Nevada RNformation - December 2021


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 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 &

Awards Gala

18 Time Management

19 Hello

23 What COVID has Taught Me

regular features

10 Research & EBP Corner

12 Nurses in the News

13 Antimicrobial Stewardship –

Infection Prevention

14 NNA Environmental Health


20 Nevada Nurses Foundation

Mary D. Bondmass,

Ph.D., RN, CNE

Dear Colleagues,

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

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Mark Your Calendars

• April 2, 2022 - 8th Annual Big Hat “Kentucky

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• 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 ..............President

Nicki Aaker, MSN, MPH, RN, CNOR, PHCNS-BC .......Vice President

Glenn Hagerstrom, PhD, APRN, FNP-BC, CNE .........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 ...................Director at Large

Bernadette Longo, PhD, RN, FAAN ..........................President District 1

Margaret Covelli, DPN, RN ..........President, District 3

Editorial Board

Managing Editor, Linda Bowman, RN,

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 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.

Published by:

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.

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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,


Vice President

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.

American Nurses Association [ANA] (2021). COVID vaccine

facts for nurses.

CDC (November 17, 2021).


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.


Robbins, R. (November 18, 2021). Leading nurses’ groups

unite to combat COVID misinformation. Medscape

Medical News (November 2021). https://www.



Director at Large

Arvin Operario, MBA, BSN, RN



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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,


NNA Course #001 Polypharmacy Problems and



Section 1: The Problems of Polypharmacy

Section 2: Adverse Effects of Overmedication

Risks Overview

Risk for Falls

Section 3: Pharmacokinetics





Other Factors

Section 4: Screening Strategies

Beers Criteria


The ARMOR Tool

Section 5: Improving Medication Management

Reducing Inappropriate Prescribing

Decreasing Polypharmacy

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,


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





Course Objectives

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

medication management.

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

• Cardiovascular


• Antibiotics/antiinfectives


• Diuretics (29.5%)

• Opioids (21.9%)

• Anti-hyperlipidemic


• Nonopioid analgesics


o Gastrointestinal tract


o Respiratory tract


o Dermatologic


• Antidepressants


• Sedatives/hypnotics


• Nutrients/

supplements (12.3%)

• Hypoglycemics


• 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%)

• Anti-parkinsonians


• Alzheimer disease


• Immunomodulators


Apply Your Knowledge:

What could have been done for Walter in our case

scenario to avoid the overdose of polypharmacy and

resultant hospitalization?

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.

Risks Overview

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




Living situation





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


• Balance

• Ability to move safely from bed to chair or to the

bathtub or toilet (transfer skills)

• Gait

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

Page 6 • Nevada RNformation December 2021, January, February 2022

CEU Course continued from page 5

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.

Other Factors

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 (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

functional status.

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

Beers Criteria

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

frequently misused

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



alprazolam (Xanax)

amiodarone (Cordarone)

amitriptyline (Elavil)


anorexic agents



belladonna alkaloids


bisacodyl (Dulcolax)


carisoprodol (Soma)

cascara sagrada

chlordiazepoxide (Librium,




chlorpheniramine (Chlor-




chlorzoxazone (Paraflex)

cimetidine (Tagamet)



clonidine (Catapres)

clorazepate (Tranxene)



cyclobenzaprine (Flexeril)


indomethacin (Indocin,

Indocin SR)

isoxsuprine (Vasodilan)


ketorolac (Toradol)


lorazepam (Ativan)


meperidine (Demerol)

meprobamate (Miltown,


mesoridazine (Serentil)

metaxalone (Skelaxin)

methocarbamol (Robaxin)

methyldopa (Aldomet)




(Android, Virilon, Testred)

mineral oil


naproxen (Naprosyn,

Anaprox, Aleve)


nifedipine (Procardia,





orphenadrine (Norflex)

cyproheptadine (Periactin) oxaprozin (Daypro)


desiccated thyroid



diazepam (Valium)

dicyclomine (Bentyl)

digoxin (Lanoxin)



dipyridamole (Persantine)

disopyramide (Norpace,

Norpace CR)

doxazosin (Cardura)

doxepin (Sinequan)


ergot mesyloids



ethacrynic acid (Edecrin)


ferrous sulfate (iron)

fluoxetine (Prozac)

oxazepam (Serax)

oxybutynin (Ditropan)


pentazocine (Talwin)



piroxicam (Feldene)



propantheline (Pro-


propoxyphene (Darvon)

and combination



quazepam (Doral)


reserpine (Serpalan,



temazepam (Restoril)

thioridazine (Mellaril)

ticlopidine (Ticlid)

triazolam (Halcion)

December 2021, January, February 2022 Nevada RNformation • Page 7

flurazepam (Dalmane)


guanadrel (Hylorel)

guanethidine (Ismelin)


halazepam (Paxipam)

hydroxyzine (Vistaril,


hyoscyamine (Levsin,





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

older adults.

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

(ANA, 2015):

• 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

dosing recommendations)

• 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

and falls

• 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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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

prescription medications

• Follow treatment guidelines for chronic and

acute disorders that affect older adults

• Identify methods for payment other than giving

drug samples

• 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

medical home.

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

dangerous prescriptions

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

to 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

in medications.

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

afp/2020/0101/p56.html and app: gives a deprescribing


Geriatric Age Specific Self Learning Module for

Clinical Staff:

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


U.S. Food and Drug Administration Educational

Resources: Ensuring Safe use of Medicine https://www.

YouTube Videos:

ARMOR: An Interdisciplinary Approach

to Drug Safety


Geriatrics-Polypharmacy in the Elderly: By

Balakrishnan Nair, MD.


Graham Hughes- Medication Awareness

and Strategies


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!


We’re Overmedicating the Elderly https://www.


Agency for Health Research and Quality (AHRQ). (2015).

National Healthcare Quality Report, 2015: Patient Safety.

Retrieved from:


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


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


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


Centers for Medicare and Medicaid Services (CMS) (2019).

Projected National Health Expenses Projection 2019-

2018. Retrieved from



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


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


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


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

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

a risk factor for hospital admission due to a fall: evidence

from the English Longitudinal Study of Ageing. BMC

Public Health 20, 1804 (2020).


(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

for medications.

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

medications properly.

d. Medications with side effects known to be

potentially dangerous.

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

medication include:

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

Submitted by

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

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 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

Privacy Assured

Easy to Use

E-mailed Job Leads

December 2021, January, February 2022 Nevada RNformation • Page 11

Clinical Research

Real Talk About Burnout

Bree Becker, MSN, NP-C, RNC-MNN

Reprinted with permission from

Georgia Nursing April 2021 issue

Knowledge Enhancement

Case Presentation

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

Travel Nursing:

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 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

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

unvaccinated. (2)

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

cures continue.

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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Med/Surg, OB/L&D, ICU, Ambulatory Care, ER, Peds,

Periop & other specialty positions available.

We offer:

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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

flood waters.

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

and floods.

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

with floodwater.

• 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.


Get Your Drinking Water Tested:

Integrated Source Water Protection for Nevada:

National Integrated Drought Information System (NIDIS).


Retallack, G.J. & Conde, G.D. (2020). Flooding induced by rising atmospheric carbon

dioxide. GSA Today, 30(10), 4-8.

The Nevada Division of Environmental Protection (2020). Nevada 2016-2018 Water Quality

Integrated Report:


United States Department of Agriculture (USDA):


United States Environmental Protection Agency:

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.

Public domain.)

Environmental Health

Heavy Rainfall

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

be reduced.

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.

Defending Professional Licenses in Administrative Proceedings.

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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

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


American Association of Nurse Practitioners (2021). Downloaded from https://www.aanp.


American College of Nurse-Midwives (2021). Downloaded from


American Organization for Nursing Leadership (2021). Downloaded from https://www.

Emergency Nurses Association (2021). Downloaded from

National Academies of Practice (2021). Downloaded from

National League for Nursing (2021). Downloaded from

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Page 18 • Nevada RNformation December 2021, January, February 2022

Nika Jenabi,

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

selfless profession.

Time Management

Tina Edwards, MBA, MSN, RN

ONA Emerging Nurse Director

Reprinted with permission Oklahoma Nurse,

´November 2020

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 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

since 2015.

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

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:


Celebrity Showroom at The NUGGET CASINO RESORT, 1100 Nugget Avenue,

Sparks, Nevada 89431. Information about Sponsorships, Advertising, and

Other Financial Support is located at:


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:

Sam McCord

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,

Sandy Olguin

December 2021, January, February 2022 Nevada RNformation • Page 23

Nevada Nurses Foundation EST 2014


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!

Possible Presentations:

• 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.

Nawal Qneibi

• Kidney Transplant Options for Rural

Communities in Nevada by Dave Tyrell

• LGBTQA+ by Brian Dankowski

• Mentoring and Transition to Practice by Dr.

Sherri Lindsey

• 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.



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2898 US Hwy 50 East • Carson City, NV 89701

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