, Pan Drug Resistant Organisms.
The problem of Antimicrobial Resistance (AR) remains an ongoing microbiological
threat that we continue to face, but AR has largely been ignored.
In February 2020 I believed the COVID pandemic would have been resolved
long before now and it scares me when truthful information about COVID that is
so clearly and readily available, that some, too many, continue to believe the lies
and misinformation that “experts” on certain TV, radio and social media outlets
We, as nurses, have the responsibility to ensure accurate information is advanced
and to dispute disinformation. If we fail to learn and document the truth - microbes
will cause chaos.
We, as nurses, must use our critical thinking abilities to sort fact from fiction. We
need be open to dialogue and understand our colleague’s point of view.
Do your own research and please communicate any ideas and interventions you
have to help control COVID. We are all in this together and must work in unison to
defeat the virus before it mutates and over powers our ability to control it.
Page 14 • Nevada RNformation December 2021, January, February 2022
NNA Environmental Health Committee
Drought & Water Quality in Nevada
The ongoing drought and occasional floods in
Nevada are some of the climate-related threats that
are affecting the state’s 3 million residents. According
to the National Integrated Drought Information System
(NIDIS), 100% of Nevada this year is experiencing
Moderate Drought resulting in decreased forage for
animals and increased fire danger. In addition, 95%
of the state, including northern Nevada from Washoe
county to Elko County, is experiencing Severe Drought.
This climate condition results in increased bear activity
and other wildlife encroaching into residential areas.
Desert plants need to implement reproductive survival
mechanisms. However, as surface water levels decline,
water clarity improves (e.g. Lake Tahoe; NIDIS, 2021).
Also, 58% of the state including the Las Vegas area
is experiencing Extreme Drought, a condition that
affects agricultural productivity. Alfalfa and hay yields
are decreased, pasture conditions are very poor, and
some producers are selling off their livestock (USDA &
NIDIS, 2021). Furthermore, central Nevada (25% of the
state) is considered to have Exceptional Drought (Fig.1).
Water reservoirs are extremely low causing boat ramps
to close, and limits on trout fishing. Some ground
water sources are affected, and wildlife populations
have been declining. In these drought conditions, the
viability of the ecosystem is threatened (NIDIS, 2021).
Since human health and well-being are embedded in
the natural world, drought can affect health in a variety
of interesting ways.
There is an abundance of scientific publications
that address Earth’s rising atmospheric carbon dioxide
(CO2), temperature extremes, exceptional weather
events, and escalating global air pollution. However,
the relationship of drought and subsequent heavy
rainfall is often not addressed as it relates to human
health apart from the consequences of a disaster.
Surface Water Quality in Nevada
It is important to understand the relationship and
impacts on health from heavy rain in a geographic
region with sustained drought. Ongoing drought
can impact existing surface water systems from the
extreme of drying up lakes and riverbeds, to having
more concentrated contaminates within the water as
levels drop. These water systems provide the source of
drinking water for both wildlife and people. Fresh clean
water is vital for life, and intricately related to health.
Yet, when a region has had drought, any subsequent
rainfall can have sweeping effects. Land with forest
or vegetation coverage has a great capacity to absorb
rainfall and therefore is less vulnerable to water erosion
during heavy precipitation. However, rising atmospheric
levels of CO2, likely associated with planetary climate
change, can alter the transpiration process of foliage
resulting in more water run offs into rivers (Retallack &
Conde, 2020). To add to this dilemma for Nevada, our
state is unique because when precipitation falls across
the basins and ranges, it doesn’t drain to the ocean.
Being an interior drainage ecosystem, stewardship
of the watersheds is essential for life. The recent and
historical wildfires across the state have left scars
of vegetation loss that can influence the health of
watersheds when extreme rainfall events occur. All
these factors can contribute to water quality.
The goal of the U.S. Clean Water Act is to restore
and maintain the chemical, physical and biological
integrity of surface waters. The Nevada Division of
Environmental Protection (NDEP) implements the
Navajo Area Indian Health Service
Gallup Service Unit
We are hiring Registered Nurses!
Healthcare facilities bordering the Navajo Nation
Gallup Indian Medical Center (Gallup, NM)
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Clean Water Act in Nevada, with oversight from the
U.S. Environmental Protection Agency (EPA). NDEP
is required to assess the quality of surface waters
biannually. In the most recent report (NDEP, 2020), of
the 700 waterbodies assessed across the state, only
30.5% are meeting standards for all or some beneficial
uses. Impairments in water quality are graded in the
report with the most common being high phosphorus
levels, excessive temperature, Escherichia (E.) coli,
mercury in fish tissue, iron, and total dissolved solids
(TDS). In addition, impairments affecting the beneficial
uses of the water source can include (a) protection
of aquatic life, (b) recreation with contact (e.g.,
swimming), (c) irrigation for agriculture, (d) watering of
livestock, (e) municipal or domestic water supply, and
(f) fish consumption. High levels of phosphorus can
lead to excessive growth of algae in water systems,
which can affect their recreational use and aquatic
life. According to the 2020 report the presence of
manganese, selenium, and other metals are the cause
of about half of all impairments to the beneficial use
of water for irrigation purposes. Boron and fluoride
are responsible for nearly another half of irrigation
impairments. These impairments can limit a crop’s
growth and overall productivity, which affects food
supply and the economy.
Despite these challenges, Nevada is active in its
watershed management to achieve its water quality
goals. Watershed management is a way of planning
and monitoring water uses and the resulting problems
in a region. The river basin has been adopted as a
management unit and is part of a paradigm shift in
terms of water resources management and planning
systems. A river basin is a large geographical region
that includes a main river, its tributaries (streams,
creeks, etc.) and springs (Fig. 2). This area is defined by
natural dividers, where the topography of the terrain
guides to where the waters will flow, and usually
converge to a single mouth, located at the lowest point
of the relief. Cities and settlements are often located
near rivers in basins and are therefore susceptible to
The 2020 NDEP report highlights impairment results
from existing river basins in Nevada. For example, in
the North, the Snake River and Humboldt River Regions
have impairments of 40.7% and 39.6%, respectively
(2020). In the Western part of the state, the Truckee
River Region is only 28.0% impaired. Yet, the nearby
agricultural and livestock areas of the Carson River
(62.0%) and Walker River Regions (64.0%) are the
highest impaired areas in the state (2020). Nearly half
(48%) of the waterbodies of the Colorado River Region
in the south are impaired.
Groundwater in Nevada
Groundwater accounts for 46% of the state's total
freshwater supply and most public drinking water
supply systems rely upon it. The waters of underground
sources (aquifers), accessible through shallow or
artesian wells, may have their quality altered if there is
contamination of the soil/rock near the drilling area or
even in its recharge areas. According to the NDEP, there
are numerous pollutants that can contaminate ground
water. Some contaminants are a result of improperly
disposed of common household products like cleaning
products, medicines, waste oil, pet waste, fertilizers,
and pesticides. Others may be used or generated by
businesses such as dry cleaners, salons, golf courses,
landfills, or petroleum storage and handling facilities.
These contaminates can migrate through the soil or
enter waterways, especially during heavy rainfall events
In Nevada, the Integrated Source Water Protection
Program is designed to protect public water supply
wells and springs. Assistance is available to develop
Water Protection Plans for communities for their water
wells. The EPA does not regulate private wells, nor
does it provide any recommended criteria or standards
for these wells. On the other hand, NDEP encourages
residents with wells to test their water and use
laboratories that are certified for testing drinking water
(see Resources). In fact, they even offer assistance with
how to interpret your home’s water testing results.
Health Effects from Contaminated Floodwater
Nevada’s nurses are key to spreading pertinent
December 2021, January, February 2022 Nevada RNformation • Page 15
NNA Environmental Health Committee
health information to the public. It is important to avoid contact with floodwater.
This is because of potentially elevated levels of contamination associated with raw
sewage and other hazardous or toxic substances that may be in the floodwater (see
Table 1). The EPA and the Department of Health and Human Services urge anyone in
contact with flood waters to follow these guidelines:
• Avoid or limit direct contact with contaminated floodwater.
• Wash your hands frequently with soap and clean water, especially before
drinking and eating.
• Do not allow children to play in floodwater or play with toys contaminated
• Properly treat cuts or open wounds and seek medical care as necessary.
• Wash clothes contaminated with flood or sewage water in hot water and
detergent before reusing them.
• Do not bathe or swim in water (rivers, streams & lakes) that may be
contaminated with floodwater. It may contain wastewater, sewage, or toxic
• Early symptoms from an exposure to contaminated floodwater may include
upset stomach, intestinal problems, headache, and other flu-like discomforts.
Those affected should seek medical evaluation.
References & Resources
Anderson, D. (2016) Pharmaceutical waste: Safe disposal. RNFormation, 25(3),14-15.
Desert Research Institute (2021). Tahoe Rain or Snow Project. https://storymaps.arcgis.com/
Get Your Drinking Water Tested: https://ndep.nv.gov/water/lab-certification/drinking-watertesting
Integrated Source Water Protection for Nevada: https://ndep.nv.gov/water/source-waterprotection/integrated-source-water-protection
National Integrated Drought Information System (NIDIS). https://www.drought.gov/states/
Retallack, G.J. & Conde, G.D. (2020). Flooding induced by rising atmospheric carbon
dioxide. GSA Today, 30(10), 4-8. https://doi.org/10.1130/GSATG427.1
The Nevada Division of Environmental Protection (2020). Nevada 2016-2018 Water Quality
Integrated Report: https://ndep.nv.gov/uploads/water-wqm-docs/IR2018_FinalEPA_
United States Department of Agriculture (USDA): https://www.drought.gov/about/partners/
United States Environmental Protection Agency:
Flooding https://www.epa.gov/natural-disasters/flooding & Flood Waters: https://www.cdc.
Bernadette M. Longo, Ph.D., RN, APHN-BC, CNL, FAAN
Chair, NNA’s Environmental Health Committee
Figure 1. The U.S. Drought Monitor started in 2000. Since 2000, the
longest duration of drought (D1–D4) in Nevada lasted 269 weeks beginning
on December 27, 2011 and ending on February 14, 2017. The most intense
period of drought occurred the week of July 7, 2021, where D4 Exceptional
Drought affected 40.63% of Nevada’s land. Credit: NIDIS
Don’t Flush those things!
Many medications can be detected above the safety limits in rivers, groundwater
and even sea water. These include hormones, antihypertensives, analgesics,
antidepressants, antibiotics (animal & human use), anticonvulsants, and stimulants.
Such substances, cause significant effects on the metabolism of aquatic organisms
and affect the health of humans through chronic exposure. Antibiotics in the
ecosystem are related to the development and dissemination of resistance to
antimicrobials. Sewage treated with conventional technologies can’t always
remove what is known as emerging pollutants, present in drugs, beauty products,
fragrances, and hormones.
Reference: Anderson, RNFormation 2016
Figure 2. The Water Cycle. (Diagram Credit: Howard Perlman, USGS.
First Flush of Surface Contaminants: pollutants on the surface of the ground
accumulate without regular rainfall. Pollutants can include pesticides, fertilizers,
automobile fluids, and organic/inorganic air pollutants. A post-drought storm will
flush high concentrations of these contaminants into the watershed.
Sudden Rush of Muddy Waters: parched soil will cause more runoff when
rainfall arrives and cause murkiness in the water. This increase in total suspended
particles can overload a water treatment facility and contaminate fresh water
sources used for drinking.
Dilution in Treated Drinking Water: water treatment plants often add residual
disinfect to keep the water safe as it travels through the pipes to the tap. During
extreme storms, pressure in the pipes may be affected and this disinfectant may
Slow Water Flow: extreme rainfall storms often cause power outages that can
affect flow of drinking water through pipes. When water sits in pipes (especially
old ones), contaminants can enter the water.
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Page 16 • Nevada RNformation December 2021, January, February 2022
Nevada has Two New Fellows in the American Academy of Nursing
Larissa Ann Africa and Susan VanBeuge are the two Nevada nurses inducted as
Fellows in the American Academy of Nursing in 2021. Below are the two new FAAN
from Nevada being recognized at the Annual Induction ceremony held October 09,
2021 in Washington D.C.
VA Southern Nevada Healthcare System
A wide array of Inpatient and Outpatient
RN and LPN Positions
VA Southern Nevada Healthcare System (VASNHS) is located in North Las
Vegas. VASNHS is comprised of an acute care hospital and has Outpatient Clinics
throughout the Las Vegas area, Pahrump, and Laughlin, NV.
Over 330 days of sunshine annually, world-class entertainment, and world-class
resorts. Las Vegas is home to the Vegas Golden Knights NHL hockey team and
home to the Las Vegas Raiders NFL football team
VASNHS is proud to be the first healthcare facility in Southern
Nevada that is American Nurse Credentialing Center (ANCC)®
Pathway to Excellence® designated.
“The premiere nursing designation for healthy work environments”
We are an employer of choice promoting a positive culture where
nurses can grow professionally and practice to their
full scope and licensure.
Apply online at www.usajobs.gov
or contact the Nurse Recruiter at
(702) 791-9000 ext.14187
December 2021, January, February 2022 Nevada RNformation • Page 17
Nursing Fellow Designation
Susan S. VanBeuge, DNP, APRN, FNP-BC, FAANP,
Nursing fellowship is a distinction many nurses pursue
in their careers. There are different types of fellowships
available in the nursing community and healthcare. The
types of fellowships vary and may differ based on the kind
of practice a nurse is engaged in. As well, nurses may be
fellows in more than one organization or type.
A good place to start is in the definition of a nursing
fellowship. Fellowship in nursing is not the same as a postdegree
experience, such as a post-PhD graduate fellowship or a clinical fellowship
upon graduation from an academic institution. Instead, designation as a Fellow
is by invitation from an organization based on demonstration of professional
practice, outstanding contributions to the profession, and substantive honors.
Each organization has its criteria for those who apply and will be based on the
institution's mission, vision, and direction granting the fellow designation.
The types of fellowships include professional organizations, service, academic and
research, and specialty fellowships. This article focuses on the honorific fellowships
to recognize many types of nursing practice from organizations. Presented here
is not an exhaustive list but includes some common and highly recognized fellow
Fellowship in the American Academy of Nursing (FAAN) was established in
1973 and has inducted approximately 2,900 Fellows since its inception. The
Fellows are described as “nursing leaders in education, management, practice and
research”. Invitation for fellowship is more than recognition, but an opportunity
and responsibility to give time, intellect, and energy to the Academy to engage in
the transformation of America's healthcare system (American Academy of Nursing,
The Academy of Nursing Education Fellow (ANEF) was established in 2007 and
is part of the National League for Nursing. Fellows inducted represent evidence
of leadership and contributions beyond their employed role. Contributions
include teaching, mentoring, scholarship, public policy, practice partnerships, and
administration (NLN, 2021).
The American Organization for Nursing Leadership (FAONL) announced its
inaugural group of fellows in 2019. Nurses who apply are expected to demonstrate
an evolution of leadership through contributions and innovation to nursing and
the American Organization for Nursing Leadership. In addition, this fellowship
designation recognizes a nurse leader's sustained contribution to nursing leadership,
commitment, and influence in shaping health care policy (AONL, 2021).
There are many specialty nursing fellowship organizations with a focus on
practice. Those highlighted below do not include all the opportunities, but they
highlight the various areas for nurses to earn the designation of Fellow.
The American Association of Nurse Practitioners (FAANP), established in 2000,
has approximately 874 inducted Fellows. Nurse practitioners (NP) with this Fellow
designation are recognized for their contributions to NP education, policy, clinical
practice or research, and developing future NP leaders (AANP, 2021).
The Fellow in the Academy of Emergency Nursing (FAEN) was established in
2004 and requires prolonged membership in the Emergency Nurse’s Association
and demonstrating enduring, substantial contributions to emergency nursing and
advancing the profession through visionary leadership (ENA, 2021).
Fellow of the American College of Nurse-Midwives (FACNM) was established in
1994 and requires that applicants be board certified by the American Midwifery
Board. This honor is awarded to midwives who demonstrate leadership, clinical
excellence, scholarship, and professional achievements both inside and outside of
the midwifery profession (ACNM, 2021).
The Fellow designation is not limited to nursing or specialty practice but may
include the opportunity for interprofessional and multidisciplinary associations.
Nurses work in collaboration with multiple professions as we provide care.
Fellowship in these broader associations demonstrates the essential need for health
care professionals to work alongside each other to improve health outcomes,
change policy, provide leadership, and infuse innovation to make change.
The National Academies of Practice Fellows (FNAP), founded in 1981, selects
Fellows for interdisciplinary groups of health care providers dedicated to issues from
allopathic medicine to nursing to veterinary medicine. For example, the nursing
group focuses on collaboration, leadership, advocacy, and establishing liaisons with
other health care disciplines to promote health care across the lifespan (NAP, 2021).
If you are considering a fellowship in an organization, look at their information
to determine the process and procedure. Most organizations require sponsorship
with another fellow in good standing. Review the application procedure to begin,
then do careful self-reflection on your skills, engagement, and outcomes that may
demonstrate the requirements for fellowship. This process of self-reflection is an
excellent way to chart out a path for professional development and an opportunity
to work with a colleague who may mentor you along this road. As you begin the
journey, network with other professionals, and start preparing for this opportunity.
As you prepare, remember that you are a success and that whether you are
accepted with your application or turned down the first time, this is not a reflection
of the person you are or the hard work you've done. It wasn't the right time. Being
turned down is another opportunity to reflect, regroup and resubmit.
Common themes presented in all the Fellow organizations noted are nursing
leadership, sustained commitment to our profession, innovation, and practice.
As you take inventory of your contributions to our profession, consider seeking
designation as a Fellow to have a seat at the table for crafting the future of nursing.
American Academy of Nursing (2021). Downloaded from https://www.aannet.org/about/
American Association of Nurse Practitioners (2021). Downloaded from https://www.aanp.
American College of Nurse-Midwives (2021). Downloaded from https://www.midwife.org/
American Organization for Nursing Leadership (2021). Downloaded from https://www.
Emergency Nurses Association (2021). Downloaded from https://www.ena.org/about/faen
National Academies of Practice (2021). Downloaded from https://www.napractice.org/
National League for Nursing (2021). Downloaded from http://www.nln.org/recognitionprograms/academy-of-nursing-education
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Page 18 • Nevada RNformation December 2021, January, February 2022
Vice-President, Nevada Nursing Student
Association and UNLV Student Nurse
Shining Stars Student Event & Awards Gala
On October 2nd, Nevada Nursing Student Association
(NVNSA) held their 6th annual Shining Stars Student Event
at the Aliante Casino and Hotel in North Las Vegas, NV.
The student event provided an opportunity for nursing
students across the State to come together for a morning
of networking, lectures by inspiring nurse leaders, and
participation in valuable conversations about the future of
the nursing profession. Students also had the chance to enter multiple raffles for
scholarships and nursing goodies, an opportunity to connect with representatives
from nursing schools across the valley, and a chance to participate in an NCLEX
review. Among the speakers was Dr. Ernest Grant, President of the American Nurses
Association (ANA). Dr. Grant discussed his nursing experience as an internationally
recognized burn-care and fire-safety expert and opened a discussion with students
about what they would like to see implemented in the nursing profession. In
addition, students discussed vital topics such as diversity in the nursing profession,
the nursing shortage, patient-to-staff ratios, nursing wages, COVID-19, and future
nursing scholarship and grant opportunities.
The Nevada Nurses Foundation (NNF) hosted the Shining Stars of Nursing in
Nevada Annual Gala in the evening. The NNF, whose mission is to "increase access
to quality healthcare for Nevada citizens by promoting the professional development
of nurses through scholarships, grants, and recognition," held the event to celebrate
and recognize nurses, student nurses, and nursing partners. The event included
nursing and governmental leaders such as Dr. Ernest Grant, President of the ANA,
Aaron Ford, Nevada Attorney General, and Richard Cherchio, the Mayor Pro
Tempore from North Las Vegas. In addition, nurses and healthcare professionals
were recognized for their sacrifice and hard work during the COVID-19 pandemic
and thanked for their contribution to the community. The event also celebrated and
honored the accomplishments of nurses all across the State, scholarship recipients,
and private and corporate sponsors.
I wanted to take this opportunity to thank NNF's CEO Dr. Sandy Olguin, Dr.
Denise Ogletree Mcguinn, and Ms. Karen Bearer, co-chairs of the event, along
with our wonderful student volunteers and all other individuals who made these
two events possible. These past few years have been challenging for our nurses,
and it has been inspiring to see the support, courage, and love within the nursing
community. As a student nurse, I am humbled to have encountered such hardworking
nurses like my professors, my mom, and other nurses who serve our
community with passion and selflessness. I am grateful to have been a part of these
two events that celebrate our nurses and genuinely excited to be joining such a
Tina Edwards, MBA, MSN, RN
ONA Emerging Nurse Director
Reprinted with permission Oklahoma Nurse,
Unexpected situations. Short staffed. Tangled wires.
Alarms going off. Call light ringing away. Another day
or night, another 12-hour shift in most cases, etc… A
whole new environment and yet, you wear more hats
than just that of a nurse. You are a leader, teacher,
mentor, team player, coach, engineer, waitress, and
many others. All of these roles can create a huge
anxiety for any nurse (even seasoned ones). Do you
struggle with managing your time filling all these roles
in a 12-hour shift?
Here are 6 signs & symptoms of time management
• Documenting after your shift is over
• Forgetting to complete a task
• Feeling overwhelmed and exhausted
• Remembering to do something after your shift is
• Having anxiety when you go back
• Losing track of what you are supposed to do
Here are 5 methods for better time management:
• Do not try to memorize hand offs of every
patient. Have a checklist ready that you create. Always
listen and ask questions after report. Remember, not
every hand off is exactly the way you would want, but
if you have your checklist then you can get key data.
Another important thing about hand off reports are
that they are the first essential step at knowing what
to prioritize. Also, be patient with the person giving
report, as you too will be tired at the end of a 12-hour
• Read the charts, look at previous labs, look to
see when labs are due, look at previous nursing
notes. Try to learn your patient as best as
possible before you go and do your assessment.
• Schedule yourself, hour by hour on a checklist.
Write down your tasks.
• Chart in live time in the room, not at the nurses’
• Most importantly, have flexibility and patience.
Do not get too overwhelmed, and if you are
feeling overwhelmed, ask for help.
The most ironic saying is, “Time management will
get better with time.”
By learning to manage time wisely, you can also
assist a coworker who may be battling with their time
management skills. Who knows? Maybe you can even
teach (teachers’ hat) them something you just learned
to make a 12-hour shift seem possible.
December 2021, January, February 2022 Nevada RNformation • Page 19
Hello, and thank you for this excellent opportunity to
represent Nevada Nurses. My name is Starla Gallagher,
and I am honored to be your new Nevada Nurses
Association Executive Director. To begin, I’d like to share
a little about myself. I have three beautiful children, ages
4,6 and 7. We live on a small farm in Beatty, Nevada
raising animals and producing locally grown foods for
our surrounding area. During the last twelve years,
I have had the opportunity to run my own business,
including the farm, bakeries, and coffee houses.
However, my most significant achievement has been
creating a children’s non-profit, helping to bring sports,
music, and other educational opportunities to my rural community.
I initially started my educational career as a nursing student and planned
to complete nursing school at Northern Arizona University. Life had different
plans, however, and I changed my degree focus. I decided to pursue an
educational option that would help me with my prehospital care endeavors
as I was already a volunteer EMT and working as a CNA. I ultimately finished
my college career with a Bachelor of Science in Emergency Management. This
educational path enhanced my background in leadership and management
and has led to me being able to help businesses and other organizations reach
their goals and objectives throughout the southwest.
As your new Executive Director, my goal is to increase membership and
membership benefits and create a volunteer base that can achieve more for all
Nevada nurses - ultimately making the world of nursing an overall better place
in Nevada. In stepping into this position, I would like to ask for your help. Any
suggestions as to how Nevada Nurses Association can better serve you can
be emailed to me directly at firstname.lastname@example.org. I very much look
forward to hearing your thoughts and ideas and to working with you in the
Page 20 • Nevada RNformation December 2021, January, February 2022
Nevada Nurses Foundation EST 2014
With a growing population in the state and need for more nurses, especially
nearly a two-year pandemic across our state and the world; highly educated and
skilled nurses are needed more than ever. Nurses need on-going education, such as
advanced degrees and training throughout their career to ensure that all Nevadans
have access to high quality healthcare. On Saturday, October 2, 2021 at 6:00PM,
The Shining Stars of Nursing in Nevada’s Sixth Annual Awards Gala was held at
the Aliante Hotel, Casino, and Spa in North Las Vegas.
The Shining Stars of Nursing in Nevada Awards Gala, presented by the Nevada
Nurses Foundation (NNF), is the ONLY statewide celebratory event honoring
nurses, students, and nursing/healthcare partners.
The NNF is the charitable and philanthropic arm of the Nevada Nurses
Association. Proudly, the NNF after receiving the federal recognition of being a
501(c)(3) non-profit organization, has recognized over 3,000 nurses and awarded
over $160,000 in nursing scholarships and grants throughout the state of Nevada
Dr. Ernest Grant, National President of the American Nurses Association provided
powerful words of inspiration as the evening’s keynote speaker. Dr. Grant became
the 36th president of the American Nurses Association in 2018 and claimed the
title of being the first male in the role. Other dignitaries bringing inspiring greetings
included Nevada State Attorney General Aaron Ford, North Las Vegas Mayor Pro-
Tem Richard Cherchio & Mrs. Cherchio. We are grateful for their support and
attention and interest in Nevada. A big thank you to Mrs. And Mayor Pro-Tem
Chercio for their very generous donation.
Endowed Scholarship Sponsors include: Dr. John & Debra Scott, Margaret &
Ian Curley, Lauren Delameter, Erik Christopherson, Joan & Arvin Operario, Greg
Peistrup, Yvette Wintermute, Front Line Nurse, Margaret Hatton, and the DeLeon-
Gamboa Seeds of Hope. Numerous Legacy Scholarship Sponsors from 2014-2021
were also noted.
From left to right: Joan & Arvin Operario, Kristin Peistrup,
& Elizabeth de Leon Gamboa
The Nevada Nurses Foundation awards and recognitions included:
* Forever Stars in Nursing: Nurses who have passed and will be forever
remembered for their dedicated Nursing service to Nevada and the world. We
cherish them and value their contributions. It is sometimes a challenge to include
all of our recently departed nursing colleagues and appreciate your help in sending
their names, a photo, and copy of their obituary. Their name will be included in our
annual Shining Stars of Nursing in Nevada souvenir program.
From left to right: Veloma Wolfe,
Dr. Ernest Grant, & Elizabeth de Leon Gamboa
Major nursing donors included: Optum Health Systems, Unitek College, College
of Southern Nevada, Carson Tahoe Health, Chamberlain University, Centennial Hills
Hospital member of the United Health System, The Perry Foundation, The Philippine
Nurses Association of Nevada, From 1 Nurse II Another, Volunteers of Medicine
Services in Nevada (Hands Together), and Nightingale College.
* Nevada Rising Stars (Student Nurse Leaders). What an incredible turn out we
had the Shining Stars Student Nurse educational event!
* Shooting Stars (Professional Progression with Advanced Degree/Certification)
December 2021, January, February 2022 Nevada RNformation • Page 21
Nevada Nurses Foundation EST 2014
expectations. Thank you, HGH, for allowing me to present the SSON awards and
being your guest.
* Shining Stars 50 under 50 (Nurse Leaders under age of 50)
Humboldt General Hospital Shining Stars of Nursing in Nevada.
* Shining Stars Nurses on Boards
* 2021 Shining Stars of Nursing in Nevada Scholarship & Grant Recipients.
From left to right: Dr. Kay Fontanilla, Ms. Regina McFerren,
Ms. Lauren Edgar, Ms. Minda Banaria, Dr. Ernest Grant,
Dr. Lowryanne Vick, and Dr. Tymeeka Davis
Dr. Angela Amar, People’s Choice Dean &
Andrea Burdette, 2021 People’s Choice CNO
Congratulations to the Shining Stars People’s Choice CNO/DON/DEAN Award
recipients. Dr. Angela Amar, Dean, University of Nevada Las Vegas, School of
Nursing, Andrea Burdette, Director of Nursing, Northern Nevada Medical Center,
and Robyn Dunckhorst, Chief Nursing Officer, Humboldt General Hospital. Ms.
Dunckhorst was unable to attend the gala however we were able to visit her and
her team in Winnemucca. Robyn, not only received the People’s Choice CNO award,
Humboldt General Hospital also recognized her accomplishments.
• Completely online
• No out-of-state tuition
• Finish in as little as 2 semesters
• Part-time and full-time enrollment available
• Admission available twice each fall, spring and summer semesters
• DSU has low costs for the students
• Ranked as the 12th most affordable
and 16th best quality RN-BSN
online program in the nation
Humboldt General Hospital and the community of Winnemucca rallied behind
their amazingly talented transformational leader, Robyn Dunckhorst.
I had the privilege to meet several HGH awardees, staff, and community
and board members. The HGH celebratory services were above and beyond my
For more information and to apply, visit https://dxl.dixie.edu/rn-bsn/
Program questions, call 435.879.4519 or
Page 22 • Nevada RNformation December 2021, January, February 2022
Nevada Nurses Foundation EST 2014
* 2021 Partnering Professional Organizations’ Stellar Nurses included:
Minda Banaria, RN, Philippine Nurses Association of Nevada
Linda Bowman, RN, Nevada Nurses Association
Dr. Tymeeka Davis, RN, From I Nurse II Another
Dr. Susan Drossulis, RN, Oncology Nursing Society
Lauren Edgar, RN, FNP-C, President, Southern Nevada Black Nurses Association
Dr. Kay Fontanilla, RN, Asian-American Pacific Islander Nurses Association
Dr. Ernest Grant, American Nurses Association
Dr. Carrie Hintz, RN, President, Sigma Theta Tau
Regina McFerren, RN, Black Nurses Rock
Lisa Pacheco, RN, Hispanic Nurses-Nevada
Dr. Andrew Reyes, RN, Sigma Theta Tau Zeta Kappa
Dr. Kim Simpson, RN, Great Basin Chapter, American Association of Critical Care
Dr. Rhigel Tan, RN, Filipino American Advance Practice Registered Nurses
Dr. Lowryanne Vick, RN, President, Chi Eta Phi Nursing Sorority, ETA ETA ETA
Chapter, Las Vegas
and last but not least:
SAVE THE DATE: 7TH ANNUAL SHINING STARS OF NEVADA GALA in the
Celebrity Showroom at The NUGGET CASINO RESORT, 1100 Nugget Avenue,
Sparks, Nevada 89431. Information about Sponsorships, Advertising, and
Other Financial Support is located at:
NEVADA NURSES FOUNDATION (NNF)
P. O. BOX 34047
RENO, NEVADA 89533-4047 EIN: 47-1388572
The mission of the NNF is to increase access to quality health care for Nevada
citizens by promoting professional development of nurses through recognition,
grants, and scholarships. To accomplish our mission, we hold two annual
fundraisers, the Big Hat High Tea in the spring and the Shining Stars of Nursing in
Nevada in October. The Big Hat “Kentucky Derby” High Tea is tentatively scheduled
at the Governor’s Mansion on Saturday, April 2nd, 2022. Tickets will go on sale at
the beginning of the new year. Tickets sell out fast! Wearing hats and dressing up is
*2021 Distinguished Nurse Leaders with Lifetime Achievement Award Winners:
Dr. Debra Toney
Rev. Dr. Denise Ogletree McGuinn
Northern Nevada Medical Center’s Royal Team at the Crowns
& Tiaras Big Hat High Tea
The enchanting members of Carson Tahoe Health at the
Yellow Brick Road Big Hat High Tea
Rev. Dr. Denise Ogletree McGuinn & Sam McCord
It was a fun-packed and beautiful evening for all, especially the Nurses of Nevada
who continue to render extraordinary care, even during a global pandemic to the
citizens of Nevada.
Ms. Sandy Kinser, Senator Bernice Mathews, and Marla Arvin
We hope you consider joining us on April 2nd, 2022 for a lovely tea, silent
auction, raffle, and entertainment.
Thank you and have great days,
December 2021, January, February 2022 Nevada RNformation • Page 23
Nevada Nurses Foundation EST 2014
SAVE THE DATE!
JOIN US! 2-day Virtual Conference - Presented by
the Nevada Nurses Foundation in partnership with the
Nevada Nurses Association
Rural & Frontier Nursing
Friday, January 28, 2022
(5 pm to 8 pm)
Saturday, January 29, 2022
(8 am to 12 pm)
Nursing Continuing Education Units
6-7 CEU's available!
• Addressing the Health Care Challenges of Rural
and Frontier Nevada through Engagement,
Education and Research by Dr. John Packham
• Health in All Policies by Sydney Gamer
• Childhood Bladder and Bowel Dysfunction by Dr.
• Kidney Transplant Options for Rural
Communities in Nevada by Dave Tyrell
• LGBTQA+ by Brian Dankowski
• Mentoring and Transition to Practice by Dr.
• Utilization of TikTok to Supplement Hypertension
Education by Marin Voyt
• Rural & Frontier Nursing Concerns by Norah Lusk
*Register before January 1st and be entered into a
drawing for a coffee card.
Students who are not members of NSNA may join and
have their fees waived.
Questions? Please contact Sandy Olguin at
Scholarships to attend may be available,
contact Sandy at above email or at 775-335-9554
To Register, email Sandy Olguin at
What COVID has Taught Me
Angela Wilson, BSN, RN, Charge Nurse
Baptist Health Hardin
Reprinted with permission from
Kentucky Nurse, December 2020
We have all had to change the way we live and how
we go about many activities that we have often taken
for granted. As nurses, we have had to adapt to everchanging
policies and protocols to protect ourselves
from the Coronavirus while avoiding any crosscontamination
to other patients. We are still expected
to give the highest quality of care to our patients. We
have become scared, burnt out, and many times sad
and angry at the situation.
I have felt the same feelings that all healthcare
workers have been dealing with through this
pandemic. I have been quarantined, lived away from
my husband, have family tell me that they are scared
to be around me because I am now a COVID nurse,
and felt the frustration and anxiety of taking care of
some of the sickest people I have seen since I became a
nurse. I have cried countless times and even considered
whether I wanted to continue nursing. Was this
something that I wanted to do as my career choice?
This is a choice but is it worth it?
After another two-week quarantine, I had a lot of
time to reflect. I tried looking at COVID from a different
perspective, through the patients’ eyes, after all, that is
why we become nurses is to help and care for others.
I felt like I was being selfish. Although things are so
very different for us, the patients are going through so
much more than I think we may realize.
Many of these patients are critical. They are being
asked to try new medications and to give consent
to enter trials for new treatments that have had
emergency approval for use by the FDA. They are
getting multiple breathing treatments, being put
on oxygen, sometimes needing more interventions
than a nasal cannula will allow. Heart problems are
developing, so we put them on monitors, order
echocardiograms and EKGs, and consult cardiology. At
this point, the patient, who may have been previously
healthy with no comorbidities, has a primary physician,
a pulmonologist, and a cardiologist involved in their
care, at the least. All information is given to the patient
by the person behind the mask and shield.
The physical toll on the patient can be
overwhelming but the mental and emotional toll can
be just as devastating. The patients are alone and
isolated at a time when they would want their family
and loved ones to be close. There are no visiting hours
for these patients. The only physical contact they
receive is from healthcare workers that they cannot
even see due to the amount of personal protection
equipment that is worn and for short amounts of time.
How utterly lonely this would be, spirit-breaking even.
So, as a nurse, I hope that this unprecedented
pandemic is teaching me a different type of patience
and empathy that I may have needed. We can be
frustrated and upset. This is something new for
everyone, not just healthcare workers. The effects
will probably have a lasting imprint on many, but we
cannot let our own emotions drown out our passion
for nursing and our love of our patients.
RNs, LPNs AND CNAs
We will work with your schedule • Tuition reimbursement available
We welcome new GRADS!
Offering Sign On Bonuses!
SILVER HILLS HEALTH CARE CENTER
Paul Kim, Administrator 702-952-2273
3450 N. Buffalo Dr. • Las Vegas, NV 89129
SILVER RIDGE HEALTHCARE CENTER
Misty Harvey, Administrator 702-938-8333
1151 S. Torrey Pines Dr. • Las Vegas, NV 89146
CARSON NURSING & REHABILITATION CENTER
Janee Flanders, Administrator 775-882-3301
2898 US Hwy 50 East • Carson City, NV 89701