Ohio Nursing CE - Simplified

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  • Ohio Nursing Laws & Rules

    Ohio Nursing Laws and Rules

    1 Contact Hour

    Released: 1/26/2021

    Expires: 1/26/2023


    Brenda Williams, PhD, MBA, RN, has been active in nursing as an RN for 34 years, working in varied areas of nursing, including, clinical (hospital, traveling, urgent care, sales, outreach education, management); insurance (workers’ compensation, short-term and long-term health insurance, vocational rehab, utilization review, Medicaid, Medicare, management); in addition to teaching health care business at the collegiate level (political, legal and regulatory, finance/economics, trends in health care, social aspects, and policy). She has authored five articles for publication in the Ohio Nurse Review in 2016 and 2017 and will be publishing her first book by the end of 2020. She is active in advocating for education of the public about dialysis options and is the director of the Parish Nursing Ministry at her church where she conducts public health research and teaches multiple health classes.

    RN Reviewer

    Taryn Hill, PhD, RN, has been a registered nurse for 29 years. Currently, she is the dean of Academic Affairs for Chamberlain University’s prelicensure BSN program in Columbus, Ohio. Dr. Hill started her nursing career in pediatric nursing on a renal and metabolic unit. Over the years Dr. Hill transitioned into adult ESRD and cared for patients in the acute, chronic, and peritoneal home dialysis settings. She was a staff nurse and a clinical manager for free-standing outpatient dialysis centers. Dr. Hill began teaching in the clinical setting in 2003 and began her full-time academic career in 2009 as a nurse educator at Chamberlain University. In addition to teaching, Dr. Hill has published several articles with Chamberlain’s Nursing Informatics Research Team. Additionally, she has reviewed several books and coauthored a book chapter. Dr. Hill is currently on the Central Ohio Region National Kidney Foundation board and is a member of the medical advisory board for the NKF’s Central Ohio Region. Dr. Hill has also served as a board member for the Mid-Ohio District Nurses’ Association and chapter president for the Phi Pi Chapter of Sigma Theta Tau International.

    APN Reviewer

     Jonda Hapner-Yengo, MPH, MS, CNP, has been a registered nurse for 24 years and a family nurse practitioner for 8 years. During this time she has worked primarily in public health or management positions at local health departments and federally qualified health care centers in New Jersey and Ohio. Currently, she is working at the Ohio State University Student Health Services as a primary care CNP and clinical lead of the preventive medicine program.

    LPN Reviewer

    Dawnara Brown, MBA, BSHu, has been a licensed practical nurse since 2007. She has worked directly with patients for over 19 years at the James Cancer Hospital and the Ohio State University Student Health Services and in industry at Cardinal Health and Abbott Nutrition for six years. Her nursing and business backgrounds have afforded her the opportunity to assist executives, medical leaders, and health care entities in providing safe and effective care while solving complicated health care and business issues. Currently, she is working per diem as a staff nurse in long-term care as an LPN and with the state of Ohio’s Fraud Division.

    Purpose Statement

    The following course fulfills the Ohio Law and Rules Category A licensure requirements on standards for competent nursing practice for RNs, APRNs, and LPNs in Ohio. A new addition this year is content regarding the foreign licensed nurse. Within the course is information regarding education, licensing, scope and standards of practice, and patient safety.

    Learning Outcomes

    Upon completion of this course, the learner will be able to:

    • Discuss the differences among the Ohio Revised Code, the Ohio Administrative Code, and the Ohio Board of Nursing.
    • Compare and contrast the difference in leadership roles among the registered nurses (RNs), licensed practical nurses (LPNs), and advanced practice registered nurses (APRNs).
    • Differentiate between the four forms of licensure: initial, renewal, endorsement, and compact.
    • Explain how the “party invitation” of who, what, when, where, and why impacts the scope and standards of nursing.
    • Analyze the protocol and subsequent actions of an RN or LPN when disputing a questionable order.

    How to receive credit

    • Read the entire course online or in print which requires a 1-hour commitment of time.
    • Complete the self-assessment quiz questions which are at the end of the course or integrated throughout the course. These questions are NOT GRADED.  The correct answer is shown after you answer the question.  If the incorrect answer is selected, the rationale for the correct answer is provided.  These questions help to affirm what you have learned from the course.
    • Depending on your state requirements you will then be asked to complete either:

    o   An affirmation that you have completed the educational activity

    o   A mandatory test (a passing score of 70 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention.

    • If requested, provide required personal information and payment information.
    • Complete the mandatory Course Evaluation.
    • Print your Certificate of Completion.

    CE Broker Reporting

    Elite, provider # 50-4007, reports course completion results within 1 business day to CE Broker.  If you are licensed in Arkansas, District of Columbia, Florida, Georgia, New Mexico, South Carolina, or West Virginia, your successful completion results will be automatically reported for you.

    Accreditations and Approvals

    Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center’s Commission on Accreditation.

    Ohio State Nursing Approval

    In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing. This program has been approved by the Ohio Board of Nursing through the OBN Approver at Northwest State Community College Division of Nursing & Allied Health for one (1) contact hour for Ohio Category A (OBN-008-92-2166IS-01262021).

    Activity Director

    Lisa Simani, MS, APRN, ACNP

    Nurse Planner


    Resolution of Conflict of Interest

    In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.

    Sponsorship/Commercial Support and Non-Endorsement

    It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.


    The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition  ©2021: All Rights Reserved.  Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC.  The materials presented in this course are meant to provide the consumer with general information on the topics covered.  The information provided was prepared by professionals with practical knowledge of the areas covered.  It is not meant to provide medical, legal, or professional advice.  Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state.  Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials.  Quotes are collected from customer feedback surveys.  The models are intended to be representative and not actual customers.

    Course Verification

    All individuals involved have disclosed that they have no significant financial or other conflicts of interest pertaining to this course.  Likewise, and in compliance with California Assembly Bill No. 241, every reasonable effort has been made to ensure that the content in this course is balanced and unbiased.


    There is more to nursing than knowing the art and science of it. Every nurse, whether a registered nurse (RN), licensed practical nurse (LPN), or an advanced practice registered nurse (APRN) must know how the Ohio Revised Code (ORC), the Ohio Administrative Code (OAC), and the Ohio Board of Nursing direct nursing decisions and actions. RNs, LPNs, and APRNs each have a distinct role with specific responsibilities. It is important to understand these roles and how they interplay together to provide unified nursing care. Once graduated, the new RN, LPN, or APRN must test for licensure and then renew at the proper dates. If nurses move between states and territories belonging to the United States, licensure by endorsement is required. Nurses who are licensed in multiple states are required to know and uphold the laws and rules regarding nursing licensure in the state where they are licensed. It is the nurses’ responsibility to know, understand, and adhere to licensing requirements in every state where they hold an active nursing license. Compact multistate licensure is an option in certain states that participate in the program. Nurses must practice within their scope and standard of practice, and the ORC and OAC provide the information for this. The Nurse Practice Act (NPA) provides guidelines for nurses to question orders that do not seem correct. Nurses are responsible for patient safety and care and therefore need to be aware of applicable rules and regulations to provide the best care.


    Meet John, Sarah, and Shannon. Each has just graduated from an accredited nursing program.  John graduated as an RN; Sarah graduated as an LPN; and Shannon graduated as an APRN. Follow them through their journeys of education, licensure, scope and practice, decision making when providing patient care, and patient protection through advocacy.

    Ohio Revised Code, Ohio Administrative Code, and Ohio Board of Nursing

    Ohio Revised Code

    The Ohio Revised Code (ORC) is a collection of the laws of the state of Ohio (The Ohio Legislature, 2019). The ORC consists of 31 titles that are further broken down into chapters. Within each chapter there are subdivisions (The Ohio Legislature, 2019). Chapter 4723 contains the laws and rules regarding nursing practice within the state of Ohio and is found within Title 47 Occupations-Professions. The scopes of practice and regulatory requirements for nurses practicing in Ohio are specified in the Ohio Nurse Practice Act, Chapter 4723, the Ohio Revised Code (ORC), and the Ohio Administrative Code (OAC), Chapters 4723-1 through 4723-27. Thus, the scope of practice of licensed nurses (licensed practical nurses, registered nurses, and advance practice registered nurses) is statutorily defined in Ohio’s laws and regulations. The Ohio State legislature (Senate and House) has the authority to adopt or modify practice acts and scopes of practice. The Ohio Board of Nursing abides by the direction of the legislature and thus the legislature grants the board legal authority to regulate the nursing profession.

    Ohio Administrative Code

    The Ohio Administrative Code (OAC) is a collection of rules that has been adopted by the various state agencies in Ohio. The intent of the rules is to execute the policies and laws that have been passed by the General Assembly (The Ohio Legislature). The chapters related to health care range from chapters 4709 through 4779. Chapter 4723 is focused on the Ohio Board of Nursing. Subdivisions of this chapter cover the organization of the board, licensing, definitions, standards of practice, education, APRNs, LPNs, RNs, continuing education, dialysis technicians, community health workers, and medication aides (LAWriterOhio Laws and Rules, n.d.a).

    Ohio Board of Nursing

    The state legislature of Ohio passed the Nursing Practice Act (NPA) and determined the regulations (laws-ORC) and scope of practice that nurses must follow (GraduateNursingEDU.org., 2019). The Ohio Board of Nursing (OBN) enforces the NPA’s laws through rules (OAC) that more clearly define the laws for licensure and the nurse’s scope of practice. This is done by determining the standards for safe nursing care; defining the scope of practice for RNs, LPNs, and APRNs; and granting, renewing, and revoking nursing licenses (GraduateNursingEDU.org., 2019).

    Ohio, along with the remainder of the 50 states, and the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, and the Virgin Islands have agreed to form a board called the National Council of State Boards of Nursing (NCSBN), which administers the NCLEX-RN and NCLEX-PN Examinations for initial licensure (GraduateNursingEDU.org., 2019).

    Ohio’s State Board of Nursing must have 13 members who are United States citizens and live in Ohio. Further requirements include the following:

    • Eight members are RNs that were actively engaged in the practice of nursing five years immediately preceding the member's initial appointment to the board.
    • Of the eight members who are RNs, at least two must be APRNs.
    • Four members shall be LPNs that were actively engaged in the practice of nursing five years immediately preceding the member's initial appointment to the board.
    • One member shall represent the interests of consumers of health care. Neither this member nor any person in the member’s immediate family can be associated with a health care provider or profession or have a financial interest in the delivery or financing of health care.
    • Representation of nursing service and nursing education and of the various geographical areas of the state shall be considered in making appointments.
    • Nursing organizations can submit up to five names for nomination to a position on the board that the governor and senate will later announce.
    • Terms will be four years (ORC 4723.02).
    • Members of the board of nursing are appointed by the governor of Ohio.

    According to Chapter 4723 of the Ohio Revised Code, the State Board of Nursing’s primary duty is to maintain an accurate and complete list of all applicants and those that have received licenses or certificates (OAC 4723 -1-03A).

    Case Study 1

    John, Sarah, and Shannon are discussing the differences between the Ohio Revised Code, the Ohio Administrative Code, and the Ohio Board of Nursing. They agree that the ORC are the laws and the OAC are the rules. They are not so sure what the OBN does.

    Self-Assessment Question 1

     What does the OBN do in relation to the ORC and the OAC?

    1. The Ohio Board of Nursing enforces the NPA’s laws through rules OAC.
    2. The Ohio Board of Nursing is a political party of 13 members that make up the laws.
    3. The Ohio Board of Nursing sets the rules for social distancing, mask-wearing, and COVID-19 testing.

    Definitions of RN, LPN, and APRN

    Registered Nurse

    The Nurse Practice Act defines an RN as one who “holds a current, valid license issued under this chapter, authorizing the practice of nursing as a registered nurse” (ORC, 4723.01.A). It goes on to define the practice of RNs as “providing, to individuals and groups, nursing care requiring specialized knowledge, judgment, and skills derived from the principles of biological, physical, behavioral, social, and nursing sciences” (ORC 4723.01B).

     The RN is responsible for the following (ORC 4723.01F1-6):

    • Identifying patterns of human responses to actual or potential health problems amenable to a nursing regimen.
    • Executing a nursing regimen through the selection, performance, management, and evaluation of nursing actions.
    • Assessing health status for the purpose of providing nursing care.
    • Providing health counseling and health teaching.
    • Administering medications and treatments and executing regimens authorized by an individual who is authorized to practice in Ohio and is acting within the course of the individual's professional practice (ORC 4723.01B1,2,3,4,5).
    • Teaching, administering, supervising, delegating, and evaluating nursing practice .

    Licensed Practical Nurse

    The Nurse Practice Act defines a licensed practical nurse (LPN) as “a nurse who has not only a current but also a valid license and is allowed to practice nursing without compromise” (ORC 4723.01E). The practice of an LPN is defined as “providing, to individuals and groups, nursing care requiring the application of basic knowledge of biological, physical, behavioral, social, and nursing sciences at the direction of a registered nurse … physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor” who is legally authorized to practice in Ohio (ORC 4723.01F).

     The LPN is responsible for the following (ORC 4723.01F1-6):

    • Patient teaching.
    • Care in diverse health care settings.
    • Contributions to the planning, implementation, and evaluation of nursing.
    • Administration of medications and treatments.
    • Administration of intravenous therapy to an adult when authorized appropriately.
    • Performing nursing tasks as delegated by a registered nurse.
    • Teaching nursing tasks to LPNs and individuals to whom the licensed practical nurse is authorized to delegate nursing tasks as directed by a registered nurse.

    Advanced Practice Registered Nurse

    To practice as an APRN, the nurse must first hold an RN license (ORC 4723.011) and then certification for the specific type of APRN (ORC 4723.01G,H,I,J). An APRN can be a certified registered nurse anesthetist, a clinical nurse specialist, a certified nurse-midwife, or a certified nurse practitioner (OAC 4723.3.01B1-4 and ORC 4723.01O1-4). As a practitioner the APRN “provides individuals and groups nursing care that requires knowledge and skill obtained from advanced formal education, training, and clinical experience” (ORC 4723.01P). APRNs develop a “standard care arrangement” in collaboration with the physician or podiatrist, which is a “written formal guide for planning and evaluating a patient’s health care” (OAC 4723-8-01H). After a standard care arrangement has been set up, the APRN must work within the quality assurance provisions of the standard care arrangement; failure to do so may result in disciplinary actions (OAC 4723-8-05C).

    APRN Quality Assurance

    • Yearly random chart reviews with a collaborating physician, podiatrist, dentist, or a member of a quality assurance committee.
    • Semiannual review of prescriptions and patterns of prescribing of the APRN.
    • After each review, a conference is to be held among all parties involved in the review.
    • A process for patient evaluation of care (OAC 4723-8-05D1,2,3).
    • Review of the standard care arrangement every two years (OAC 4723-8-04C7a).
    • Review and confirmation between the collaborating physician and the APRN that the APRN is meeting expectations of each patient’s OARRS report (OAC 4723-8-047d).

    Case Study 2

    John, Sarah, and Shannon are comparing their responsibilities as health care providers. They note some similarities such as having to be licensed, but they also note dissimilarities. Answer their responsibilities in the following questions.

    Self-Assessment Question 2

    The RN is responsible for all EXCEPT:

    1. Health counseling and teaching.
    2. Administering medications and treatments.
    3. Identifying patterns of human responses.
    4. Housekeeping.

    Self-Assessment Question 3

    LPNs are responsible for all EXCEPT:

    1.  Housekeeping.
    2. Administering medications and treatments.
    3. Teaching nursing tasks to peers.
    4. Observation.

    Self-Assessment Question 4

    There are four categories of APRN. Which one is NOT correct?

    1. Certified registered nurse anesthetist.
    2. Clinical nurse specialist.
    3. Certified gerontologist.
    4. Certified nurse practitioner.


    A nursing program must abide by the requirements of the Ohio Administrative Code to gain and retain approval of the Board of Nursing (OAC 4723-5-02A). “The [Registered Nursing] curriculum shall be derived from a philosophy, conceptual framework, or organizing theme that is consistently evident throughout the curriculum” (OAC 4723-5-13B).

    Following are the objectives, teaching strategies, and evaluation methods that must be used  (OAC 4723-5-13C1,2,3,4):

    • Developed and written by program faculty.
    • In accordance with the law for nursing practice.
    • Implemented as written.
    • Distributed to each student.

    The curriculum shall include the following (OAC 4723-5-13F):

    • Nursing art and science.
    • Physical, biological, and technological sciences.
    • Social and behavioral sciences.

    Registered Nurse

    The nursing program will be administered by a registered nurse with the following qualifications (OAC 4723-5-10A1a,b,c,d,e):

    • Experience of at least five years in the practice of nursing, including two as a faculty member in a registered nursing education program.
    • A master’s degree in nursing.
    • Valid RN license.
    • If the program is a baccalaureate or graduate program, a doctoral degree is required (OAC 4723-5-10A1a,b,c,d,e).
    • Associate administrators must meet the same requirements, although a doctorate is not required (OAC 4723-5-102a,b,c,d).

    The faculty must have at least two years’ experience practicing as an RN; a master’s degree (if a bachelor of science degree in nursing [BSN], the master’s degree does not have to be in nursing If not a BSN, “the master’s or other academic degree, including, but not limited to a PhD, shall be in nursing”; and a valid RN license (OAC 4723-5-103a,b,ci,ii,d).

    Licensed Practical Nurse

    The curriculum for an LPN program shall have the same set up as an RN program, “including content that validates the student’s acquired knowledge, skills, and behaviors that are necessary to safely and effectively engage in the practice of licensed practical nursing” (OAC 4723-5-14B,C1,2,3,4,E1,2,3, F1,2,3,4,5,6,7,8). The main difference is in the length of each program. The LPN program will be 30 weeks (OAC 4723-5-14D1) compared to 104 weeks in the RN program (OAC 4723-5-13D1). An additional class on intravenous therapy will be included in the licensed practical nursing education program (OAC 4723-5-14F1-8).

    An administrator of an LPN program must have the following qualifications: valid RN license; at least five years of experience in nursing, including two as faculty; and a master’s degree. If not a BSN, the master’s or other degree, including PhD, must be in nursing. If a BSN degree, then the master’s degree does not have to be in nursing. An associate administrator must meet the same requirements as an administrator (OAC 4723-5 11A2,a,b,c,i,ii,d).

    Faculty in the LPN program must meet the same requirements except a BSN is the only degree required in addition to only two years of active practice experience (OAC 4723-5-11A3a,b,c,d).

    Advanced Practice Registered Nurse

    APRNs must have a master of science or a doctoral degree with a major in a nursing specialty (GraduateNursingEDU.org., 2020). The educational programs are geared toward four types of APRN: nurse practitioner, clinical nurse specialist, certified registered nurse Anesthetist, and certified nurse midwife (GraduateNursingEDU.org., 2020).

    Here are the APRN Education Requirements (GraduateNursingEDU.org., 2020):

    • Three or more courses in advanced pathophysiology, advanced health assessment, and advanced pharmacology.
    • Comprehensive coursework to enable the APRN to practice correctly in the chosen population.
    • Direct/indirect clinical supervision in accordance with national specialty organizations and accreditation guidelines.

    Each of the four APRN roles work with a different patient population and have different duties.

    The nurse practitioner’s scope of practice is in health promotion, disease prevention, health education, counseling, and diagnosis/treatment of acute/chronic diseases working as a clinical nurse leader in one of six patient populations  (GraduateNursingEDU.org., 2020):

    1. Women’s health, including midwifery (https://nursing.osu.edu/academics/masters/traditional-master-science-nursing/traditional-ms-curriculum).
    2. Adult gerontology, including specializations in acute care, primary care, and clinical nurse specialist (https://nursing.osu.edu/academics/masters/traditional-master-science-nursing/traditional-ms-curriculum).
    3. Neonatal.
    4. Pediatrics, including specializations in acute care and primary care (https://nursing.osu.edu/academics/masters/traditional-master-science-nursing/traditional-ms-curriculum).
    5. Family/individual across the lifespan.
    6. Psych/mental health.

    The clinical nurse specialist (CNS) focuses on disease management, health promotion, and prevention with the coursework depending on the type of subspecialty chosen such as women’s health, emergency, diabetes, rehabilitation, mental health, or wounds, to name a few (GraduateNursingEDU.org., 2020). 

    Certified registered nurse anesthetists (CRNAs) are capable of providing anesthesia care to all individuals depending on the setting chosen (hospital, outpatient, adult practice, children’s clinic) with their educational program, including applied science of anesthesia, principles, evidence-based practice, advanced technologies, clinical decisions, and fieldwork (GraduateNursingEDU.org., 2020).

    Certified nurse-midwives (CNMs) are concerned with every aspect of the female lifespan from gynecology to prenatal and postpartum care (GraduateNursingEDU.org., 2020). CNMs work in many different types of settings from hospitals to homes (GraduateNursingEDU.org., 2020).


    After completion of an accredited nursing program (RN or LPN) that has been approved by the Ohio Board of Nursing, the new graduate must apply to take the NCLEX-RN or the NCLEX-PN Examination (OAC 4723-7-02A,B,C,E1).


    After applying and paying the fee to take the exam, the Ohio Board of Nursing checks the following. If the Board determines that the applicant is eligible for testing, an “authorization to test” letter will be sent to that applicant so the registration can be completed and an appointment scheduled within one year to take the NCLEX exam via the official testing service that the board approves (OAC 4723-7-03A,B).

    • Evidence of successful completion of an approved nursing program (OAC 4723-7-02C).
    • If the applicant is from another state, the nursing program administrator will send an official transcript (OAC 4723-7-02F2).
    • Criminal background check (ORC 4723.09A2b).
    • Has not been convicted of, pleaded guilty to, or had a judicial finding of guilt:
      • Aggravated murder (ORC 2903.01), murder (ORC 2903.02), or voluntary manslaughter (ORC 2903.03).
      • Felonious assault (ORC 2903.11).
      • Kidnapping (ORC 2905.01).
      • Rape (ORC 2907.02), sexual battery (ORC 2907.03), or gross sexual imposition (ORC 2907.05).
      • Aggravated arson (ORC 2909.02).
      • Aggravated robbery (ORC 2911.01) or aggravated burglary (ORC 2911.11).
      • Nonpayment of child support (ORC 3123.43).
      • Fraud in obtaining nursing license (ORC 4723.28A).
      • Selling, giving away, or administering drugs or devices for other than intended use (ORC 4723.28B5).
      • Self-use of illegal drugs (ORC 4723.28B8).
      • Misappropriation of funds or valuables (ORC 4723.28B13).
      • Failure to use universal precautions (ORC 4723.28B18).
      • Activities outside of the nursing practice scope (ORC 4723.28B20).


    License renewal for RNs, APRNS, and LPNs can be found online (OAC 4723-7-09B and OAC 4723-8-08A1,a,b,c,2,B). RNs and APRNs renew in the odd years and LPNs renew in the even years, both by September 15 (OAC 4723-7-09C; OAC 4723-8-08Ad; and ORC 4723.24C). If the RN license is initially granted “on or after July 1 of an odd-numbered year, that license shall be current through October 31 of the next odd-numbered year” (OAC 4723-7-09J). If the LPN is initially granted “on or after July 1 of an even-numbered year, that license will be current through October 31 of the next even-numbered year” (OAC 4723-7-09K). To renew their license, the RN, APRN, and LPN must demonstrate completion of 24 hours of continuing education (ORC 4723.24C1a and OAC 4723-8-10B1), one of which must be “related to the statutes and rules pertaining to the practice of nursing in this state” (ORC 4723.24C1c).

    Specific Requirements for APRNs

    APRNs will renew their licenses in the odd years, the same as RNs, and must follow these guidelines:

    • Submit an application for their specialty (nurse anesthetist, nurse midwife, nurse practitioner, nurse specialist).
    • Document that they are currently certified by a national certifying organization.
    • Clinical nurse specialist certified before December 31, 2000, does not have to prove certification but must prove continuing education of 12 hours of CE related to the specialty (https://nursing.ohio.gov/wp-content/uploads/2020/10/OhioBoardCEforAPRNs1.0.pdf).
    • All APRNs mush have completed 24 hours of continuing education in the licensed specialty (https://nursing.ohio.gov/wp-content/uploads/2020/10/OhioBoardCEforAPRNs1.0.pdf).
      • 12 hours of CE in advanced pharmacology (ORC 4723.24C2c and OAC 4723-8-10B2) as part of the 24 required hours.
      • Eight hours can be substituted for CE if the APRN provided health care as a volunteer to indigent and uninsured people (OAC 4723-8-10A4a-E3).
    • A list of all of the collaborating physicians and podiatrists.
    • Fee (OAC 4723-8-08,A1,a,b,c,2,B).


    If an already licensed nurse (RN or LPN) wishes to obtain licensure in another state, the following items need to be documented:

    • Proof of a current valid unrestricted nursing license (ORC 4723.09B1a).
    • Graduation from an approved nursing program from the National Council of State Boards of Nursing (OAC 4723-7-05A1).
    • Proof of two hours of CE (OAC 4723-7-05B4).
    • Submit a Nursing Licensure by Endorsement Application along with the corresponding fee (OAC 4723-7-05A2).
    • Agree to a criminal records check (OAC 4723-7-05B2d).
    • Has not been convicted of, pleaded guilty to, or had a judicial finding of guilt for the same crimes as those listed in initial licensing (ORC 2903. 01,02,03,11; ORC 2905.01; ORC 2907.02,02,05; ORC 2909.02; ORC 2911.01,11; ORC 3123.43; ORC 4723.28A,B5,8,13,18,20).

    APRNs that work in another state must do the following:

    • Complete an Advanced Practice Registered Nurse License Application and submit the fee to practice in Ohio (OAC 4723-8-09).
    • Provide proof of graduation with a master’s or doctoral degree in nursing or in a related field that qualifies the applicant to sit for the certification examination of a national certifying organization approved by the board (ORC 4723.41A2).
    • Provide proof of passing the certification exam (ORC 4723.41A3).
    • Indicate the specialty the nurse seeks (ORC 4723.41A4c).
    • Provide proof of authority to practice nursing and is in good standing in the previous jurisdiction (ORC 4723.41B2).

    Foreign Nurse Licensure

    When a foreign nurse applies for licensure in Ohio, the following information is required by the Ohio Board of Nursing:

    • A full education course-by-course report from the credentialing evaluation service (CES) of the commission of graduates of foreign nursing schools (CGFNS) (OAC 4723-7-04,A1).
    • Evidence of obtaining the minimum passing score on the Test of English as a Foreign Language (TOEFL iBt). There are exceptions to this rule. Foreign nurses that were educated in Australia, Ireland, New Zealand, the United Kingdom, South Africa, Trinidad and Tobago, Jamaica, Barbados, or Canada, except that, with respect to Canada, the exception from the requirement does not apply to Quebec unless the individual graduated from McGill university, Dawson college in Montreal, Vanier college in St. Laurent, John Abbot college in Sainte-Anne-de-Bellevue, or Heritage college in Gatineau (OAC 4723-7-04,A2).
    • Criminal records check (OAC 4723-7-04,A3).
    • Does not have to sign up as a sex offender (ORC 2950, sexual predator, habitual sex offender, sexually oriented offender) (OAC 4723-7-04,A4).
    • Submit a completed Nursing Licensure by Examination Application with fee (OAC 4723-7-04,A5) and complete the registration process (OAC 4723-7-04,A6).

    Foreign Nurse Licensure by Endorsement

    Registered Nurse. The RN must submit the following information:

    • Must have been originally licensed by examination to practice as a registered nurse in a jurisdiction of the National Council of State Boards of Nursing (OAC 4723-7-04,B1).
    • If licensed before January 1, 1953, must prove a licensing exam was taken (OAC 4723-7-04,B1a)
    • If licensed after January 1, 1953, but before July 1, 1982, must have a score of 350 on each subject in the State Board Test Pool Examination (OAC 4723-7-04B1b).
    • If licensed between July 1, 1982, and before October 1, 1988, then a score of more than 1600 on the NCLEX-RN (OAC 4723-7-04B1c).
    • If licensed after October 1, 1988, must have a “pass” score on the NCLEX-RN (OAC 4723-7-04B1d).

    Licensed Practical Nurse. The same rules apply for the LPN except (OAC 4723-7-04,3,4b,5b,6-9,E,F1,2):

    • If licensed on or after July 1, 1956, but before July 1, 1982, must have a score of at least 350 on the State Board Test Pool Examination (OAC 4723-7-04B2a).
    • If licensed on or after July 1, 1982, but before October 1, 1988, must have a score of at least 350 on the NCLEX-PN (OAC 4723-7-04B2b).
    • If licensed after October 1, 1988, must have a “pass” score on the NCLEX-PN (OAC 4723-7-04B2c).

    Compact License

    If an RN or an LPN wishes to obtain a compact multistate license (the capability to practice in multiple states with one license without a license for each state), the nurse must live in a compact-eligible state. Ohio is not a compact state; however, Senate Bill 341 is waiting to be heard as of 2020. A nurse whose primary residence is Ohio can have as many individual state licenses as they desire. APRNs cannot participate in the Compact Multistate License program and must hold individual licenses for each jurisdiction or state (National Council of State Boards of Nursing, Inc., 2019b).

    Case Study 5

    John, Sarah, and Shannon are preparing to sit for their RN and LPN exams. John and Sarah are new graduates and will be taking their tests for the first time. Shannon already is an RN and will renew her license with additional requirements because she is an APRN. They are at lunch, comparing their licensure requirements.

    Self-Assessment Question 5

    John and Sarah are taking their initial RN and LPN licensing exams. To qualify to sit for the test, each must:

    1.  Have graduated from any nursing program.
    2. Sign a document attesting to no criminal activity.
    3. Receive an email for authorization to test.
    4. Schedule and sit for their exams within one year.

    Self-Assessment Question 6

    Shannon is already an RN. She has a graduate degree in nursing to practice as an APRN. She has additional requirements to renew her license in addition to her RN requirements. She must meet all of the requirements EXCEPT:

    1.  Provide documentation of 24 hours of continuing education.
    2. Current certification in her specialty.
    3. Names and addresses of all collaborating physicians and podiatrists.
    4. Renewal in even years.

    Self-Assessment Question 7

    John, Sarah, and Shannon want to apply for compact licenses so they can practice in multiple states. Which statement is not true?

    1. To apply for a compact license, the RN or LPN must live in a compact state.
    2. Ohio is not a compact state.
    3. APRNs can hold compact licenses.

    Scope and Standards of Nursing Practice

    The scope and standards of nursing practice covers the services that qualified and licensed RNs, LPNs, and APRNs can perform (ANA Enterprise, n.d.). There are two steps to defining the scope of practice. They are the Nurse Practice Act, a law that originates at the state legislature, and the regulatory bodies that create the rules and regulations (ANA Enterprise, n.d.). The standards of practice are found in the Ohio Administrative Code (OAC 4723-4-03A-K5).

    Decision-Making Model

    The Ohio Board of Nursing created a decision-making model (Figure 1.) for APRNs, RNs, and LPNs to determine if an existing, modified, or new procedure, activity, or task they encounter may be performed as part of and within their scope of practice. The decision-making model is based on relevant statutes and is a guide for determining whether a specific procedure, task, or activity is within the nurse’s scope of practice.

    Figure 1.  Ohio Board of Nursing’s Decision-Making Model

    Dicision making model diagram

    Ohio Board of Nursing. (2019, September). RN and LPN Decision Making Model.


    Case Study 6

    John and Sarah have passed their initial NCLEX-RN and NCLEX-PN exams. Both are working on the med-surg floor. John is faced with a procedure that he is not familiar with. He is trying to decide what to do. Shannon is rounding on the floor at this time, so he asks her for guidance.

    Self-Assessment Question 8

    John is not sure how to proceed with a procedure that he has never carried out. He knows what the procedure is, the reasoning behind it, and has seen it demonstrated when in nursing school. He talks to Shannon who advises him to consult the Ohio Board of Nursing’s decision-making algorithm. After reading through the algorithm, John determines that he should not carry out the task. What should he do next?

    1.  Do the procedure anyway; he has seen it done.
    2. Ask Shannon to do it and show him how.
    3. Ask Shannon to watch him and instruct him as he does it.
    4. Discuss the procedure and concerns with his manager.

    Patient Safety

    In October 2019, the Ohio Board of Nursing created a document titled, Scopes of Practices: Registered Nurses (RNs) and Licensed Practical Nurses (LPN), to provide guidance regarding the practice for RNs and LPNs based on the requirements in the Nurse Practice Act and administrative rules. ORC 4723.01A-V denoted the scopes of practice for RNs and LPNs. OAC 4723-4-03A-K5 stipulated RN and LPN standards of practice and addressed patient safety and nursing processes.

    RN and Patient Safety: Orders

    It is the RN’s responsibility to “maintain current knowledge of the duties, responsibilities, and accountabilities for safe nursing practice” (OAC 4723-4-03B). When an RN is given an order, it is the nurse’s responsibility to carry out the order unless a problem has been identified such as inaccuracy of the order, the order has not been properly authorized, or the order is not valid or has expired (OAC 4723-4-03E1a,b,c). If the nurse deems that the order may cause harm to the patient or is contraindicated, then it is the nurse’s responsibility to clarify the order with another licensed practitioner (OAC 4723-4-03Ed,eF1), and if, after the clarification, the nurse decides not to proceed, the nurse must notify the ordering practitioner and then document the notification as well as the reason for not following the order in the patient’s chart (OAC 4723-4-03F2,3). If further action is required to keep the patient safe, the nurse must do what is needed to protect the patient (OAC 4723-4-03F4).

    LPN and Patient Safety: Orders

    Before an LPN can undertake any task, an RN must first assess the situation including the “condition of the patient, the type of nursing care required and the complexity and frequency of the nursing care needed” (OAC 4723-4-03K1,2,3). The RN must then consider the “training, skill, and ability of the Licensed Practical Nurse … [as well as] the availability and accessibility of resources necessary to perform the … procedure” (OAC 4723-4-03K4,5). Standards of practice for LPNs are the same as for RNs (OAC 4723-4-04A-E).

    APRN and Patient Safety: Orders

    To practice as an APRN, the nurse must first be an RN and follow all the rules for RNs. APRNs have a wider scope of practice related to advanced education, clinical experience, and national certification (OAC 4723-8-02A, OAC 4723-8-02B2). Because of the APRN’s additional education and experience, a plan must be in place for chart review when the nurse (APRN) has direct patient care, education, or management, serving as another layer of protection for the patient (OAC 4723-8-047d). APRNs must collaborate with a physician or podiatrist that is in the same specialty and develop a standard care arrangement consisting of “a written formal guide for planning and evaluating a patient’s health care” (ORC 4723.431H).

    The standard care arrangement contains the following:

    • Signatures of the nurse and each collaborating physician or designee – another physician who serves as the department or unit director or chair, in the same institution, or practice specialty as the nurse (OAC 4723-8-04C1).
    • A listing of services that the APRN will be offering and a description of the scope of prescriptive practice (OAC 4723-8-04C5).
    • Criteria for referral from the APRN to the collaborating physician or podiatrist (ORC 4723.431B1).
    • A process for the APRN to consult with the collaborating physician or podiatrist (ORC 4723.431B2).
    • A plan for coverage in case the APRN or the collaborating physician or podiatrist is not available and another physician or podiatrist can supervise the APRN (ORC 4723.431B3).
    • A process for dispute resolution between the APRN and the collaborating physician or podiatrist (ORC 4723.431B4). When the APRN has prescriptive authority, a plan must be in place for “timely direct, personal evaluation of the patient with a collaborating physician” (OAC 4723-8-04,11a). An APRN may prescribe drugs or therapeutic devices if they are within the APRN’s specialty scope of practice, consistent with the terms of the standard care arrangement with a collaborating physician, and do not exceed the prescriptive authority of the collaborating physician (ORC 4723-9-10;13D1,2,3; Ohio Board of Nursing, 2019, May, para.1-2).

    As of September 28, 2018, hospitals are permitted to hire clinical nurse specialists, certified nurse-midwives, and certified nurse practitioners as employees and can negotiate their standard care arrangements (between the employee and the employee’s collaborating physician) with pending approval of the medical staff and governing body of the hospital (ORC 4723.431E).

    Case Study 7

    Shannon has written an order for Sarah’s patient. Sarah reads the order but does not agree with it because it is unclear and could represent a patient safety hazard. Shannon has left the floor. Sarah finds John and asks him to interpret the order. He agrees with Sarah, it is ambiguous.

    Self-Assessment Question 9

    John and Sarah disagree with Shannon’s order for a patient as it seems to present a safety hazard. They should take all of the following steps EXCEPT:

    1. Clarify the order with another licensed practitioner.
    2. Talk about it with the rest of the nurses on the floor.
    3. Contact the ordering practitioner and request clarification and then document it in the chart.
    4. Do whatever needs to be done to protect the patient.

    Case Study 8

    Shannon is now practicing as an APRN. Because of the APRN’s additional education and experience, a plan must be in place for chart review, which provides an extra layer of protection for patients. APRNs must collaborate with a physician or podiatrist that is in the same specialty and develop a standard care arrangement.

    Self-Assessment Question 10

    The contents of a standard care arrangement consist of all of the following EXCEPT:

    1. A process for dispute resolution between a physician and the APRN.
    2. Prescriptive authority requires timely and direct evaluations from the collaborating physician or podiatrist.
    3. A list of services and prescriptive authority the APRN will be offering.
    4. A plan for physician coverage for the APRN if the collaborating physician or podiatrist is not available.
    5. If the collaborating physician or podiatrist is not available, the APRN can consult with any other physician or podiatrist. Ohio Board of Nursing.


    Each nurse is responsible for knowing the laws and rules that pertain to the practice of nursing. Every nurse must know where to find the Ohio Revised Code and the Ohio Administrative Code, reviewing both frequently. No one is exempt from the law because of lack of knowledge. Although  many nurses perceive that laws and rules are to protect them, in reality, the laws and rules were made to protect the patient.

    This course provided information on how the Ohio Revised Code, the Ohio Administrative Code, and the Ohio Board of Nursing work in collaboration to provide safe patient care. The definitions and requirements of a registered nurse, licensed practical nurse, and advanced practice nurse were explored. In addition to the different types of nurses, there are different requirements for the education of each. There are four types of licensure: initial, renewal, endorsement, and compact. The most important item covered in this course is what the nurse should do when facing an order that seems incorrect. Whether it is inaccurate, not properly authorized, or invalid, it is the nurse’s responsibility to identify a problem with the order, question it with peers and then the prescriber, and then document the situation and resulting action. Above all, it is the nurse’s responsibility to protect the patient at all costs.


    ANA Enterprise, (n.d.). Scope & practice. http://www.nursingworld.org/practice-policy/scope-of-practice/

    GraduateNursingEDU.org., (2019). What is a state board of nursing? http://www.graduatenursingedu.org/state-board-of-nursing/

    GraduateNursingEDU.org., (2020). Master of science in nursing as a path to advanced practice licensure. http://www.graduatenursingedu.org/masters-in-nursing-for-aprns/

    LAWriter Ohio Laws and Rules. (n.d.a). Ohio Administrative Code. Chapter 4723 Ohio Board of Nursing. http://codes.ohio.gov/oac/4723

    LAWriter Ohio Laws and Rules. (n.d.b). Ohio Revised Code. Chapter 4723 Nurses. http://codes.ohio.gov/orc/4723

    National Council of State Boards of Nursing, Inc. (2019a). Nurse licensure compact. http://www.ncbsn.org/compacts.html

    National Council of State Boards of Nursing, Inc. (2019b). NLC FAQs. http://www.NCSBN.org

    Ohio Board of Nursing. (2019, May). Exclusionary formulary. www.nursing.ohio.gov

    Ohio Board of Nursing. (2019, September). RN and LPN decision-making model. http://www.nursing.ohio.gov/practice-resources/practice-rn-lpn/

    Ohio Board of Nursing. (2019). Scopes of practices: Registered nurses (RNs) and licensed practical nurses (LPNs). http://www.nursing.ohio.gov

    Ohio Codes; Ohio Revised Code. The Ohio Legislature. 133rd General Assembly. (2020). Legislature.ohio.gov/laws/ohio-codes


    1. The correct answer is A.

    Rationale: The Ohio Board of Nursing enforces the NPA’s laws through rules (OAC) that more clearly define the laws for licensure and the nurse’s scope of practice (GraduateNursingEDU.org., 2019).

    1. The correct answer is D.

    Rationale: The RN is responsible for providing health counseling and health teaching, administering medications and treatments, and Identifying patterns of human responses (ORC 4723.01B1,2,3,4,5).

    1. The correct answer is A.

    Rationale: Administration of medications and treatments, Teaching nursing tasks to LPNs, and observation (ORC 4723.01F1-6).

    1. The correct answer is C.

    Rationale: An APRN can be a certified registered nurse anesthetist, a clinical nurse specialist, a certified nurse-midwife, or a certified nurse practitioner (OAC 4723.3.01B1-4 and ORC 4723.01O1-4).

    1. The correct answer is A.

    Rationale: Successful completion of an approved nursing program (OAC 4723-7-02C).

    1. The correct answer is D.

    Rationale: A renewed advanced practice registered nurse license is subject to renewal in odd-numbered years (OAC 4723-8-08,A1,a,b,c,2,B).

    1. The correct answer is C.

    Rationale: APRNs cannot participate in the Compact Multistate License program and must hold individual licenses for each jurisdiction or state (National Council of State Boards of Nursing, Inc., 2019b).

    1. The correct answer is D.

    Rationale: According to the Ohio Board of Nursing’s decision-making model, John should NOT perform the procedure. He should contact his manager and get guidance as to how to proceed.

    1. The correct answer is B.

    Rationale: If the nurse deems that the order may cause harm to the patient or is contraindicated, then it is the nurse’s responsibility to clarify the order with another licensed practitioner (OAC 4723-4-03Ed,eF1).

    1. The correct answer is E.

    Rationale: Signatures of the nurse and each collaborating physician or designee—another physician who serves as the department or unit director or chair, in the same institution, or in the same practice specialty as the nurse (OAC 4723-8-04C1).

    Final Examination


    Answer A

    Answer B

    Answer C

    Answer D



    What is the Ohio Revised Code? 

    The rules.

    The laws.

    The scope of practice.

    A new code number to access the laws.



    Advanced practice registered nurses can specialize as a:

    Certified registered nurse anesthetist,

    clinical nurse specialist, certified nurse-midwife, and certified nurse practitioner.

    Clinical nurse specialist, certified nurse practitioner, certified emergency nurse,

    certified registered nurse anesthetist.

    Certified nurse-midwife, certified operating room nurse, certified emergency nurse, and certified psychiatric/mental health nurse.

    Certified nurse practitioner, certified optometric nurse, certified med-surg nurse, certified newborn ICU nurse.



    Baccalaureate and graduate nursing program administrators must have a valid RN license, a master’s degree, five years’ prior nursing practice, and:

    Last year’s federal tax return.

    Five years’ prior experience in teaching at the collegiate level.

    A recommendation from the Ohio Board of Nursing.

    A doctoral degree.



    When a graduate of a registered nursing or licensed practical nursing program applies for the initial license, the following crimes will forfeit the license:

    Murder and failure to use universal precautions.

    Nonpayment of child support, murder, and failure to use universal precautions.

    Kidnapping, refusal to get vaccinations, murder, and arson.

    Failure to use universal precautions, Nonpayment of federal income taxes, failure to obtain malpractice insurance.



    When do LPNs, RNs, and APRNs renew their licenses?

    RN, LPN, APRN in the even years.

    RN, LPN, APRN in the odd years.

    RN, LPN in the odd years

    RN and APRN in the odd years and LPN in the even years.



    Two steps define the scope of practice. They are:

    Ohio Revised Code and Nurse Practice Act.

    Nurse Practice Act and the Ohio Administrative Code.

    Ohio Administrative Code and the National Council of State Boards of Nursing.

    Nurse Practice Act and regulatory bodies within the state.



    Advanced practice nurses must collaborate with a physician or podiatrist and write up a standard care arrangement that delineates:

    A plan of coverage in case the physician or podiatrist is unavailable for consultation or collaboration.

    A list of agreed-upon rules that both will follow with a plan of coverage for the APRN in case of emergency.

    A process for the APRN to consult with the collaborating physician or podiatrist and dates for semiannual reviews.

    A list of vacation dates and a plan for dispute resolution between the APRN and the collaborating physician or podiatrist.



    The National Council of State Boards of Nursing administers:

    The NCLEX-RN and PN.

    The laws.


    The rules.



    The practice of registered nurses is:

    Providing nursing care to individuals and groups using specialized knowledge and skills.

    Advocating for patients.

    Collaborating with doctors and other health care professionals.




    A registered nursing curriculum must:

    Be clearly written.

    Written by program faculty in accordance with the law for nursing practice.

    Developed by outside vendors in accordance with the law for nursing practice.

    Changed as needed.


  • An Overview of Dietary Supplements for Nurses

    An Overview of Dietary Supplements for Nurses COURSE INFORMATION

    3 contact hours

    Released: 1/11/21 Expires: 1/11/24


    Bradley Gillespie, PharmD, is a clinical pharmacist. He has practiced in an industrial setting for the past 25+ years. His initial role was as a clinical pharmacology and biopharmaceutics reviewer at FDA, followed by 20 years of leading early development programs in the pharma/biotech/nutritional industries. In addition to his industrial focus, he remains a registered pharmacist and enjoys mentoring drug development scientists and health professionals, leading workshops, and developing continuing education programs for pharmacists, nurses, and other medical professionals.


    Shellie Hill, DNP, FNP-BC, currently serves as full-time faculty as the FNP program coordinator and assistant professor in the MSN-NP program at Saint Louis University. She has been a practicing family nurse practitioner for 19 years and an RN for 26 years. Most of her clinical practice has been in primary care. She also has experience in urgent care and cardiology.

    Clinically, she works in corporate health care clinics part time and volunteers as an FNP in a clinic that manages underserved patients.

    Purpose Statement

    Nurses in many practice settings are likely to encounter patients that are using dietary supplements – some appropriately – whereas in other instances, not. This course is designed to provide an overview of these products that will empower nurses to guide their usage safely and effectively. Dietary supplements of many types are widely used by Americans. As a result, it is likely that nurses, in a variety of settings, will encounter patients who use these products.

    This educational program is designed to provide an overview of the following:

    • The regulation of nutritional supplements.

    • Main categories of nutritional supplements, their potential activity, and safety concerns.

    • Resources available to provide additional information.

      Evidence-based practice is summarized, where appropriate, to support the safe and efficacious use of dietary supplements. Nursing considerations are included to further aid in the application of this information to practice.

      Learning Objectives

      Upon completion of the course, the learner should be able to do the following:

    • Detail two key events responsible for the regulation of dietary supplements.

    • Describe one sign associated with vitamin deficiency.

    • Name one benefit of vitamin C that has support in the scientific literature.

    • Explain why supratherapeutic doses of water-soluble and fat-soluble vitamins can have different consequences.

    • Discuss the difference between macrominerals and microminerals.

    • Develop an awareness of “miracle” supplements.

    • Identify two body systems that may be susceptible to adverse events when using St.

      John’s wort.

    • State one potential drug interaction associated with the use of St. John’s wort.

    • Provide a potential use for fish oil that is well supported by the scientific literature.

    How to receive credit

    • Read the entire course online or in print which requires a 3-hour commitment of time.

    • Complete the self-assessment quiz questions which are at the end of the course or integrated throughout the course. These questions are NOT GRADED. The correct answer is shown after you answer the question. If the incorrect answer is selected, the rationale for the correct answer is provided. These questions help to affirm what you have learned from the course.

    • Depending on your state requirements you will then be asked to complete either:

      • An affirmation that you have completed the educational activity

      • A mandatory test (a passing score of 70 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention.

    • If requested, provide required personal information and payment information.

    • Complete the mandatory Course Evaluation

    • Print your Certificate of Completion.

    CE Broker Reporting.

    Elite, provider # 50-4007, reports course completion results within 1 business day to CE Broker. If you are licensed in Arkansas, District of Columbia, Florida, Georgia, New Mexico, South Carolina, or West Virginia, your successful completion results will be automatically reported for you.

    Accreditations and Approvals:

    Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center’s

    Commission on Accreditation.

    Individual State Nursing Approvals

    In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing

    by: Alabama, Provider #ABNP1418 (valid through March 1, 2021); California Board of Registered Nursing, Provider #CEP17480 (valid through January 31, 2022); California Board of Vocational Nursing and Psychiatric Technicians (LVN Provider # V15058, PT Provider #15020) valid through December 31, 2021;

    District of Columbia Board of Nursing, Provider # 50-4007; Florida Board of Nursing, Provider #50-4007; Georgia Board of Nursing, Provider #50-4007; and Kentucky Board of Nursing, Provider #7-0076 (valid through December 31, 2021). This CE program satisfies the Massachusetts Board’s regulatory requirements as defined in 244 CMR5.00: Continuing Education.

    Activity Director

    Lisa Simani, MS, APRN, ACNP Nurse Planner


    Resolution of Conflict of Interest

    In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.

    Sponsorship/Commercial Support and Non-Endorsement

    It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.


    The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition ©2021: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.

    Course Verification

    All individuals involved have disclosed that they have no significant financial or other conflicts of interest pertaining to this course. Likewise, and in compliance with California Assembly Bill No. 241, every reasonable effort has been made to ensure that the content in this course is balanced and unbiased.



    Most Americans consume at least one product defined as a dietary supplement each day; others may use them on a more irregular basis. Although products categorized as dietary supplements can include a variety of preparations, this educational program will consider common dietary supplements identified by the National Institutes of Health’s (NIH) Office of Dietary Supplements as vitamins, minerals, herbs, botanicals, amino acids, probiotics, and fish oils. Dietary supplements can be ingested using a variety of formulations. Examples include tablets, capsules, powders, drinks, and energy bars. Supplements that are commonly consumed contain vitamins, minerals, herbs, fish oil, and probiotics (NIH, 2020b).

    The Federal Food, Drug, and Cosmetic Act defines dietary supplements similarly to the NIH but adds that these substances are used to increase total dietary intake. Further, the U.S. Food & Drug Administration (FDA) states that dietary supplements are not intended to treat, diagnose, prevent, or cure diseases. As such, drug-like marketing claims such as “pain reducer” or

    “treatment of heart disease” are prohibited (FDA, 2020).


    Contemporary thinking may assume that the nutrient depletion that some Americans suffer as a result of processed food consumption is a recent problem. Nonetheless, a review of nutritional history suggests that we have faced this problem for over 100 years. In actual fact, today’s most popular dietary supplement, the multivitamin, was developed in the early 1900s. Before inventing this critical supplement, though, scientists first needed to acknowledge and understand the existence and need for substances now known as vitamins. Before this era nutrients were roughly categorized into three food groups: proteins, carbohydrates, and fats. Contemporary thinking of the time also blamed poor sanitation and hygiene deficiencies as the source of all disease. In response to this concern, food was often sterilized to remove germs and toxic substances. Grains were milled to remove their husks, and rice grains were polished (this is how brown rice is modified to become white rice). These efforts succeeded in extending food longevity but also led to unknown and sometimes harmful consequences (Tweed, 2017).

    For example, well-intentioned grain processing decimated critical B vitamins, resulting in an increased incidence of two diseases common to the time: pellagra – niacin deficiency resulting in a variety of sores and sometimes delusions; and beriberi – thiamine (vitamin B1) deficiency, which can lead to nerve damage, sometimes to the extent of paralysis. Further, the practice of milk sterilization destroyed its vitamin C resulting in an increased incidence of scurvy.

    Interestingly, scurvy commonly occurred in affluent families, those able to afford the so-called

    “best food.” These maladies were quite mysterious and not understood (Tweed, 2017).

    The practice of rice polishing resulted in a hotbed of scientific interest around the turn of the 20th century. Many scientists in Europe and Asia realized the nutritional value of rice polishing (the substance removed from brown rice during its refinement) and endeavored to identify what part of it was important. Some of the more industrious investigators even tried to synthesize this material. One example of such a trailblazer was Casimir Funk, a Polish biochemist. In 1910 he reported that he had isolated the active factor in rice polishing. Though history would show that his findings were faulty, he did go on to make a critical contribution to the science, suggesting that his isolate belonged to the chemical class of amines. Further to that, he hypothesized that all of the organic trace nutrients linked to preventing disease

    belonged to that same class of chemicals. He then created the term “vitamin,” to describe all of

    these vital amines. In a few years, Funk’s hypotheses were disproven; not all of the chemicals in this category were amines. Nevertheless, the nomenclature was slightly shortened to vitamin, and it stuck (Carpenter, 2020).

    For at least 14 years before 1926, intermittent nominations had been submitted for the Nobel Prize in Physiology or Medicine on the basis of vitamins. Although it is unknown why vitamin work never rose to the level of receiving this valued award, it may have been a result of skeptics who declared these substances to be only hypothetical; it was true that, up until this time, no one had ever seen a vitamin. This all changed in 1926 when a pair of Dutch scientists, Jansen and Doanth, produced pure crystals extracted from rice polishing. Only one-hundredth of a milligram of their extract, administered daily, was required to cure vitamin-deficient pigeons.

    By 1929 the award committee decided that it was time to honor the work of the vitamin pioneers.

    The problem was that so many had contributed to this developing science, whose work should be honored. Ultimately, the prize was jointly awarded to Christiaan Eijkman and Sir Frederick Hopkins. Eijkman’s work centered around his study of beriberi in the Dutch East Indies. He noted that some of the chickens in his laboratory developed symptoms of beriberi after the cook refused to allow the birds to be fed leftover rice. When rice was procured from an alternative source, the animals quickly recovered, leading him to believe that something in the rice was responsible for preventing this disorder. Hopkins was an influential advocate for the importance of vitamins. As a result of these efforts, in 1929 the award was granted to these two men, cementing the importance of vitamins (Carpenter, 2020).

    Over time, as the body of research developed, it became evident that vitamins were critical to supporting growth and function. It is now established that there are a total of 13 vitamins: vitamins A, C, D, E, K and the B vitamins (thiamine, riboflavin, niacin, pantothenic acid, biotin, B6, B12, and folate). Each of these diverse substances has different roles – some help to avoid infection or promote nerve health; others assist in the extraction of energy from food or serve as critical factors required for proper blood coagulation. Generally, if individuals follow proper dietary guidelines, they can consume the majority of the vitamins that they need from the food that they eat (National Institute on Aging [NIA], 2019).

    In addition to vitamins to promote proper function, the body also relies on a number of minerals. Although most minerals, such as iodine and fluoride, are required in only small quantities, greater quantities of others are needed. Examples of minerals with larger requirements are calcium, magnesium, and potassium. The good news is that, like vitamins, a

    varied and balanced diet is typically adequate to supply enough of most minerals needed to support good health (NIA, 2019).

    In summary, Funk’s declaration that vitamins are vital is as true today as it was when he first suggested it over 100 years ago. Without them, horrible things will happen to the body. This well-accepted truth makes it very easy to market and sell vitamins as well as other substances purported to promote health. This is evidenced by a current explosion of start-up organizations stating that their products work for almost everyone. The Internet is packed with examples of sometimes expensive vitamin concoctions claiming to be essential for good living, many for seemingly exorbitant prices. Some marketers take it a step further by offering online personal surveys allowing consumers to create personalized supplement blends – in essence a multivitamin engineered to meet each individual’s needs. A wise consumer may acknowledge that, though vitamins are important and worthwhile, perhaps not all available supplement regimens are worth their lofty prices (Palus, 2019).


    Even though FDA-regulated products account for over 20% of consumer expenditures (Abram, 2017), the agency is not responsible for regulating harmful dietary supplements until a tainted or mislabeled product is sold. Further, the agency has no responsibility for ensuring the effectiveness of supplements. Nonetheless, FDA is planning to modernize and strengthen its oversight of dietary supplements. To this end it has listed a number of steps designed to improve the safe and effective use of dietary supplements, with a primary goal of preserving access while protecting consumers from dangerous products (Norman, 2019).

    In spite of FDA’s intention to modernize the regulation of dietary supplements, any useful modifications to law are not yet in place. Organizations manufacturing nutritional and dietary supplements are well aligned with Congress, which typically endorses industry-friendly regulations that support the concept of self-regulation (Brown, 2019). Nevertheless, hundreds of laws have been enacted to provide oversight of these diverse product lines. Over the history of FDA, many significant events have been recorded.

    Seven key events are responsible for the regulation of the dietary supplement industry today. Taken together, these laws effectively provide a working definition of a dietary supplement.

    1. The 1938 Food, Drug, and Cosmetic Act: In 1938 the Federal Food, Drug, and Cosmetic (FD&C) Act was passed in response to a legally marketed toxic elixir that killed 107 people, including a number of children. The FD&C Act led to a complete overhaul of the public health system, featuring an authorization of FDA to demand solid evidence of safety and proper

      labeling for new drugs, sanctioning factory inspections, and adding new enforcement tools (FDA, 2018).

    2. Nutrition Labeling and Education Act of 1990 (NLEA): Although the NLEA of 1990 was geared mainly toward food labels, certain aspects of this mandate were relevant to the regulation of dietary supplements. The nutritional labeling guidelines described in this legislation were designed to work in tandem with previously established requirements for statements of identity, net contents, ingredient lists, and the name and place of the manufacturer/distributor. Of interest, NLEA regulated health claims that could be made on behalf of a supplement. NLEA provisions were issued in January 1993 and applied to all supplements except those that were eligible for exemption. In the case of some small businesses or where labeling was impractical or not feasible, manufacturers could apply for such exemptions (GovTrack, n.d.b.).

    3. The Dietary Supplement Health and Education Act of 1994 (DSHEA): DSHEA was unanimously passed by Congress based on a number of findings that emphasized the need to communicate information to the public regarding the potential risks and benefits of dietary supplements. DSHEA was intended to protect the rights of consumers to continue to access safe supplements as a means to promote wellness. DSHEA provided FDA with the regulatory authority and enforcement mechanisms to allow the access of supplements to consumers while providing some level of protection. DSHEA specifically defined dietary supplements as a category of food, while making it clear that supplements would not be regulated as food additives. Further, DSHEA mandated that dietary supplements must be produced in compliance with current good manufacturing practices (cGMP). It is critical to note that the enhanced enforcement capabilities laid out in DSHEA gave FDA the authority to remove unsafe products from the market (Council for Responsible Nutrition [CRN], n.d.a.).

    4. New dietary ingredient (NDI) notifications: As part of DSHEA, it was established that dietary supplements that were in commerce before 1994 could be considered safe based on their history of use and can remain on the market without additional evidence of safety. All other

      dietary ingredients will be considered “new” and will require that a formal notice is provided to FDA with evidence that it is reasonably expected to be safe (NDI notification). If FDA has reason to suspect that the NDI is unsafe, it has the authority to request additional information (FDA, 2019b).

    5. Good manufacturing practices (GMP): This is a specific set of rules and documentation that governs the manufacture of dietary supplements. These guidelines, finalized in 2007, mandate high standards intended to ensure the consistent manufacture of dietary supplements. Dietary supplement GMP include guidelines stating that all ingredients are thoroughly tested for

      identity and purity, as well as requiring products to meet prospectively determined quality specifications. Dietary supplement manufacturers are accountable to FDA to show proper documentation of all ingredients and processes. GMP documentation also covers sanitation, batch records, training of employees, process validation, and release testing to document conformance to the product label (CRN, n.d.b.).

    6. Dietary Supplement and Nonprescription Drug Consumer Protection Act (2006): This amendment to the FD&C Act requires the manufacturer, packer, or distributor whose name appears on the label of a dietary supplement to report within 15 days to the secretary of health and human services any serious adverse event associated with the use of its product. Further, this act requires that all related records are maintained for a period of 6 years and that they will allow inspection of these documents (GovTrack, n.d.a.).

    7. The Food Safety & Modernization Act (2011): This provision granted FDA the authority to issue a mandatory recall in the event that the manufacturer or distributor fails to enact a voluntary recall of a dietary supplement after being requested by FDA (CRN, n.d.b.).

      This current characterization states that a dietary supplement is a product that meets the following requirements (NIH, 2020b):

      • It is designed to supplement the diet.

      • It is intended to be taken orally, formulated as a capsule, tablet, liquid, gel cap, or soft gel.

      • It contains one or more dietary ingredient: vitamins, minerals, herbs, botanicals, amino acids, or other specific substances.

      • It has proper labeling identifying it as a dietary supplement.

    Nursing Consideration

    Although the regulation of dietary supplements is not as rigorous as for prescription or over-the-counter medications, certain requirements must be met to legally market these products in the United States. When completing medication histories, nurses and nurse practitioners should ensure that the supplements used by their patients meet all applicable regulatory requirements. Further, patients may benefit from discussing their therapeutic objectives and available supportive data.

    FDA has proposed that a listing be created describing all products marketed as dietary supplements. Although FDA has the authority to act against noncompliant products, there is currently a problem with identifying all available products. Such a registry would allow FDA to

    know when new products enter the marketplace and provide the agency the tools needed to quickly identify and act against dangerous products (Mister, 2020).

    The 2015 Dietary Guidelines Advisory Committee (DGAC) was formed as a joint effort of the

    U.S. Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA) to evaluate dietary guidelines and identify critical new research. An overarching objective was to develop food-based recommendations that were critical to good health. In a 2015 publication, these agencies noted that approximately 50% of American adults suffered from a preventable chronic disease. Further, they stated that about two of every three Americans were either overweight or obese. Although the causes of these issues were multifactorial, poor dietary patterns were at least partly to blame, with the potential for positive changes to diet capable of influencing them (USDA, 2015).

    A national survey showed that more than 30% of adult Americans and about 12% of children employ healthcare approaches that are outside of traditional Western medical practice. When such a nonmainstream practice is used together with conventional medicine, it is termed “complementary healthcare.” This combined and coordinated practice is known as “integrative health” (NIH, 2018).

    Complementary health approaches are often used to try to promote overall well-being rather than to try to manage the symptoms of a health problem. Although nutritional supplement use is a mainstay of complementary health, many people find that combining it with other approaches, such as yoga, is helpful. The state of wellness is multidimensional to include emotional welfare (coping and the creation of satisfying relationships) and physical well-being (the recognition of need for healthy food, sleep, and physical activity). The National Center for Complementary and Integrative Health has conducted research that suggests that people who employ complementary approaches with an aim towards wellness have better overall health than people who use complementary approaches to manage an existing health problem (NIH, 2020g). These findings support the concept that supplements may be best suited for prevention of disease, in line with FDA regulations stating that dietary supplements are not intended to treat, diagnose, prevent, or cure diseases.

    Nutrient Recommendations: Dietary Reference Intakes (DRI)

    The Food and Nutrition Board is a component of the National Academies of Sciences, Engineering, and Medicine (NASEM). As part of its task of ensuring nutritional well-being for all Americans, it provides policy guidance designed to use nutrition and food science to enhance the health of Americans. Since its establishment in 1940, the Food and Nutrition Board has been evaluating myriad issues relevant to the adequacy and safety of the US food supply. As a

    component of this nutritional study, it has provided authoritative perspectives on the complicated relationships and the dependencies of food intake, health maintenance, nutrition, and the prevention of disease (NASEM, 2018).

    Dietary reference intake (DRI) is a generalized term that describes the reference values for nutrient intakes in healthy individuals. In addition to their usefulness in assessing nutrient intakes, they can also be employed to plan diets and supplementation strategies. It is critical to note that these values, in some cases, vary by sex and age. Multiple values are subsequently derived from DRI, including the following (NIH, n.d.):

    • Recommended dietary allowance (RDA): RDA is estimated to be an average level of a nutrient required every day to meet the nutrient needs of most (97% to 98%) healthy individuals.

    • Adequate intake (AI): In some cases, available evidence is inadequate to determine an RDA. In these instances, an AI is established at levels thought to allow for adequate nutrition.

    • Tolerable upper intake level (UL): Because many dietary supplements are not totally innocuous and may cause toxicity at some levels, ULs are often characterized to represent the maximum daily intake that is unlikely to lead to adverse impacts on health.

    Nursing Consideration

    Good nutrition is a cornerstone to good health. Nurses should incorporate a discussion of nutritional needs into patient education. This conversation could begin with determining their patients’ diets and an assessment to determine if they are obtaining the nutrients needed through their diet. Based on this evaluation, suggestions can be made for an appropriate regimen of dietary supplementation.

    Categories of Dietary Supplements

    A wide variety of dietary supplements is marketed for consumption to Americans, and they contain many ingredients intended to convey multiple benefits. For the purposes of this educational program, supplements covered are limited to those characterized by the National Institute of Health’s Office of Dietary Health as those commonly encountered: vitamins, minerals, herbs/botanicals, amino acids, probiotics, and fish oil preparations. Because of the large number of products available, specific usage details are not included in this program.

    Instead, an overview of critical information that includes potential uses, supportive evidence, and safety issues is described. For details needed to guide the proper use of specific dietary supplements, practitioners are advised to consult a reputable reference source. A good

    overview of dietary supplements is provided by the NIH Office of Dietary Supplements and can be accessed at https://ods.od.nih.gov/

    FDA publishes a dietary supplement ingredient advisory list designed to disclose to the public whenever FDA determines that certain ingredients used in dietary supplements do not appear to be lawfully used. Inclusion on this list is not necessarily an indication that FDA has definitively concluded that the ingredient is unsafe; rather, it means that FDA is working to further evaluate its safety. This list is kept current by FDA and can be accessed at https://www.fda.gov/food/dietary-supplement-products-ingredients/dietary-supplement- ingredient-advisory-list (FDA, 2019a).


    Vitamins are a classification describing a category of organic substances that are available in very small amounts in the food that humans consume. Vitamins are critical to life; they help sustain normal metabolic processes. In cases where people do not ingest adequate amounts of vitamins, a variety of pathologies may result. All vitamins are organic compounds, meaning that they contain the element carbon. Further, the 13 vitamins classified as essential cannot be generated by the body and must be obtained either through foodstuffs or dietary supplementation (Brazier, 2017a).

    The 13 essential vitamins fit into two distinct categories:

    1. Fat-soluble vitamins are able to accumulate in fatty tissues throughout the body. The fat-soluble vitamins are vitamins A, D, E, and K. In many cases, these vitamins can be absorbed more readily in the presence of dietary fats (MedlinePlus, 2020c).

    2. The remaining nine essential vitamins are water soluble and cannot be stored by the body. As a result, these vitamins must be provided on an as-needed basis. Any surplus water-soluble vitamins are excreted. An exception is vitamin B12, which can remain in the liver for many years (MedlinePlus, 2020c).

    Each essential vitamin plays an important and unique role in the body’s proper function. In cases where a person does not receive an adequate amount of a specific vitamin, a vitamin deficiency may result. In some cases, deficiencies can lead to (sometimes serious) health problems (MedlinePlus, 2020c). The function of each of the 13 essential vitamins is briefly described below.

    Fat-Soluble Vitamins

    Vitamin A (retinol, retinoic acid) is an important nutrient critical to vision, cell division, reproduction, and immunity. In addition, vitamin A has antioxidant properties. Vitamin A

    naturally occurs in spinach, dairy products, and liver. When used as a dietary supplement, it may benefit those with pancreatic disease, eye disease, or measles (Mayo Clinic, 2017d).

    Vitamin D sometimes colloquially referred to as the “sunshine vitamin,” is not actually a vitamin, but a prohormone (hormone precursor) that can be made by the body if it is exposed to adequate levels of sunshine. In cases where not enough sunshine exposure is appreciated, vitamin D supplementation is needed because it is difficult to obtain adequate dietary vitamin

    D. Vitamin D facilitates calcium absorption and is thus useful in the promotion of healthy bones and teeth. Further, it supports immune, brain, and nervous system health while helping to regulate insulin levels (Ware, 2019b).

    Evidence-Based Practice

    Although vitamin D deficiency has been described in alarming terms, Cashman and colleagues (2016) recognized that available vitamin D levels in European people were of questionable quality. As such they set out to systematically evaluate the literature with an eye towards the NIH-led International Vitamin D Standardization program (VDSP). To estimate vitamin D levels across various age groups in Europe, they examined a total of 18 well-controlled studies (reanalysis of 15 studies as well as new analysis of samples from three studies using a validated assay), providing a total sample size of 55,844 participants. Using these datasets, investigators obtained estimates of the prevalence of vitamin D deficiency. When all of the data were pooled, irrespective of age or ethnicity, their data showed that 13% of the study participants were vitamin D deficient (< 30 nmol/L), on average, over the course of the year. Quite different results were obtained when evaluated by season: 18% were deficient in the winter; 8% were deficient in the summer. When participants were classified by skin pigmentation, analyses showed that dark-skinned ethnicities had higher (threefold to seventy-onefold) levels of vitamin D compared to fair- skinned participants. Investigators concluded that vitamin D deficiency is evident throughout Europe at concerning rates of prevalence requiring public health action.

    Vitamin E functions as an antioxidant and occurs naturally in a variety of foods such as nuts, seeds, and leafy green vegetables. Vitamin E is critical for a variety of bodily functions, to include the creation of red blood cells and the proper facilitation of vitamin K (Drugs.com, 2019).

    Vitamin K is involved in blood coagulation, bone metabolism, and the regulation of calcium levels in the body. A key role of vitamin K is to facilitate production of the blood clotting factor prothrombin. As a result of its potential to impact clotting, vitamin K, both through dietary and

    supplemental ingestion, must be carefully considered in patients using anticoagulants such as warfarin. It is critical to note that vitamin K deficiency in adults is rare (Ware, 2019a).

    Water-Soluble Vitamins

    Biotin is one of eight B vitamins, sometimes called vitamin B7 or vitamin H, stemming from the German words haar and haut (hair and skin). Biotin is required by the body to facilitate the function of a number of enzymes called carboxylases. These enzymes are critical to a number of metabolic processes, to include the production of glucose and fatty acids. These reactions are useful for maintaining healthy nails and hair as well as supporting pregnancy and breastfeeding. Fortunately, because biotin exists in a wide variety of foods, deficiencies are rare, with the exception of some pregnant women and heavy drinkers (Palsdottir, 2020).

    Niacin, also known as vitamin B3, is naturally present in many foods such as poultry, beef, fish, legumes, and grains. All the body’s tissues are able to convert niacin into its active form, the coenzyme nicotinamide adenine dinucleotide (NAD). NAD is critical to life, with more than 400 enzymes needing it to function properly. In cases of severe niacin deficiency, the disease pellagra may occur, marked by a pigmented rash on skin exposed to sunlight, sometimes also manifesting with neurologic symptoms. Fortunately, pellagra is rare in the developed world, mostly limited to people living in poverty (NIH, 2020d).

    Folic acid (sometimes referred to as folate) works in concert with vitamin B12 to assist in the formation of red blood cells. Further, folate is required in the production of DNA; it subsequently controls the growth of tissues and cell function. In pregnant women, low levels of folate are associated with birth defects such as spina bifida. As a result, a number of foods are fortified with folate to ensure adequate dietary folate (MedlinePlus, 2020c).

    Nursing Consideration

    In addition to promoting good nutrition in all patients, it is critical that nurses caring for pregnant women stress the importance of folic acid. In addition to fortification in many foods, multivitamins that are designed for pregnant women typically contain additional folic acid.

    Pantothenic acid, sometimes called vitamin B5, is found in a variety of foods, to include meat, vegetables, grains, and eggs. This vitamin is implicated in the proper metabolism of carbohydrates, proteins, and lipids. Further, it is sometimes associated with healthy skin.

    Typically, pantothenic acid is used in combination with other B vitamins. Although there is not

    solid, convincing evidence of its efficacy, it is commonly taken to prevent acne, allergies, baldness, asthma, and many other maladies (eMedicineHealth, 2019).

    Riboflavin, sometimes called vitamin B2, works in concert with the other B vitamins. Specifically, riboflavin is associated with proper growth and the production of red blood cells (MedlinePlus, 2020c).

    Thiamine (vitamin B1) helps the body to use carbohydrates for energy, also playing important roles in the function of nerves, the heart, and muscle. It is well established that thiamine requirements increase during pregnancy and lactation. Meat, fish, and grains all serve as good sources of thiamine. In some cases, white flour and breakfast cereals are enriched with thiamine. Because thiamine is not stored in the body, humans require a constant supply.

    Thiamine deficiency is associated with the disease beriberi, manifested by peripheral nerve problems and wasting (Brazier, 2017b).

    Vitamin B6 (pyridoxine) participates in many bodily functions and is involved in more than 100 separate enzyme reactions, many critical to protein metabolism. Although present in many foods, the richest sources of vitamin B6 are fish, beef liver and other organ meats, potatoes, and fruit. It is critical to note that glycosylated forms exist in some fruits, vegetables, and grains, reducing its availability for absorption. Vitamin B6 deficiency is associated with microcytic anemia, weakened immunity, and a variety of other pathologies (NIH, 2020f).

    Vitamin B12 (cyanocobalamin) is needed to maintain the proper function and development of the brain, nerves, blood cells (deficiencies may result in pernicious anemia), and a variety of other body systems. It is also useful in the treatment of cyanide poisoning and hyperhomocysteinemia. Vitamin B12 can be found in meat, fish, and dairy products. In some cases, vitamin B12 is synthesized in a laboratory (WebMD, n.d.d.). Deficiencies in vitamin B12 may lead to a variety of neuropsychiatric problems, including gait abnormalities and behavioral disturbances. Psychiatric manifestations of vitamin B12 deficiency may be related to abnormal neurotransmitter transmission, hyperhomocysteinemia, and increased levels of methylmalonic acid (Kerkar, 2018).

    Case Study 1

    Advanced Practice Nurse (APN) Dan is caring for a 2-year-old patient, Will. Notable medical history showed that he suffers from granuloma annulare and nearly continuous constipation. In addition, as a newborn he was given a diagnosis of gastrointestinal reflux disease (GERD), which persisted until he was about 6 months old. He began walking at around 9 months of age but soon developed ataxia. A brain MRI at the time showed no obvious issues. About the time Will

    turned 1 year old, he began to experience behavioral problems, including irritability and an extremely harsh temper. He often woke in the night screaming, which worsened as he grew older. Will began self-harming at age 18 months and suffered from frequent violent outbursts. After his second birthday, the violence escalated, and he began biting and kicking anyone who came near him. A qualified behavioral therapist was astonished and unable to provide useful guidance. His previous pediatrician determined that Will was likely suffering bipolar disorder and oppositional defiant disorder (ODD).

    Dan has a special interest in treating children with behavioral issues and was not certain that he agreed with the initial diagnoses. He began his assessment by collecting blood for a variety of tests to see if he could identify a biochemical rationale for Will’s behavior. All of the test results came back within the reference range. Dan took interest in the serum B12 value, nonetheless, since it was near the lower limit. He was aware that this test’s reference range is inaccurate in some cases, so he considers treatment with vitamin B12. In this case Dan administered a dose of vitamin B12. Within a week of daily injections, Will’s demeanor had changed drastically. He had moved from a violent and depressed state to one of happiness and content. Will’s parents were in shock by the seemingly impossible change to their previously distressed and crazy life.

    Self-Assessment Quiz Question 1

    In the case of Will, it appears most evident that the main consequence of vitamin B12 deficiency was manifested by behavioral issues. Nonetheless, this deficiency could also be associated with other problems. What are some examples of things that Dan should look into?

    1. Blood cell development. If Dan did not obtain a complete blood count, he should.

    2. Kidney dysfunction.

    3. Visual field disturbances.

    4. Adrenal function.

    Self-Assessment Quiz Question 2

    What can an astute nurse learn by observing Dan’s care of Will?

    1. Clinical laboratory levels are rarely useful as diagnostic tools.

    2. Clinical laboratory reference ranges are based on a population of patients and may not represent normal for all individuals.

    3. In many cases a second clinical opinion can provide value to making the correct diagnosis.

    4. Both b and c.

    Vitamin C (ascorbic acid) is acknowledged as an antioxidant that is useful in the promotion of healthy teeth and gums. Additional roles of vitamin C are to assist in the absorption of dietary

    iron, the maintenance of healthy tissue, and promotion of proper wound healing (MedlinePlus, 2020c). In the early 1970s, Linus Pauling, a winner of the Nobel Prize, proposed the theory that vitamin C administered as megadoses (up to 18,000 mg per day) is helpful in the prevention of colds. To confirm/refute this theory, many clinical studies were conducted examining supplementation with 200 mg or more vitamin C. Overall, these studies were unable to show reduced risk of catching a cold. Nonetheless, data do support that vitamin C supplementation can sometimes make a cold less severe and modestly shorten its duration. Some data suggest that 6 to 8 grams of vitamin C per day can shorten the duration of a cold in adults by about 18% (Gunnars, 2018).

    A critical concept is the proper dose levels of essential vitamins, especially in cases of fat- soluble vitamins that can accumulate to potentially toxic levels in the body. In general, patients should follow vitamin RDA when considering proper dosages of dietary supplements containing vitamins. Naturally, clinicians may suggest different levels for some patients depending on their individual needs (MedlinePlus, 2020c). RDA may vary by age or sex; current RDA are described in a table provided by the Food and Nutrition Board of the Institute of Medicine, National Academies that can be found at https://www.nal.usda.gov/sites/default/files/fnic_uploads//RDA_AI_vitamins_elements.pdf

    Nursing Consideration

    It is critical for nurses and nurse practitioners to distinguish between water- and fat-soluble vitamins relative to their ability to accumulate in the body. Unfortunately, the human mindset is often based on the premise that more is better. As such, massive doses of vitamins are not uncommon. In the case of water-soluble vitamins such as vitamin C, surplus vitamins are typically excreted in urine. Although this is economically wasteful, this is usually benign from a safety perspective. In contrast, elimination of fat-soluble vitamins is more difficult, meaning that excess vitamins can accumulate in the body. In extreme cases toxicities may result. This is important educational material that nurses should discuss with their patients.

    Case Study 2

    Nurse Jeanine is a staff nurse at small college health center. Today she is meeting with a new student, Gerri, who has come to her for some advice on how to prevent and manage the cold and flu season. In addition to taking a full course load, Gerri works the predawn shift at a local bakery for extra spending money. She realizes that all of this work has created high levels of stress, and she is thus concerned for her health going into the fall cold and flu season. Her multiple commitments make it very important that she not lose time because of illness, further adding to her stress levels. Specifically, Gerri is interested in Jeanine’s insights on a new

    supplement called MegaRed designed to prevent colds, flu, and a variety of other ailments. Although one of her friends highly recommended it, Gerri remains skeptical. Gerri learned through an Internet search that the supplement facts label showed that each MegaRed tablet contained (as a percentage of RDA) 33% for vitamin A; 700% for vitamin C; 200% for niacin; and 100% for vitamin B6. The label suggested that she take two to three tablets daily to maintain good health and another two to three tablets every 3 hours at the first sign of feeling unwell. To this point the product seemed to make sense to Gerri until she clicked on the “buy now” button and found that 100 tablets, described as a month’s supply, cost $79.99. This seemed like a lot of money to Gerri, thus motivating her to get Jeanine’s opinion. Jeanine, sharing Gerri’s skepticism, decided to turn it into a teaching moment by asking Gerri a series of questions to see how well she understood vitamins and how to use them.

    Self-Assessment Quiz Question 3

    When MegaRed is used as directed, which of the vitamin ingredients will provide all that Gerri likely needs daily, based on the recommended dietary allowance?

    1. Niacin.

    2. Vitamin B6.

    3. Vitamin C.

    4. All of the above.

    Self-Assessment Quiz Question 4

    Although MegaRed appears to rely on relatively high doses of most vitamins, each tablet provides only 33% of the recommended dietary allowance for vitamin A. What would be a plausible reason for this difference?

    1. Vitamin A has been proven to have little impact on colds.

    2. The relatively high dose of vitamin C is compensatory.

    3. Vitamin A is fat soluble allowing the possible accumulation of supertherapeutic doses.

    4. Vitamin A is minimized because as an ingredient it is cost prohibitive.

      Self-Assessment Quiz Question 5

      It appears that the most prevalent (largest dose) ingredient in MegaRed is vitamin C. Why do you think that is?

      1. Some data suggest that vitamin C can reduce the duration of a cold.

      2. Other data show that vitamin C may decrease the severity of a cold.

      3. Both a and b.

      4. Vitamin C is proven to prevent colds.

    Self-Assessment Quiz Question 6

    The cost of $79.99 for a one-month supply of MegaRed may be considered exorbitant to some individuals. Provide a plausible explanation for the relatively high cost.

    1. The product is aggressively marketed, and the manufacturers suspect that the relatively high cost will suggest high quality.

    2. The ingredients contained in MegaRed are uncommon and thus expensive.

    3. The cost is required to recoup company research and development efforts.

    4. The cost is largely driven by the relatively high dose of vitamin C.


    Dietary minerals work hand in hand with vitamins to provide complete nutrition. Minerals are needed for heart and brain function as well as the generation of certain hormones and enzymes. Dietary minerals can be broken into two main classifications based on how much the body requires: macroelements (large amounts required for proper nutrition: calcium, phosphorous, sodium, potassium, chloride, magnesium) and microelements (trace amounts needed: iron, nickel, zinc, fluoride, copper, chromium, manganese, selenium, iodine, molybdenum). Though an adequate quantity of minerals can usually be obtained with a healthy balanced diet, some populations may require supplementation. Candidates for mineral supplementation include pregnant women, nursing mothers, vegans, people who depend excessively on processed food, and older individuals (Kubala, 2020).

    Key dietary minerals and their function are listed below.


    Calcium, the most common mineral in the body, is needed to form bones and teeth, for muscle function, nerve transmission, and hormonal secretion. Most (99%) of the body’s calcium is stored in the bones and teeth. The body maintains the proper levels of calcium through constant resorption and deposition of calcium in the bones. In younger people, deposition generally exceeds resorption. The opposite is true in older people, especially postmenopausal women (NIH, 2020a).

    Phosphorus is second only to calcium in terms of abundance in the body, with which it works closely to construct strong bones and teeth. Smaller amounts of phosphorus can be found in tissues throughout the body. This mineral also plays a key role in the storage and usage of energy, as well as the growth, maintenance, and repair of tissues and cells. Although most people will get plenty of phosphorus in their diet, some health disorders can lead to decreased levels in the body. Further, anorexia and the use of some antacids can also cause phosphorous levels to drop (WebMD, 2020b).

    Sodium: The body requires some sodium to support the proper function of nerves and muscles and maintain a proper fluid balance, but most people receive too much sodium in their diets. Increased sodium levels can result in hypertension, which can lead to a variety of pathologies. Rather than supplementing sodium, most patients require assistance in limiting their intake of this mineral. This is especially important in people with high blood pressure, diabetes, and kidney problems; those who are African American; and people over age 50 (MedlinePlus, 2020b).

    Potassium is an electrolyte, meaning that it can conduct electricity in the body. As such it is crucial to proper heart function and is required for skeletal and smooth muscle contraction. Potassium is found in a wide variety of foods, making supplementation unnecessary for most individuals. It is important to maintain proper potassium blood levels; both too much (hyperkalemia) or too little (hypokalemia) can be dangerous. A variety of pathologies can cause hypokalemia; hyperkalemia is more prevalent in older individuals. Lastly, a variety of medications can impact potassium levels in some patients (Weatherspoon, 2019).

    Chloride can typically be found in the body in conjunction with sodium and water. It is useful to maintain the proper osmotic pressure of body fluids and is a critical partner to hydrogen in the formation of hydrochloric acid, a key digestive acid. Chloride is excreted or retained by the kidneys to maintain proper levels (Haas, n.d.).

    Magnesium is required as a component for more than 300 biochemical reactions in the body. For example, it is important in the maintenance of nerve and muscle function, immune system, heart rhythm, and bones. Most people get enough magnesium in their diets and supplementation is not generally indicated. It is rare that a person is ever truly magnesium deficient (MedlinePlus, 2019).


    Iron is needed by the body to make red blood cells. As a result, a lack of iron can lead to iron deficiency anemia. Though an adequate amount of iron can usually be obtained from the diet, some people may require supplementation. As an example, women who lose a large amount of blood during their menstrual cycle are at a higher risk of iron deficiency anemia and may be good candidates for supplementation. High doses of iron can be toxic, even fatal, especially in young children (National Health Service [NHS], 2020).

    Nickel: Although nickel’s exact mechanism of action is not well understood, it is useful in aiding the absorption of iron and treating osteoporosis. Although nickel deficiencies have not been reported in humans, low nickel levels have been observed in animals (WebMD, n.d.c.).

    Zinc is extremely important to good health. It impacts the immune system, cell division, and DNA synthesis. Although zinc deficiencies have been observed in people with insufficient intake, poor absorption, alcoholism, those with certain gene mutations, and the elderly, in most cases it is easy for people to consume adequate zinc in their diet. Like many things, though, too much zinc can result in adverse events such as nausea and vomiting, headaches, and decreased HDL cholesterol (Kubala, 2018).

    Fluoride aides in the development of strong bones and teeth. Fluoride is likely best known for its role in strengthening the enamel that protects teeth. It is critical to note that excess fluoride ingestion has been linked to a variety of health issues, such as dental fluorosis (tooth discoloration), skeletal fluorosis (decreased elasticity leading to pain and increased fracture risk), problems with the parathyroid, and some neurological issues (Brazier, 2018).

    Copper is present in all body tissues and works in concert with iron to form red blood cells. In most cases dietary copper is adequate. In cases of low levels of copper, anemia or osteoporosis can result. In excess, copper can be toxic, leading to hepatitis and kidney and brain issues (MedlinePlus, 2020a).

    Chromium has a variety of roles in the body, including the digestion of food. The presence of chromium may help slow the loss of calcium, to the benefit of people at risk of osteoporosis. It is critical to note that there is extensive commercial promotion of chromium as an aid in the building of muscle and burning fat. Nonetheless, there is inadequate available data to support these claims (WebMD, n.d.b.).

    Manganese is present mainly in the bones, liver, kidneys, brain, and pancreas. Manganese is vital to a variety of functions, to include amino acid, cholesterol, and glucose metabolism.

    Further, it is involved in the formation of bone, the clotting of blood, and inflammation reduction. In addition to being found in many foods, manganese can sometimes be derived from drinking water. Deficiencies are rare, nonetheless, and are sometimes associated with reduced glucose tolerance, fertility problems, and other issues. It is important to note that it is much more likely that a person would suffer from overexposure to manganese than a deficiency (Fletcher, 2019).

    Selenium, naturally available in a variety of foods, plays a critical role in thyroid hormone metabolism, reproduction, and DNA synthesis, as well as in providing protection from oxidative damage and infection. The major body storage site for selenium is in skeletal muscle, which accounts for 28% to 46% of the total body’s pool. Although most people obtain adequate

    selenium in their diet, deficiencies can generate biochemical changes that may leave some people vulnerable to stresses that can predispose them to certain illnesses. Selenium is contained in most multivitamin supplements (NIH, 2020e).

    Iodine is an essential part of the thyroid hormones thyroxine (T4) and triiodothyronine (T3). Thyroid hormones are involved in the regulation of several critical biochemical reactions in the body, including enzymatic activity, protein synthesis, and the regulation of metabolic activity. Further, thyroid hormones are needed to ensure the proper perinatal development of the skeletal and nervous systems (NIH, 2020c).

    Molybdenum plays a role as a cofactor for at least four essential enzymes, including sulfite oxidase. Sulfite oxidase works to help degrade the sulfites that occur in a number of chemically preserved foods and specific proteins. Even though most of this mineral is absorbed and stored in organs, some is converted to molybdenum cofactor, and excess is excreted in the urine. As with many vitamins and minerals, true deficiencies are rare, although long-term molybdenum deficiencies have been linked to esophageal cancer (Rowles, 2017).

    Just as with vitamins, it is critical that proper levels of essential minerals are maintained and supplemented only in cases where indicated by documented low-blood levels. This is especially important in situations where minerals can accumulate to potentially toxic levels in the body. In general, patients should follow vitamin RDA when considering proper dosages of dietary supplements containing minerals. Naturally, healthcare professionals may suggest different levels for some patients depending on their individual needs; RDA varies by age and sex.

    Current RDA are described in a table provided by the Food and Nutrition Board of the Institute of Medicine, National Academies that can be found at https://www.ncbi.nlm.nih.gov/books/NBK56068/table/summarytables.t3/?report=objectonly

    Nursing Consideration

    For most patients, an adequate amount of all essential vitamins and minerals can be obtained with a daily multivitamin. As a result, an investment in multivitamins may be the most cost-effective health intervention for many patients. Nurses should consider sharing this insight as part of their approach to patient education.


    Herbs and botanicals are plants or parts of plants that some patients use either as a treatment or preventive measure. Such products are formulated in teas, capsules, tablets, liquids, or powders. It is critical to note that, although these supplements are generally natural products,

    they are not always safer than prescription medications because they may be quite foreign to the human body. As a result, many of these products can be strongly impactful – sometimes causing serious adverse events. Some research has been conducted to characterize a few herbal/botanical products, but in most cases, a comprehensive understanding of the potential risks and benefits has not been achieved. Because these dietary supplements are classified by FDA as food, their safety and efficacy are not required to be proven. It is also important to know that some patient subpopulations can be at an increased risk of adverse events from herbal/botanical dietary supplements. Examples include those who are pregnant or breastfeeding or who have certain medical conditions. Some herbal products may cause problems with surgery, such as excessive bleeding. Further to that, some herbal products have the potential to impact the disposition of other medications. For instance, St. John’s wort can affect the metabolism of a large number of medications, decreasing their concentrations and subsequent effects. It is always critical to discuss the usage of all supplements with appropriate healthcare professionals (Family Doctor, 2020).

    Nursing Consideration

    Many patients do not consider dietary supplements when asked about their medications. Because of the potential pharmacologic properties of these products, especially herbal products, it is critical to specifically address supplements when obtaining medication histories.

    Like all medications and dietary supplements, the FDA requires that herbal/botanical products are accurately and truthfully labeled. Labeling must include its name, manufacturer/distributor, a complete list of ingredients, and the quantity contained in the package. In addition, proper directions for safe usage should be included. Any products that do not have this information on the label should be avoided. If a dietary supplement is found to be unsafe or is mislabeled, FDA is empowered to remove it from the marketplace. Patients who decide to take these products should use the products as directed and in the recommended amounts (Family Doctor, 2020).

    Although hundreds of different herbal/botanical dietary supplements are available, some of the more common herbal supplements include the following.

    Cannabidiol (CBD), a component of marijuana, has been shown to have effects on the brain through unknown mechanisms. Apparently, it impacts pain, mood, and mental function.

    Preliminary research has shown that CBD may be effective for a variety of disorders, to include bipolar disorder, Crohn’s disease, diabetes, dystonia, fragile-X syndrome, graft versus host

    disease, Huntington’s disease, and insomnia. At this time, though, none of these indications has been proven out in properly powered, randomized, controlled clinical trials (WebMD, n.d.a.).

    Nonetheless, specific CBD products have been shown to be safe and efficacious and thus approved as prescription drugs for the treatment of certain seizures (Epidiolex) and in combination with THC (Sativex) for the treatment of multiple sclerosis in 25 countries outside of the United States (WebMD, n.d.a.).

    CBD has been shown to have the potential to interact with a large number of medications, both through modulation of at least two common metabolic enzymes and a key protein involved with the absorption and excretion of drugs (P-glycoprotein). As a result, the potential for CBD drug interactions with commonly used medications is great. Although a comprehensive list of all potential drugs is beyond the scope of this educational program, a list of medications with the potential to interact with CBD can be found in Brown and Winterstein’s review article (2019): https://www.mdpi.com/2077-03/8/7/989

    Spirulina is a variety of blue-green algae considered by some to be a superfood. Spirulina, high in protein and vitamins, is suitable for vegetarians. Some research has suggested that it has antioxidant properties and may be capable of regulating the immune system. People may take spirulina to aid in weight loss, improvement of gut health, managing the symptoms of diabetes, reduction of cholesterol, controlling blood pressure, prevention of heart disease, increasing basal metabolism, reduction of allergy symptoms, and supporting mental health (Burgess, 2018).

    Although the literature contains a number of nonclinical and small human trials providing some evidence of effect, current knowledge can only suggest that spirulina is a safe food supplement without significant side effects. Its effectiveness is yet to be definitively established.

    St. John’s wort (Hypericum perforatum) is a European flowering shrub. The flowers and the leaves of this plant are known to contain a pharmacologically active chemical called hyperforin. Unlike many other herbal/botanical supplements, reasonable clinical evidence has been generated to demonstrate its potential efficacy in the treatment of mild to moderate cases of depression. In fact, some investigations suggest that it may incur efficacy on the magnitude of some prescription antidepressant medications. A potential pitfall to the use of St. John’s wort is its drug interaction potential. St. John’s wort reacts not only with antidepressants, but also with anticoagulants, birth control medications, HIV/AIDS medications, and many others. As a result, its use may be hazardous in patients using concomitant medications (Mayo Clinic, 2017c).

    Turmeric is a spice that is commonly used to color curries, mustards, and other foods. Turmeric root is also widely used as an alternative medicine, possibly aiding in reduction of cholesterol, treatment of pain from osteoarthritis, and treatment of stomach ulcers, rheumatoid arthritis, tuberculosis, Alzheimer’s disease, cancer, and inflammatory bowel disease (Multum, 2019). The literature contains a number of nonclinical and small human trials providing some evidence of effect, but current knowledge can only suggest that turmeric is a safe food supplement without significant side effects. Its effectiveness is yet to be definitively established.

    Evidence-Based Practice

    Apaydin and colleagues (2016) conducted a systematic review of the scientific literature to assess the safety and efficacy of St. John’s wort (SJW) for the treatment of major depressive disorder (MDD) compared to both placebo and active control. They considered randomized controlled trials (RCT) employing at least a 4-week treatment period. A total of 35 published clinical trials enrolling a total of 6,993 patients met their criteria and were included in their analyses. Results showed a response rate for SJW-treated patients that was 53% higher than those who received placebo (16 RCT enrolling 2,888 patients). Reported adverse events were similar between SJW-treated and placebo-treated patients with the exception of those related to the eye, ear, nervous, hepatic, renal, and reproductive systems. Investigators noted that assessments of adverse events across studies were limited, lowering the quality of evidence. When SJW-treated patients experienced fewer adverse events, investigators concluded that SJW monotherapy is superior to placebo and not significantly different from antidepressant medications for the treatment of mild to moderate depression.

    Nursing Consideration

    The potential use of St. John’s wort to treat depression may be attractive to many patients, especially those interested in natural remedies. Its drug interaction potential, however, is a liability with possibly serious consequences. As a result, it is critical that nurses keep this in mind when collecting medication histories or recommending this product to their patients.

    Case Study 3

    Mary M. is an 83-year-old woman with a history of hypertension and myocardial infarction. She is visiting with her APN, Jenny. Midway through their conversation, Jenny realizes that Mary seems a bit different than she remembers, somehow lacking the sparkle in her eye and the normal wit in her expression. After a bit of probing, Mary communicates that she has not felt

    normal lately. More specifically, she feels a bit down after the holidays. After she thought about it a bit, she admitted that this always happens in January. Jenny realized the importance of listening at this point, so she allowed Mary to continue. Eventually, Mary asked Jenny if she thought that she might be suffering from depression. She said that she had been discussing her feelings with a close friend, who said she often feels the same and feels better after taking St.

    John’s wort. Now that Jenny was thinking about it, she realized that Mary could be suffering from a seasonal type of depression. Rather than going straight to a prescription antidepressant medication, Jenny wondered to herself if Mary might be a good candidate for a trial with St.

    John’s Wort. Jenny had read publications that suggested that this herbal product can be as effective as conventional antidepressants and, because it is a natural product, perhaps it might be safer. She quickly reviewed a recent review article focused on the use of St. John’s wort for mild to moderate depression and reviewed Mary’s current medications. Mary was taking lisinopril 10 mg, hydrochlorothiazide 25 mg, and clopidogrel 75 mg.

    Self-Assessment Quiz Question 7

    Which of the following statements about St. John’s wort is FALSE?

    1. Although it is an herb, it has pharmacologically active properties.

    2. According to some clinical studies, its efficacy against mild to moderate depression is similar to that afforded by prescription antidepressants.

    3. No adverse events are associated with the use of St. John’s wort.

    4. St. John’s wort has the potential to interact with other medications.

    Self-Assessment Quiz Question 8

    It has been established that St. John’s wort should be treated like a prescription medication. Before prescribing it, drug interactions with existing medications must always considered.

    Which of Mary’s concomitant medications has the greatest chance of interacting with St. John’s


    1. Lisinopril.

    2. Clopidogrel.

    3. Hydrochlorothiazide.

    4. None of the above.

    Pomegranate juice and extract: Pomegranate (Punica granatum) is a tree bearing fruit native to Western and Central Asia with a long history of being grown in temperate climates worldwide. It can be consumed as a fruit, juice, or extract product. Pomegranates, enjoyed for millennia, were always thought of as having health benefits. Pomegranates are a good source of vitamin C, vitamin K, iron, calcium, potassium, and folate. Recent scientific research suggests that pomegranates also possess multiple key properties that may be beneficial to health. Many of

    these health claims are based on multiple polyphenolic compounds found in the pomegranate. These phytochemicals have been shown to act as antioxidants, impacting numerous body systems. Some examples of potential benefits include reduction of cholesterol and plaque buildup in artery walls and reduction of inflammatory cytokines, and decreasing the symptoms of osteoarthritis, rheumatoid arthritis, and other inflammatory diseases. Despite these potential benefits and a relatively benign adverse event profile, pomegranate has the potential to interact with multiple medications, to include warfarin, enalapril, and other ACE inhibitors (WebMD, 2020a).

    Animal models have shown that some pomegranate components inhibit the metastasis of ovarian cancer by way of downregulating multiple matrix metalloproteinases. When pomegranate’s effect on prostate cancer cells was evaluated, a similar effect on matrix

    metalloproteinases was observed, inducing apoptosis and impairing metastasis. Work with a pomegranate extract product suggested a prevention of breast cancer through multiple anti- inflammatory processes. Although these preclinical data are encouraging, more extensive clinical research is required for confirmation of effect (Memorial Sloan Kettering Cancer Center [MSKCC], 2019).

    Evidence-Based Practice

    Decreasing prostate specific antigen doubling time (PSADT) is generally associated with increased risk of prostate cancer recurrence. Paller and investigators (2013) conducted a double-blind, placebo-controlled trial in 104 recurrent prostate cancer patients with decreasing PSADT. Subjects were randomized to receive either 1 or 3 grams of pomegranate extract daily for up to 18 months. Data showed that PSADT was elongated from 12 to 19 and 12 to 18 months in the low- and high-dose groups, respectively (p < 0.001). There was no statistical difference between the two dose levels (p = 0.554). PSADT increases > 100% were observed in 43% of patients, and declining PSA levels were observed in 13% of patients.

    Although no significant adverse events were observed in either group, the incidence of diarrhea was higher in the high-dose group (14% vs. 2%). Investigators concluded that, although significant increases in PSADT were observed at both dose levels, these results need to be confirmed in a placebo-controlled trial.

    Amino Acids

    The Internet is awash with opportunities to purchase a wide variety of amino acid-based dietary supplements designed to improve health. In one recent article describing the use of these products, amino acid supplements are purported to offer health benefits for people wanting to replenish their bodies after a workout or just remain healthy. The manufacturer’s argument states that these supplements contain the essential amino acids – those that the body cannot

    make – needed to form necessary proteins. The idea is that there is a need to supplement the dietary input of amino acids. Thus, amino acid supplements serve as a sort of insurance policy to ensure that the body receives all of the amino acids needed. Further, it is theorized that the supplements are required at times of elevated protein demand, such as during illness or when recovering from an injury. Amino acid supplements are broken down into two distinct categories: branched-chain amino acids (BCA) (contain leucine, isoleucine and valine, potentially the most studied amino acids used for dietary supplementation), and those that are designed to be high in arginine and glutamine. Because 33% of skeletal muscle is composed of BCA, it follows that they may play a role in exercise recovery. The single amino acid supplements arginine and glutamine are described as offering specific health benefits. Arginine, an essential amino acid, can be converted to nitric oxide, which relaxes blood vessels and may be useful in the management of high blood pressure. Glutamine, which is not essential, is thought to assist in wound healing and reducing the rate of infection (Annigan, 2018).

    Additional amino acid supplements intended to provide health benefits include L-tryptophan, aspartate, orthenine, lysine, tyrosine, and taurine (Annigan, 2018).

    Unfortunately, the scientific literature does not contain a large body of research to solidly document the utility of these supplements (Annigan, 2018).

    Evidence-Based Practice

    Wolfe (2017) noted that a lucrative industry has formed based on the hypothesis that BCA, given alone, are able to drive an anabolic response in humans that stimulates the synthesis of muscle protein. His review of the literature revealed no studies in humans where the response of muscle protein synthesis was observed as a result of orally ingested BCA. Nonetheless, he identified two studies where BCA were administered via intravenous infusion. In these examinations, a decrease in muscle protein synthesis coupled to protein breakdown was correlated to BCA administration. These findings, then, suggest a decrease in the turnover of muscle protein. In other words, muscle protein catabolism exceeded the rate of new muscle synthesis during BCA infusion. He theorizes that muscle synthesis is rate limited by the lack of other essential amino acids. In summary, the author concluded that the claim of BCA, administered alone, stimulating muscle protein synthesis in humans is unwarranted.

    The findings of Wolfe leave open the possibility that if BCA could be combined with other essential amino acids, a positive effect on muscle recovery could be realized. Unfortunately, such supplementation must be empirically based, as there are no reputable data available to support this hypothesis.

    Nursing Consideration

    There is little evidence available to support the use of amino acid-based dietary supplements in most patients. Nurses may find that some of their patients are strong believers in the benefit of these products. In some cases, however, it may be useful to have a tactful, yet direct, conversation with their patients regarding the potential shortcomings of these products.


    Probiotics are bacteria that are ingested in an effort to maintain a proper balance of intestinal microflora. The gastrointestinal (GI) tract typically hosts approximately 400 species of bacteria that act in concert to crowd out harmful bacteria. When functioning as intended, these organisms help maintain a healthy digestive tract. Assessment of the GI tract demonstrates that the most common probiotic bacteria are of the lactic acid variety. The most common species is Lactobacillus acidophilus, which is also found in live yogurt cultures. Other common organisms are classified within the yeast family. Many species are available as dietary supplements and are intended to treat a variety of gastrointestinal problems. Some people take probiotics in an effort to prevent the diarrhea, gas, and cramping that often accompany the use of certain antibiotics. The theory behind this practice is that antibiotics often kill “good” bacteria, allowing opportunistic “bad” bacteria to flourish. This is thought to result in gastrointestinal distress, overgrowth of vaginal yeast, and urinary tract infections. The aim of probiotics is to replace the bacteria lost as collateral damage to antibiotic therapy (WebMD, 2020c).

    It is critical to note that only certain species of yeast and Lactobacillus are beneficial. Further research is needed to clearly demonstrate which specific probiotic species are effective at treating disease. Further, many of the species with demonstrated efficacy are not widely available in practical supplement formulations. The majority of probiotics are composed of organisms native to the body and have been consumed for many years in the form of fermented foods and cultured milk products. As a result, these products do not raise significant safety concerns. Nonetheless, it is evident that additional research is needed to fully understand the safety of probiotics in immunocompromised young and older individuals (WebMD, 2020c).

    Acidophilus (Lactobacillus acidophilus) is native to humans within the mouth, the GI tract, and the vagina. It is also a common dietary supplement ingredient. Acidophilus is found in a variety of dairy products, such as yogurt, and is generally formulated for use as a supplement in capsules, tablets, wafers, powders, and as vaginal suppositories. It is commonly used in an effort to prevent or treat bacterial vaginosis and various digestive issues, as well as to simply promote the growth of beneficial GI bacteria.

    A large amount of clinical research has been conducted in an effort to promote the benefits of acidophilus. Efficacy has been demonstrated in the treatment of bacterial vaginosis. Data have also been generated supporting its use in the treatment of respiratory infections and some varieties of diarrhea, bloating, and cramps caused by antibiotic usage, to include the more serious C. difficile-induced diarrhea. Oral acidophilus may also be beneficial during pregnancy and breastfeeding to reduce the occurrence of atopic dermatitis in infants and young children who are breastfeeding. One issue with the use of acidophilus is a lack of standardization among available supplements, which complicates the proper dosing of this probiotic as a dietary supplement. Although additional research is required to provide the data needed to guide the proper use of acidophilus, available evidence suggests that there is little harm in using these products. Nevertheless, ingestion of a balanced diet that includes fermented foods may provide adequate levels of these useful bacteria (Mayo Clinic, 2017a.).

    Fish Oil

    Fatty fish and some shellfish contain polyunsaturated fatty acids, collectively known as omega-3 fatty acids. Omega-3 fatty acids are critical to a variety of functions in the human body. The most abundant omega-3 fatty acids are alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). ALA is prevalent in vegetable oils, especially canola and soybean oils. Flaxseed oil is a good vegetarian source of ALA, but its use in the common American diet is limited. EPA and DHA can be generated in the body through ALA conversion, but this source too is limited. The best source of EPA and DHA is fatty fish such as salmon, trout, and tuna, as well as shellfish such as crab, oysters, and mussels. In addition to these sources, omega-3 fatty acids are widely available as dietary supplements. Although vegetarians may consider flaxseed and algae oils as supplemental sources of EPA and DHA, respectively, fish oil- based supplements are a common source of all three fatty acids (National Center for Complementary and Integrative Health [NCCIH], 2018).

    It is well acknowledged that omega-3 fatty acids are critical to facilitate a variety of functions, including the activity of muscles, clotting of blood, cell division/growth, and fertility. More specifically, DHA is needed to support brain development and function. ALA is considered “essential,” meaning that there is no way for the body to make it; it must be obtained from either food or dietary supplementation. Perhaps because of the many potential health benefits of omega-3 fatty acids, research has been conducted examining their role in a variety of pathologies. Examples evaluated include conditions affecting the circulatory system, brain, nervous system, mental health, the eye, rheumatoid arthritis, and infant development (NCCIH, 2018).

    The 2012 National Health Interview survey showed that fish oil supplements are the most commonly used nonvitamin and nonmineral natural products consumed by American adults and children. This survey indicated that nearly 8% of adults had used a fish oil supplement in the previous 30 days (NCCIH, 2018).

    Evidence-Based Practice

    Calder (2015) acknowledged that inflammation contributes to the pathology of various disease states and that EPA and DHA, found in fish oil supplements, are able to partially blunt this condition through a number of distinct mechanisms. Further, he stated that both substances facilitate the generation of mediators that work to resolve inflammation through multiple linked biochemical mechanisms. Unfortunately, not all of these processes are fully understood. He goes on to note that animal research in models of rheumatoid arthritis (RA), inflammatory bowel disease (IBD), and asthma respond to treatment with omega-3 fatty acids. In humans, though benefit has been shown in the treatment of RA, clinical trials of fish oil in the treatment of IBD and asthma are inconsistent and unable to show any evidence of efficacy.

    NCCIH’s opinion aligns with Calder’s findings and comments on other potential indications (NCCIH, 2018):

    • Fish oil may be useful to relieve symptoms of rheumatoid arthritis.

    • Omega-3 supplements have not been shown to reduce the risk of heart disease. People who consume seafood regularly are less likely to die of heart disease.

    • High-dose omega-3 supplementation may reduce triglyceride levels (included as an indication for prescription-only fish oil products).

    • Omega-3s have not been convincingly shown to be beneficial in the treatment of age- related macular degeneration and many other conditions (NCCIH, 2018).

      When used as directed, fish oil supplements are typically considered to be safe and well tolerated. Nonetheless, belching, bad breath, heartburn, nausea, loose stools, rash, and nosebleeds have been associated with their use. Further, at high-dose levels, fish oil may increase the risk of bleeding and stroke. Lastly, it is unclear if people with allergies to fish or shellfish can safely use fish oil (Mayo Clinic, 2017b).

      Nursing Consideration

      There appears to be reasonable evidence that eating seafood confers some health benefits. It is not clear, based on research conducted to date, that all of these same benefits can be obtained by consuming fish oil supplements. As a result, nurses should discuss these potential differences with their patients. In any case, all patients will benefit with a shift to more healthy eating habits.

      Case Study 4

      In preparation for Steve’s appointment with his APN, he is completing a medication history with Nurse Jill. In the past, he has been taking a prescription omega-3 ethyl ester supplement (Lovaza) to help reduce his chances of suffering heart disease. Unfortunately, as a result of the COVID-19 pandemic, Steve has lost his job and is unable to afford COBRA health insurance and its pharmaceutical benefit. He was happy with how Lovaza was working for him and asks Jill if she can suggest a less expensive alternative. His clinical laboratory results indicate a total cholesterol level of 220 mg/dL, LDL-cholesterol of 80 mg/dL, and a triglyceride level of 612 mg/dL. He is not taking any other medications other than a daily multivitamin and suffers no outward medical conditions.

      Self-Assessment Quiz Question 9

      Identify the parts of Jill’s potential response to Steve that are factually correct based on

      currently accepted use guidelines for fish oil:

      1. She recommends an over the counter (OTC) fish oil product with a high concentration of omega-3 that is verified by the United States Pharmacopeia (USP) to help prevent heart disease.

      2. She reviews with Steve the approved indications for Lovaza, noting that it is not indicated for prevention of heart disease and that there is not sufficient data to support this use.

      3. Jill notes that his triglyceride levels are greater than 500 mg/dL, indicating that fish oil may be appropriate to treat that abnormality.

      4. Both b and c.

      Self-Assessment Quiz Question 10

      Steve appreciated Jill’s sharing information on the proper use of fish oil and wanted to consider using an OTC fish oil product in an effort to bring down his triglycerides. This might be effective, and it might be less expensive than paying cash for a prescription product. Nonetheless, before taking this to his APN, he asks Jill what he might expect as far as side effects. He had experienced fatigue when taking Lovaza and wanted to know if he should expect this to

      continue. Which of the following adverse events is known to be associated with the use of fish oil supplements?

      1. Nausea.

      2. Heart palpitations.

      3. Unexplained weight loss.

      4. Alopecia.



      The National Center for Complementary and Integrative Health has issued several themes that summarize the material presented in this educational program (NCCIH, 2019):

    • Dietary supplements contain many ingredients. Although solid clinical research has confirmed the value of some, others remain unproven.

    • The safe use of supplements requires that users carefully read the labels’ directions. It is also important to recognize that claims of natural sources do not always translate to safety. This is especially true in the case of herbal/botanical products that may contain multiple ingredients – some unknown.

    • Supplement-food and supplement-drug interactions are always a possibility; some interactions pose significant risks. Further, the majority of supplements have not been adequately evaluated for safety in children or women who are pregnant or breastfeeding.

    • Although FDA does provide some oversight of dietary supplements, the regulations are generally less rigorous than those used for prescription or over-the-counter medications.

    Nursing Consideration

    The combination of dietary supplements’ sometimes unknown pharmacology and safety liabilities may complicate the provision of healthcare, especially in pharmacotherapy. As a result, it is critical that nurses work with the healthcare team to obtain comprehensive medication histories to include dietary supplements.


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    Gunnars, K. (2018). Vitamin C for colds — Does it actually work? https://www.healthline.com/nutrition/does-vitamin-c-help-with-colds

    Haas, E. M. (n.d.). Minerals: Chloride. http://www.healthy.net/Health/Article/Chloride/2050

    Kerkar, P. (2018). What are the neurological symptoms of vitamin B12 deficiency? https://www.epainassist.com/vitamins-and-supplements/what-are-the-neurological- symptoms-of-vitamin-b12-deficiency

    Kubala, J. (2018). Zinc: Everything you need to know. https://www.healthline.com/nutrition/zinc#1

    Kubala, J. (2020). 16 Foods rich in minerals. https://www.healthline.com/nutrition/foods-with- minerals

    Mayo Clinic. (2017a). Acidophilus. https://www.mayoclinic.org/drugs-supplements- acidophilus/art-20361967

    Mayo Clinic. (2017b). Fish oil. https://www.mayoclinic.org/drugs-supplements-fish-oil/art- 20364810

    Mayo Clinic. (2017c). St. John's wort. https://www.mayoclinic.org/drugs-supplements-st-johns- wort/art-20362212

    Mayo Clinic. (2017d). Vitamin A. https://www.mayoclinic.org/drugs-supplements-vitamin-a/art- 20365945

    MedlinePlus. (2019). Magnesium in diet. https://medlineplus.gov/ency/article/002423.htm MedlinePlus. (2020a.) Copper in diet. https://medlineplus.gov/ency/article/002419.htm MedlinePlus. (2020b). Sodium. https://medlineplus.gov/sodium.html

    MedlinePlus. (2020c). Vitamins. https://medlineplus.gov/ency/article/002399.htm

    Memorial Sloan Kettering Cancer Center. (2019). Pomegranate. https://www.mskcc.org/cancer- care/integrative-medicine/herbs/pomegranate

    Mister, S. (2020). A mandatory dietary supplement registry: Transparency as “disinfectant.” https://www.raps.org/news-and-articles/news-articles/2020/6/a-mandatory-dietary- supplement-registry-transparen

    Multum, C. (2019). Turmeric. https://www.drugs.com/mtm/turmeric.html

    National Academies of Sciences, Engineering, and Medicine. (2018). Food and Nutrition Board. http://nationalacademies.org/hmd/about-hmd/leadership-staff/hmd-staff-leadership- boards/food-and-nutrition-board.aspx

    National Center for Complementary and Integrative Health. (2018). Omega-3 supplements: In depth. https://www.nccih.nih.gov/health/omega3-supplements-in-depth

    National Center for Complementary and Integrative Health. (2019). Using dietary supplements wisely. https://nccih.nih.gov/health/supplements/wiseuse.htm

    National Health Service. (2020). Iron. https://www.nhs.uk/conditions/vitamins-and- minerals/iron/

    National Institute on Aging. (2019). Vitamins and minerals. https://www.nia.nih.gov/health/vitamins-and-minerals

    National Institutes of Health. (n.d.). Nutrient recommendations: dietary reference intakes (DRI). https://ods.od.nih.gov/HealthInformation/Dietary_Reference_Intakes.aspx

    National Institutes of Health. (2018). Complementary, alternative, or integrative health: What’s in a name? https://www.nccih.nih.gov/health/complementary-alternative-or-integrative- health-whats-in-a-name

    National Institutes of Health. (2020a). Calcium. https://ods.od.nih.gov/factsheets/Calcium- HealthProfessional/

    National Institutes of Health. (2020b). Dietary and herbal supplements. https://www.nccih.nih.gov/health/dietary-and-herbal-supplements

    National Institutes of Health. (2020c). Iodine. https://ods.od.nih.gov/factsheets/Iodine- HealthProfessional/

    National Institutes of Health. (2020d). Niacin. https://ods.od.nih.gov/factsheets/Niacin- HealthProfessional/

    National Institutes of Health. (2020e). Selenium. https://ods.od.nih.gov/factsheets/Selenium- HealthProfessional/

    National Institutes of Health. (2020f). Vitamin B6. https://ods.od.nih.gov/factsheets/VitaminB6- HealthProfessional/

    National Institutes of Health. (2020g). Wellness and well-being.


    Norman, B. (2019). New FDA regulations on supplements: What do they mean? https://www.ghs.org/healthcenter/ghsblog/new-fda-regulations-on-supplements-what-do- they-mean/

    Paller, C. J., Ye, X., Wozniak, P. J., Gillespie, B. K., Sieber, P. R., Greengold, R. H., Stockton, B. R.,

    Hertzman, B. L., Efros, M. D., Roper, H. R., Liker, H. R., & Carducci, M. A. (2013). A randomized phase II study of pomegranate extract for men with rising PSA following initial therapy for localized prostate cancer. Prostate Cancer Prostatic Diseases, 16, 50-55. https://doi.org/10.1038/pcan.2012.20

    Palsdottir, H. (2020). What are the health benefits of biotin? https://www.medicalnewstoday.com/articles/318724

    Palus, S. (2019). How vitamins went from medical marvel to marketing scam. https://slate.com/human-interest/2019/03/vitamins-careof-marketing-not-necessary- wellness-evidence.html

    Rowles, A. (2017). Why molybdenum is an essential nutrient. https://www.healthline.com/nutrition/molybdenum

    Tweed, V. (2017). The 100-year history of vitamins: A timeline of the storied history of multivitamins. https://www.betternutrition.com/supplements/history-of-vitamins

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    Ware, M. (2019b). What are the health benefits of vitamin D? https://www.medicalnewstoday.com/articles/161618

    Weatherspoon, D. (2019). Potassium. https://www.healthline.com/health/potassium

    WebMD. (n.d.a.). Cannabidiol (CBD). https://www.webmd.com/vitamins/ai/ingredientmono- 1439/cannabidiol-cbd

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    Self-Assessment Answers and Rationale

    1. The correct answer is a. Rationale: Vitamin B12 deficiencies are sometimes associated with pernicious anemia. Many times, people with this condition are unable to properly form red blood cells, and those that they do make may not function properly.

    2. The correct answer is d. Rationale: It is important to know that diagnostic reference ranges are designed to represent normal for most people. As such, it is always possible that some individuals may not fall within those standards. Because of this, clinicians must always rely on their experience and discretion, even in cases where the diagnostic data do not exactly align with what is expected. Secondly, it is important to acknowledge the amount of subjectivity involved in patient care. As a result, it may make sense to get a second opinion, especially in cases where the consequences of a misdiagnosis are great.

    3. The correct answer is d. Rationale: MegaRed, when taken at a maintenance dose of two to three tablets per day, is formulated to provide more than is needed to meet the nutritional needs of 97% to 98% of healthy adults for niacin, vitamin B6, and vitamin C. If two tablets are taken, it would provide 66% of the daily suggested vitamin A intake; three tablets would give 99%.

    4. The correct answer is c. Rationale: Vitamin A is a fat-soluble vitamin. As a result, in cases where excess is ingested, it is typically stored in fat cells, allowing potentially dangerous accumulation.

    5. The correct answer is c. Rationale: There is no compelling data to suggest that taking large doses of vitamin C will prevent a person from catching a cold. Nonetheless, some studies have provided evidence that vitamin C may be able to reduce the duration and severity of a cold.

    6. The correct answer is a. Rationale: all of the vitamins used to make MegaRed are readily available at relatively low cost. The manufacturer of this product has developed a proprietary formulation with desirable, but questionable, utility. Although the product likely does not intrinsically command such a cost, it seems possible that the manufacturer is creating an illusion of value by demanding an exorbitant cost. Gerri, on a student budget, could likely procure similar amounts of each ingredient individually at a lower total cost.

    7. The correct answer is c. Rationale: St. John’s wort contains drug-like, pharmacologically active substances. As such, it should be afforded the same consideration as prescription medications. Like most medications, the occurrence of adverse events has been associated with the use of St. John’s wort.

    8. The correct answer is b. Rationale: St. John’s wort is known to sometimes interact with

      anticoagulant medications such as clopidogrel.

    9. The correct answer is d. Rationale: Although fish oil has historically been used for the prevention of heart disease, this indication is not supported by current clinical guidelines and is not an approved use of prescription fish oil products. Nonetheless, fish oil has been shown effective in the treatment of triglyceridemia and is indicated as such in the package insert for Lovaza.

    10. The correct answer is a. Rationale: The most frequently reported adverse events associated with the use of fish oil are belching, bad breath, heartburn, nausea, loose stools, rash, and nosebleeds. At very high doses, fish oil can lead to bleeding or the occurrence of stroke.

  • Challenges in Attaining and Maintaining Good Nutrition

    Challenges in Attaining and Maintaining Good Nutrition

    7 Contact Hours

    Released: 2/21/20

    Expire: 2/21/23

    Author: Adrianne E. Avillion, D.Ed., RN

    Adrianne E. Avillion, D.Ed, RN, is an accomplished nursing professional development specialist and health care author. She earned her doctoral degree in adult education and her MS in nursing from Penn State University and a BSN from Bloomsburg University. Dr. Avillion has held a variety of nursing positions as a staff nurse in critical care and physical medicine and rehabilitation settings with emphasis on neurological and mental health nursing as well as a number of leadership roles in nursing professional development. She has published extensively and is a frequent presenter at conferences and conventions devoted to the specialty of continuing education and nursing professional development. Dr. Avillion owns and is the CEO of Strategic Nursing Professional Development, a business that specializes in continuing education for health care professionals and consulting services in nursing professional development. Her publications include the following: The Path to Stress-Free Nursing Professional Development: 50 No-Nonsense Solutions to Everyday Challenges and Nursing Professional Development: A Practical Guide for Evidence-Based Education.

    Reviewer: Shellie Hill DNP, FNP-BC

    Shellie Hill DNP, FNP-BC is an Assistant Professor in the MSN-NP program at Saint Louis University.  Here she teaches the clinical courses for the Family Nurse Practitioner students, and she teaches health assessment and health promotion to MSN students.  Dr. Hill has been a practicing Family Nurse Practitioner for 18 years.  Most of her practice has been in primary care, but she also has experience urgent care and cardiology.  Her current practice is in corporate health.  She is passionate about dermatology and has studied it extensively.  Her doctorate study was titled “Skin Cancer Screenings in Primary Care.”  Dr. Hill attends national nurse practitioner conferences regularly.  She has also presented at several local and regional conferences on dermatological problems.  She also teaches suturing workshops.

    Purpose Statement: Obesity, a problem that affects more than 90 million adults in the United States, is associated with the development of cardiac disease, stroke, type 2 diabetes, and certain cancers.  The purpose of this course is to provide current information about nutrition best practices as well as recommendations related to weight reduction and select eating disorders.

    Learning Objectives:

    1. Discuss the current state of eating patterns in the United States.
    2. Explain the impact of obesity on health and wellness.
    3. Describe common eating disorders.
    4. Discuss the recommended guidelines for a healthy diet.
    5. Describe the components of specific nutrients.
    6. Differentiate among the components of various types of diets.
    7. Identify nutritional needs for specific populations.
    8. Discuss nursing interventions regarding nutritional needs for healthcare consumers.
    9. Explain intent to change practice regarding nutrition.

    How to receive credit

    • Read the entire course online or in print which requires a 7-hour commitment of time.
    • Complete the self-assessment quiz questions which are at the end of the course or integrated throughout the course. These questions are NOT GRADED.  The correct answer is shown after you answer the question.  If the incorrect answer is selected, the rationale for the correct answer is provided.  These questions help to affirm what you have learned from the course.
    • Depending on your state requirements you will then be asked to complete either:
      • An affirmation that you have completed the educational activity
      • A mandatory test (a passing score of 70 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention.
    • If requested, provide required personal information and payment information.
    • Complete the mandatory Course Evaluation
    • Print your Certificate of Completion.

    CE Broker Reporting. 

    Elite, provider # 50-4007, reports course completion results within 1 business day to CE Broker.  If you are licensed in Arkansas, District of Columbia, Florida, Georgia, New Mexico, South Carolina, or West Virginia, your successful completion results will be automatically reported for you.

    Accreditations and Approvals:

    Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center’s Commission on Accreditation. 

    Individual State Nursing Approvals

    In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by:  Alabama, Provider #ABNP1418 (valid through March 1, 2021); California Board of Registered Nursing, Provider #CEP17480 (valid through January 31, 2022); California Board of Vocational Nursing and Psychiatric Technicians (LVN Provider # V15058, PT Provider #15020) valid through December 31, 2021;  District of Columbia Board of Nursing, Provider # 50-4007; Florida Board of Nursing, Provider #50-4007; Georgia Board of Nursing, Provider #50-4007; and Kentucky Board of Nursing, Provider #7-0076 (valid through December 31, 2021).  This CE program satisfies the Massachusetts Board’s regulatory requirements as defined in 244 CMR5.00: Continuing Education.

    Activity Director

    June D. Thompson, DrPH, MSN, RN, FAEN

    Lead Nurse Planner


    Resolution of Conflict of Interest

    In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.

    Sponsorship/Commercial Support and Non-Endorsement

    It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.


    The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition  ©2020:  All Rights Reserved.  Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC.  The materials presented in this course are meant to provide the consumer with general information on the topics covered.  The information provided was prepared by professionals with practical knowledge of the areas covered.  It is not meant to provide medical, legal, or professional advice.  Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state.  Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials.  Quotes are collected from customer feedback surveys.  The models are intended to be representative and not actual customers.

    Course Verification

    All individuals involved have disclosed that they have no significant financial or other conflicts of interest pertaining to this course.  Likewise, and in compliance with California Assembly Bill No. 241, every reasonable effort has been made to ensure that the content in this course is balanced and unbiased.


     Nurses are in an advantageous position to provide counseling and education regarding healthy eating. Teaching healthcare consumers about nutrition is an essential component of health maintenance and illness prevention, and is within the nurse’s scope of practice. As health care moves from a model of treating illness to a model of prevention, nurses are expected to include dietary education as part of wellness promotion activities.

     Obesity, a problem that affects more than 90 million adults in the United States (U.S.), is associated with the development of cardiac disease, stroke, type 2 diabetes, and certain cancers (Centers for Disease Control and Prevention [CDC], 2018a). It is, therefore, imperative that nurses incorporate nutritional education as part of routine patient/family education.

    Current State of Eating Patterns in the United States

     Most Americans are aware that a healthy diet should contain an abundance of fruits and vegetables and limited amounts of saturated fats, sugars, and salt. Despite the availability of accessible information, Americans continue to make poor nutritional choices. It is estimated that about 75% of the population has an eating pattern that is low in vegetables, fruits, and healthy oils. The majority of Americans exceed the dietary recommendations for added sugars, saturated fats, and sodium (Health.gov., 2015, 2016a).

     The most widely advertised foods tend to be high in calories and low in nutrients, and there are fewer advertisements for healthy foods, such as fruits, vegetables, whole grains, and beans. In addition, many individuals find it difficult to make lifestyle changes, such as improving dietary habits and incorporating exercise into their regular routines. Busy work schedules often leave little time to prepare healthy meals at home. How can the healthcare community reverse this dangerous trend in nutritional intake in the U.S.?

     First, a review of the history of Dietary Guidelines can help to establish a basis for nursing interventions regarding nutrition.  In order to understand the current state of eating patterns in the U.S., it is important to understand how dietary recommendations have changed over the course of time.

    History of Dietary Recommendations

    The release of dietary recommendations is not a new phenomenon. The U.S. Department of Agriculture has been issuing dietary recommendations for over a century. Although nutritional research has grown in pace and sophistication over the years, many of the current dietary recommendations remain significantly similar to those published many years ago (Davis & Saltos, n.d.).

     The first dietary recommendations were published by the U.S. Department of Agriculture (USDA) in 1894. At that time, specific vitamins and minerals had not even been discovered. These initial recommendations were written by W.O. Atwater, the first director of the Office of Experiment Stations in the U.S. Department of Agriculture. His research on nutritional needs and the composition of foods established the foundation of a guide for healthy-eating patterns (Davis & Saltos, n.d.).

     The first U.S. Department of Agriculture food guide was written by Caroline Hunt, a nutritionist. Published in 1916, Food for Young Children classified food into five groups: milk and meat, cereals, vegetables and fruits, and fats and fatty foods, and sugars and sugary foods. In 1917, the next publication focused on foods for the general public. How to Select Foods was based on the same food groups as the 1916 guide. In 1921, the latest edition of the guide expanded recommendations to suggest amounts of foods to purchase every week for the average family. Modified in 1923, the guide was now written to include households that were different from the average (at that time) five-member size (Davis & Saltos, n.d.).

     By the early 1930s, Dietary Guidelines were affected by the financial impact of the Great Depression. In 1933, a U.S. Department of Agriculture economist developed food plans at four cost levels to help persons with varying incomes shop for food (Davis & Saltos, n.d.).

     The early 1930s saw the establishment of the U.S. Department of Agriculture Foods program. This program was developed as an outgrowth of government policies written to bolster food prices and help American farmers survive the economic devastation of the Great Depression. Farmers lost their farms while the amount of farmland increased (U.S. Department of Agriculture, n.d.).

     Farmers who managed to keep their farms planted more food in an attempt to make up for poor prices, which further reduced food prices while increasing surpluses since much of the food went unsold. Millions of people in cities and rural areas lost their jobs and were unable to afford food at even low prices. Malnutrition among children became a significant, national concern (U.S. Department of Agriculture, n.d.).

     In 1933, the Commodity Credit Corporation was established to provide farmers with loans and help them store nonperishable foods until prices increased. Ultimately, farmers could forfeit their crops to the federal government to repay loans. This meant that the government had to sell or distribute surplus foods to domestic and international food programs to prevent waste and spoilage (U.S. Department of Agriculture, n.d.).

     Throughout the 1930s, Congress passed legislation to help support farmers and provide food distribution to those who needed it. For example, in 1935, eligible categories of recipients were established so that needy families had access to food. Eventually, it was the donations of surplus food that started the school lunch and other child-feeding programs (U.S. Department of Agriculture, n.d.).

     Nursing Consideration: During World War II, food shortages and gasoline rationing that limited food transportation decreased shipments of food to schools. Legislation was enacted to provide financial help for schools and childcare centers to provide food for lunch programs (U.S. Department of Agriculture, n.d.). Nurses have an obligation to be aware of the impact of political and social changes and upheavals that interfere with nutritional intake and work to facilitate programs that support the intake of a healthy diet.

     In 1941, the National Nutrition Conference for Defense published the first set of Recommended Dietary Allowances (RDAs) by the Food and Nutrition Board of the National Academy of Sciences. Specific recommendations were given for the intake of calories and nine essential nutrients: protein, iron, calcium, vitamins A and D, thiamin, riboflavin, niacin, and ascorbic acid (Davis & Saltos, n.d.).

     In 1941, the National Nutrition Conference for Defense published the first set of Recommended Dietary Allowances (RDAs) by the Food and Nutrition Board of the National Academy of Sciences. Specific recommendations were given for the intake of calories and nine essential nutrients: protein, iron, calcium, vitamins A and D, thiamin, riboflavin, niacin, and ascorbic acid (Vitamin C) (Davis & Saltons, n.d.).

     In 1956, a new food guide was published that recommended a minimum number of foods from the “Basic Four” food groups: milk, meat, fruits and vegetables, and grain products. This 1956 guide was extensively used throughout the next two decades (Davis & Saltron, n.d.).

     By the 1970s, research showed that consuming excessive amounts of certain types of food products such as saturated fats, sugars, and sodium increased the risk of chronic diseases (e.g., heart disease and stroke). So significant was the research deemed in terms of health that, in 1977, the Senate Select Committee on Nutrition and Human Needs published Dietary Goals for the United States. This publication signaled a new direction for Dietary Guidelines. For the first time the emphasis moved from obtaining adequate nutrients to avoiding excessive intake of food products associated with chronic disease development. However, since this publication’s goals were so different from previous guidelines, the U.S. Department of Agriculture did not incorporate the goals into its own food plans and guidelines (Davis & Saltron, n.d.).

     However, the growing body of research linking nutritional intake to health and wellness made a shift in focus inevitable. The following information is a summary of the new direction of Dietary Guidelines from the 1970s through the present:

    • 1979: The U.S. Department of Agriculture began to address the association of fats, sugars, and sodium with chronic diseases in its publication titled This was accompanied by a new food guide, Hassle-Free Guide to a Better Diet. This new guide introduced a fifth food group: fats, sweets, and alcoholic beverages (U.S. Department of Agriculture, n.d.).
    • 1980: The first edition of Nutrition and Your Health: Dietary Guidelines for Americans (issued by the U.S. Department of Agriculture and the Department of Health and Human Services) was published. This began what would be an ongoing process of writing and updating Dietary Guidelines that would eventually be published every five years. The first edition triggered some concerns among consumers, nutrition scientists, and food industry groups about the causal relationship between some of the guidelines and health (U.S. Department of Agriculture, n.d.).
    • 1980–1990s: Throughout the 1980s and the 1990s, the U.S. Department of Agriculture worked on developing and publishing materials to help the general public use the Dietary Guidelines (U.S. Department of Agriculture, n.d.).
    • 1992: The Food Pyramid was published. This booklet was developed to provide a graphic picture of the food guide to help consumers understand and implement good dietary guidelines. The Food Pyramid was widely used until early in the 21st century (U.S. Department of Agriculture, n.d.).

    Source: U.S. Department of Agriculture/U.S. Department of Health and Human Services https://www.fns.usda.gov/mypyramid

    • 2011: First Lady Michelle Obama unveiled a new graphic representation of recommended food guidelines called MyPlate, which took the place of the once iconic Food Pyramid. MyPlate is represented by a plate divided into four sections for fruit, vegetables, grains, and protein. A smaller circle sits beside the plate for dairy products. Its focus is on reminding consumers about the essentials of a healthy diet (The New York Times, 2011).


    Source: https://www.choosemyplate.gov/eathealthy/WhatIsMyPlate

    • 2011: The Harvard Medical School developed its own graphic representation of food guidelines called the Healthy Eating Plate, as they felt there were certain omissions in MyPlate. According to Harvard experts, MyPlate does not tell consumers that whole grains are better for health; in addition, it does not include a discussion of fats, and does not identify which proteins are healthier than others. Moreover, they concluded that MyPlate does not distinguish between potatoes and other vegetables, and seems to show a smaller portion of fruit than vegetables. Harvard experts also note that MyPlate recommends dairy at every meal and does not comment on sugary drinks or juice. Harvard’s Healthy Eating Plate promotes the choosing of whole and less refined grains, identifies healthy sources of protein, encourages an abundant variety of vegetables, and encourages the use of healthy oils and fats. It also encourages the consumption of water and other calorie-free beverages. However, MyPlate remains the government’s graphic representation of Dietary Guidelines (Harvard Health Publications Harvard Medical School, 2017; The New York Times, 2011).

    For more information on the Healthy Eating Plate visit: https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/

    • 2015–2020: The eighth edition of Dietary Guidelines for Americans covers the five-year period from 2015–2020. These current guidelines focus on: (1) stressing that eating patterns have a significant impact on health and (2) that healthy-eating patterns are adaptable to incorporate many types of foods (Healthcare.gov., 2016).

    Data on Current Eating Patterns

     The media is flooded with information about the poor quality of the average American’s diet and the obesity epidemic. Is there any good news about the way Americans eat? Before providing the grimmer statistics, it seems appropriate to note some positive information as well.

     Research indicates that there are decreases in low-quality carbohydrates (primarily added sugar) and increases in high-quality carbohydrates. A study of trends in dietary carbohydrate, protein, and fat intake among U.S. adults from 1999–2016 was conducted on 43,996 adults (Shan et al., 2019). From 1999 to 2016, U.S. adults experienced (Shan et al., 2019):

    • Significant decreases in the percentage of energy intake from low-quality carbohydrates.
    • Significant increases in the percentage of energy intake from high-quality carbohydrates (mainly whole grains).
    • Significant increases in plant proteins (mainly whole grains and nuts), and polyunsaturated fat.

         Despite the previous encouraging statistics, there is still a great deal of work to be done when it comes to healthy eating in the U.S. Research also shows that 42% of energy intake is still derived from low-quality carbohydrates, and the intake of saturated fat remains above 10% of energy (Shan et al., 2019).

         According to information from the President’s Council on Sports, Fitness, and Nutrition (HHS.gov., 2017):

    • The typical American diet exceeds the recommended intake in four categories: calories from solid fats and added sugars, refined grains, sodium, and saturated fat.
    • In general, Americans eat less than the recommended amounts of vegetables, fruits, whole grains, dairy products, and oils.
    • About 90% of Americans consume more sodium than is recommended for a healthy diet. American adults consume an average of 3,400 mg/day of sodium, which is well above federal guidelines of less than 2,300 mg daily.
    • Reducing sodium consumption by 1,200 mg per day could save up to $200 billion a year in medical costs.
    • Since the 1970s the number of fast food restaurants has more than doubled.
    • More than 23 million Americans live in areas that are more than a mile away from a supermarket.
    • Empty calories from added sugars and solid fats contribute to 40% of total daily calories for 2- to 18-year-olds.

    Nursing Interventions

     What impact does the history of food guidelines and current patterns of eating have on nursing interventions? What nursing interventions are important to these issues? Nurses and other healthcare professionals have an obligation to (Davis & Saltos, n.d.; Healthcare.gov, 2015)

    • know the history of American Dietary Guidelines and how they indicate dietary trends.
    • stay abreast of current research pertaining to current eating patterns of Americans.
    • use knowledge of history and current research to counsel patients and families about healthy dietary patterns.

    All answers and rationales to self assessment questions are at the end of the course.

    Self-Assessment #1

    Dana, a nursing student in her junior year, is working on a project about nutrition, health, and the American diet. She decides to go to the Student Union and quietly observe the eating habits of students, faculty, staff, and visitors. She saw a wide variety of food choices. Many of her fellow students chose fast food type items such as hamburgers and pizza. Some faculty and students did seem to make conscious choices about adding fruits and vegetables to their diets. Desserts are popular items among all age groups. Still, other people, in particular female students, seemed to eat very little. Dana overheard a group of these young women bragging that they only eat 500 calories a day. Many people of all ages were obviously overweight. Overeating, undereating, and good and bad nutrition choices were all observed by Dana. She wonders what steps should, and could, be taken to improve the American diet?

     When Dana is presenting her findings to her classmates, she wants to impress upon them the typical diet of an average American. She tells her classmates which one of the following?

    1. Americans should reduce sodium consumption by 1,200 mg per day.
    2. Most Americans eat less than the recommended amounts of saturated fat.
    3. From 1999–2016, there were significant decreases in the consumption of plant proteins.
    4. Americans should increase the amount of refined grains that they eat.

    The Impact of Obesity on Health and Wellness

    Obesity Statistics

     Obesity is not a problem unique to the U.S. In fact, obesity is a global epidemic and one of the most serious health problems in the world. It is estimated that 1.9 billion adults (defined as 18 years of age and older) have excess weight, of which over 660 million are obese.  This means that 13% of the world’s adult population is obese. In preschool children, (defined as 0–5 years of age), about 41 million throughout the world are obese. Over 340 million children and adolescents aged five  to 19 are overweight (World Health Organization [WHO], 2018).

    Nursing Consideration: Even adults who are strongly motivated to improve their health and achieve/maintain optimal weight will resist making behavioral changes if they are made to feel embarrassed or ridiculed (Kelley, Sbrocco, & Sbrocco, 2016). Nurses should be especially sensitive to the manner in which they provide education and counseling regarding weight loss and any other health issues.

     Some statistics related to overweight and obesity in the U.S. adult population include the following (CDC, 2018a):

    • The prevalence of obesity was nearly 40% and affected about 93.3 million of U.S. adults in 2015–2016.
    • Hispanics (47%) and non-Hispanic blacks (46.8%) had the highest age-adjusted prevalence of obesity, followed by non-Hispanic whites (37.9%) and non-Hispanic Asians (12.7%).
    • The prevalence of obesity was 35.7% among young adults aged 20 to 39 years, 42.8% among middle-aged adults aged 40 to 59 years, and 41.0% among older adults aged 60 and older.
    • Overall, men and women with college degrees had lower obesity prevalence compared with those with less education.
    • Among men, obesity prevalence was lower in the lowest and highest income groups compared with the middle-income group.
    • Among women, obesity prevalence was lower in the highest income group than in the middle and lowest income groups.


    Some statistics related to childhood (2 to 19 years) obesity include the following (CDC, 2019a):

    • The prevalence of obesity was 18.5% and affected about 13.7 million children and adolescents.
    • Obesity prevalence was 13.9% among two- to five-year-olds, 18.4% among six- to 11-year-olds, and 20.6% among 12- to 19-year-olds. Childhood obesity is also more common among certain populations.
    • Hispanics (25.8%) and non-Hispanic blacks (22.0%) had higher obesity prevalence than non-Hispanic whites (14.1%).
    • Non-Hispanic Asians (11.0%) had lower obesity prevalence than non-Hispanic blacks and Hispanics.
    • The prevalence of obesity decreased with the increasing level of education of the household head among children and adolescents aged 2–19 years.
    • Obesity prevalence was 18.9% among children and adolescents aged 2–19 years in the lowest income group, 19.9% among those in the middle-income group, and 10.9% among those in the highest income group.
    • Obesity prevalence was lower in the highest income group among non-Hispanic Asian and Hispanic boys.
    • Obesity prevalence was lower in the highest income group among non-Hispanic white, non-Hispanic Asian, and Hispanic girls. Obesity prevalence did not differ by income among non-Hispanic black girls.

    Financial Impact of Obesity

     Overweight and obesity are associated with significant financial consequences. These include the following (HHS.gov., 2017):

    • Obesity-related illness, including chronic disease, disability, and death, is estimated to carry an annual cost of $190.2 billion.
    • Those who are obese have medical costs that are $1,429 more than those of normal weight on average (roughly 42% higher).
    • The annual cost of being overweight is $524 for women and $432 for men; annual costs for being obese are even higher: $4,879 for women and $2,646 for men.
    • Obesity is also a growing threat to national security. A surprising 27% of young Americans are too overweight to serve in our military. Approximately 15,000 potential recruits fail their physicals every year because they are unfit.

    Obesity and Disease

         Obesity-related conditions include heart disease, stroke, respiratory disease, type 2 diabetes, mental health, and certain types of cancer (CDC, 2018a). The following overview of disease and obesity is not all-inclusive. Research continues to provide evidence that obesity impacts many (if not most) diseases. Therefore, this education program provides general information about several of the most commonly recognized conditions that are significantly impacted by obesity.


     Obesity and Mental Health. Research suggests that mental health disorders that may be triggered by obesity include depression, eating disorders, distorted body image, and low self-esteem (Collingwood, 2018).

    EBP Alert! Research findings from some studies show that clinically significant depression is three to four times higher in severely obese persons than in similar nonobese persons (Collingwood, 2018).  Nurses must be alert to signs and symptoms of depression (e.g., loss of interest in activities that were once enjoyed, isolation from family and friends, changes in sleep patterns, feelings of sadness and hopelessness, lack of energy, emotional outbursts) in obese patients and assess for the disorder.

     A study conducted at the University of Texas Health Science Center in Houston consisted of data gathered from 2,123 participants. The investigators took into account factors such as social class, social support, chronic medical conditions, and life events. Analysis showed that obesity at baseline was associated with an increased risk of depression five years later. However, the reverse was not found to be true: depression did not increase the risk of future obesity (Collingwood, 2018).

     The mental health impact of obesity can become evident in childhood. Children who are overweight or obese have an increased risk of experiencing significant victimization. Peer victimization has been associated with negative psychosocial and health outcomes as well. Peer victimization has been defined as overt (e.g., pushing, hitting) or relational (e.g., teasing, gossiping, excluding) types of aggression carried out by an individual or by a group of peers (Collingwood, 2016).

         The following are emotional consequences of childhood obesity (Healthchildren.org., 2017):

    • Social stigma: Society places great value on thinness, even extreme thinness. Research shows that children as young as six years of age may associate negative stereotypes with excess weight. They may believe that overweight or obese children are not as likable as someone who is of normal weight.
    • Self-esteem and bullying at school: Children who are obese are more likely to have low self-esteem, body shame, and lack of self-confidence than thinner children. Obese or overweight children are more likely to be teased and bullied as well.
    • Depression: The social stigma, low self-esteem, and bullying may lead to the development of clinical depression.
    • Emotional eating: Some children who are overweight or obese may seek emotional comfort in food, eat more, and increase the number of calories ingested.
    • Discrimination: Some children and adolescents may face discrimination based on their weight alone. Research suggests that they are less likely to be accepted by a prestigious university, find good jobs, date, or marry.


     Cardiovascular Disease.  Heart disease is the leading cause of death in the U.S. for both men and women. About 610,000 people die of heart disease every year (one in every four deaths). Coronary artery disease (CHD), which is the most common type of heart disease, kills over 370,000 people every year. About 735,000 Americans have a heart attack every year (CDC, 2017).

     The healthcare community has spent many years attempting to find ways to prevent and treat heart disease. Risk factors for such disease include obesity, which has a negative impact on many of the other modifiable risk factors (Cleveland Clinic, 2019).

     In fact, obesity has been found to have an impact on the following modifiable risk factors (Cleveland Clinic, 2019):

    • Obesity raises blood cholesterol and triglyceride levels.
    • Obesity lowers “good” HDL cholesterol. HDL cholesterol is associated with a reduced risk for heart disease.
    • Obesity raises LDL cholesterol. LDL (“bad”) cholesterol is associated with an increased risk for heart disease.
    • Obesity increases blood pressure, another known risk for heart disease.
    • Obesity increases the risk for diabetes, which is also a risk factor for heart disease.

    Nursing Consideration: Obesity is linked to a number of serious heart disease risk factors. When teaching patients and families about weight control, it is important nurses include information about the impact of obesity on the development (or worsening) of heart disease.

     Stroke. Obesity increases risk factors for stroke. Many of the risk factors for stroke are the same as for heart disease, such as hypertension, diabetes, and elevated cholesterol (WebMD, 2018a). Therefore, obesity significantly increases the risk for stroke.

    EBP Alert! Research indicates that losing as few as 10 pounds can lower body weight and reduce the risk of developing heart disease or stroke. Losing even more weight further reduces risk (American Heart Association, 2017). Thus, it is imperative that nurses work with their patients and families to control weight when counseling about stroke and heart disease prevention.

         Diabetes. About 9.4% of the U.S. population (30.3 million people) has diabetes. Of these 30.3 million, 23.1 million are diagnosed, and 7.2 million are undiagnosed (CDC, 2018b).

         Being overweight or obese significantly increases the risk of developing type 2 diabetes. Obesity is thought to account for 80% to 85% of the risk of developing type 2 diabetes (Diabetes.co.uk, 2019).

     Obesity is associated with an increase for the following types of cancers (and possibly others as well) (National Cancer Institute, n.d.):

    • breast (postmenopausal),
    • colon and rectum,
    • endometrial,
    • esophagus,
    • gallbladder,
    • gastric,
    • kidney,
    • liver,
    • meningioma,
    • multiple myeloma,
    • ovarian,
    • pancreatic, and

    Why does obesity increase the risk for some cancers? While there is no definitive answer   to this question, several theories have been proposed, including the following (National Cancer Institute, n.d.):

    • Fat tissues produce excess amounts of estrogens, high levels of which damage DNA and are associated with breast, endometrial, and ovarian cancers.
    • Obese people have increased blood levels of insulin (insulin resistance), which is associated with the development of colon, kidney, prostate, and endometrial cancers.
    • Fat cells produce adipokines, hormones that may stimulate or inhibit cell growth.
    • Fat cells may have direct and indirect effects on tumor growth.
    • People who are obese often have chronic low level or “subacute” inflammation, which has been associated with an increased risk for cancer.

         Research continues regarding the link between obesity and cancer. At this time, however, it is important that healthcare consumers and health care providers become aware of the increased risk for certain cancers among obese patients.

     Gallbladder Disease. Obesity is also linked to gallbladder disease. Gallbladder disease and gallstones are more common among people who are overweight. Paradoxically, rapid weight loss or loss of a large amount of weight may increase the likelihood of gallstones. Losing about one pound a week is less likely to cause gallstones (WebMD, 2018a).

     Gout. The prevalence of gout has now reached epidemic proportions, and researchers say obesity is to blame. Obesity, BMI, and visceral fat have a linear correlation with the increase of serum uric acid and can influence gout development. Weight reduction and a decrease in the consumption of high-calorie foods can alleviate gout symptoms, and may prevent its development (Galanis, 2018).

     Obstructive Sleep Apnea. The most common cause of sleep apnea in adults is obesity, which is associated with an excess amount of soft tissue of the mouth and the throat. As adults sleep, the muscles of the throat and tongue are more relaxed and soft tissue blocks the airway (WebMD, 2018b).

     Patients who have obstructive sleep apnea and gain 10% of their body weight are six times more likely to have disease progression. A 10% weight loss, however, correlates with a 20% improvement in the severity of the disease (Obesity Medicine Association, 2019).

     Respiratory Disease. Obesity adversely affects the function of the lungs. Obesity can lead to abnormalities in ventilator mechanics, muscle function, ventilator control, pulmonary gas exchange, and cardiac performance, all of which have an adverse impact on the lungs (Dixon & Peters, 2018; Mafort, Rufino, Costa, & Lopes, 2016).

      Here are examples of some respiratory diseases and conditions that are linked to obesity  (Dixon & Peters, 2018; Mafort, Rufino, Costa, & Lopes, 2016).

    • Asthma: Asthma can be more difficult to control in obese patients because of increased airway inflammation, decreased response to medications, and the impact of conditions that often co-exist with obesity, such as obstructive sleep apnea and gastroesophageal reflux disease (GERD).
    • Chronic Obstructive Pulmonary Disease (COPD): COPD includes emphysema and chronic bronchitis. Obesity severely and negatively impacts patients experiencing chronic lung diseases. Research shows that “weight loss is the best health strategy for obese patients with COPD.”
    • Obstructive Sleep Apnea (OSA): Although obstructive sleep apnea has already been discussed, it is worth mentioning again in context of the respiratory system. Characterized by abnormalities of the upper airway and facial structures, obstructive sleep apnea can be life-threatening. Weight loss is associated with a decreased risk for this condition as well as a decrease in its severity in patients already diagnosed with the problem.

     Pain. Managing pain in patients who are obese can be a challenge. Obesity is a risk factor for pain. In obese people, general and specific musculoskeletal pain is common. Excessive weight increases mechanical stress to the joints and tissues of the body, leading to physical limitations, and ultimately, bodily pain (Zdziarski, 2015).

     Exercise is generally recommended as a weight-loss strategy. But it is hard to exercise when exercise causes or exacerbates pain. Health care providers may consult with physical therapists to help obese patients exercise safely, comfortably, and with positive outcomes (Zdziarski, 2015).

    Nursing Consideration: Pain medication dosage is influenced by the patient’s weight. Nurses must be aware how weight impacts the effects of analgesics and how to counsel patients about their use (Comerford & Durkin, 2020).

     Pregnancy and obesity. Obesity during pregnancy can have significant negative impact on the health of both mother and baby. Pregnant women who are obese face an increased risk of various types of pregnancy complications, including the following (Mayo Clinic, 2018a):

    • Birth Defects: Research findings suggest that obesity during pregnancy slightly increases the risk of having an infant who is born with a birth defect.
    • Chronic Conditions: Infants born to obese women are at greater risk for developing heart disease, diabetes, or other chronic conditions than those born to women of normal weight.
    • Emergency C-Section: Obesity increases the risk of emergency C-sections. Obesity also increases the risk of C-section complications such as infection.
    • Gestational Diabetes: Obese women are more likely to develop gestational diabetes than those who are of normal weight.
    • Infection: Obesity increases the risk of urinary tract infections as well as the development of post-partum infections, whether the baby is delivered vaginally or via C-section.
    • Labor Complications: The need for labor induction is more common in obese women compared to those of normal weight. Obesity can also interfere with the effectiveness of certain types of analgesia, such as an epidural block.
    • Macrosomia: The risk of delivering an infant with macrosomia (an infant who is significantly larger than average) is higher in women who are obese.
    • Miscarriage: The risk of miscarriage is higher in women who are obese.
    • Overdue pregnancy: It is more likely that pregnancy will continue beyond the expected due date in women who are obese.
    • Preeclampsia: Women who are obese are at greater risk for developing preeclampsia, which is characterized by hypertension and signs and symptoms of damage to other organs, often the kidneys.

    Nursing Consideration: The preceding diseases and conditions (although not all-inclusive) are those that are currently linked to obesity by scientific research findings. However, ongoing research continues to produce evidence that obesity affects all body systems and contributes to negative impacts on most aspects of health (Mayo Clinic, 2019a); National Cancer Institute, 2019). It is essential that nurses monitor the findings of research related to obesity and update their knowledge and skills to work to help healthcare consumers achieve optimal weight.

     Nursing Interventions. Nurses have an obligation to be aware of how obesity impacts health and wellness. Many of the nursing interventions related to the impact of obesity on health involve education, including the following (American Heart Association, 2019a; WebMD, 2018a):

    • Incorporating height and weight measurement as part of the physical assessment.
    • Teaching patients and families how obesity impacts the body’s vital organs.
    • Teaching patients and families recommendations for a healthy diet.
    • Reinforcing exercise guidelines per health care provider recommendations.
    • Teaching patients and families how to implement treatment regimens for chronic conditions as prescribed by their health care providers.

      It is critically important for nurses to be able to provide patient/family education in an objective and supportive manner. In order to do this, nurses must adhere to the following principles of adult education (Avillion, 2015; O’Neil, 2019):

    • Adults need to know that what they are learning has a practical purpose. In other words, they need a “reason” to learn. In the case of weight loss, patients and families need to learn about the practical, observable benefits of weight loss.
    • Adults bring a wealth of life experiences to every learning situation. These experiences include how they earn a living, function as part of a family, develop interpersonal relationships, guide and teach others, and how they learn. Experiences should be acknowledged and used by the nurse and other educators to help patients acquire knowledge and use that knowledge to improve their states of health and wellness.
    • Adults are self-directed learners. They are responsible for their own learning. It is the nurse’s responsibility to provide education in terms that the patients and families can comprehend and in an objective and supportive manner. However, the responsibility for learning remains with the adult learners. They must be willing to learn and to use what is learned to improve their health status.
    • Adults are interested in acquiring knowledge that can be used to improve their daily lives. Adults want to know that devoting time and effort to learning and taking action based on learning (such as losing weight) is going to improve their lives.

     A critical component of patient/family education is assessing whether or not the patients and families actually acquired knowledge necessary to improve their health status. Such assessment is performed by establishing measurable learning objectives and to determine whether or not they have been achieved (American Heart Association, 2019a; WebMD, 2018a). For example, when teaching about weight loss, learning objectives might include that patients/families will be able to do the following:

    • Describe the components of a healthy diet as described by the recommended Dietary Guidelines.
    • Give examples of a healthy breakfast, lunch, and dinner that comply with recommended Dietary Guidelines.
    • Demonstrate a weight loss of 12 pounds within a period of six weeks.

     These examples show that objectives must include a measurable verb that requires patients/families to actively demonstrate learning. Measuring objectives such as these allow the nurse to determine if learning has actually taken place

     Finally, nurses must be sure to make learning objectives realistic. For example, expecting a weight loss of 20 pounds in 3–4 weeks is not realistic. Expecting someone who has eaten red meat five times a week to suddenly eat red meat twice a month may be overwhelming. Nurses must work with patients and families to set realistic goals in a manner that is devoid of judgment.

    Self-Assessment #2

    Steven is the nurse manager of a large outpatient clinic. As part of the clinic’s health initiative, he is planning a series of community education programs on nutrition and healthy eating. Steven researches statistics regarding obesity and the impact of obesity on health and wellness. He wants to be able to explain just how devastating the consequences of obesity can be. But more than that, Steven wants to be able to offer encouragement and practical suggestions for achieving and maintaining an appropriate weight. He knows that being judgmental or critical can have a negative impact on patients’ and on families’ desire to learn and their commitment to weight loss.

    Sharon should include which of the following pieces of information in her presentation?

    1. People who want to lose weight should set a goal of five pounds per week.
    2. In order to reduce symptoms of obstructive sleep apnea people should lose 20% of their body weight.
    3. People who are obese should be counseled about their increased risk for breast cancer.
    4. The prevalence of obesity is greatest in families whose head of household has graduated from college.

    Eating Disorders

     Not all problems related to nutrition are as obvious as obesity. Being thin is often, especially by society’s standards, determined to be not only aesthetically pleasing but a sign of good health as well. However, that is not always the case. The following common eating disorders significantly impact the nutritional status of patients.

    Anorexia Nervosa

     Anorexia nervosa, commonly referred to as anorexia, is an eating disorder defined as “restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health” (American Psychological Association, 2013, p.338).

     Anorexia nervosa is characterized by an abnormally low body weight, an extreme, intense fear of gaining weight, and a distorted perception of weight. Persons who have anorexia highly value their ability to control their weight, shape, and food intake. They go to extremes to lose weight that significantly impacts their health and interferes with their lives (Mayo Clinic, 2018b).

     Anorexia nervosa is a serious disease that can be lethal. As people reach states of near starvation, all body systems are affected, fluid and electrolyte imbalances occur, and considerable stress is placed on the cardiac system (American Psychological Association, 2013; Mayo Clinic, 2018b).

     Some central features of anorexia nervosa include the following (American Psychological Association, 2013; Mayo Clinic, 2018b):

    • A distorted body image. Despite an obviously gaunt, emaciated appearance, the clients still perceive themselves to be fat and unattractive. Even though family, friends, teachers, and/or co-workers try to convince clients otherwise, they firmly believe that they must continue to lose weight. They have an unshakeable belief that they are fat and see themselves as such no matter what evidence to the contrary is presented to them.
    • An extreme, irrational fear of gaining weight. This fear makes clients go to extremes to lose weight and to avoid gaining weight. Such extremes include literally starving themselves and, possibly, exercising to the point of exhaustion.

    Nursing Consideration: Thin does not equal healthy. When assessing nutritional status nurses need to carefully evaluate all patients for healthy nutritional intake and intervene appropriately.

     Treatment generally initially involves correction of life-threatening complications, such as fluid and electrolyte imbalances, cardiac abnormalities (e.g., arrhythmias), and psychotherapy. Treatment requires a team approach that includes physicians, mental health professionals, nurses, and dieticians. It is imperative that persons affected by anorexia nervosa have ongoing therapy and nutritional education to achieve and maintain recovery (Mayo Clinic, 2018c).

     Psychotherapy is as important to recovery as the intake of fluids and food. Family therapy is the only evidence-based treatment for teenagers with anorexia. Family therapy may be helpful for all members of the family, as well as for the client. Issues that may be evident among family members include conflict, difficulty handling emotions, unclear boundaries, and controlling behaviors. Therapy is not a short-term process and may take years of work (American Psychological Association, 2013; Collingwood, 2018; Mayo Clinic, 2018c).

     Cognitive behavioral therapy (CBT) is another form of psychotherapy used as a treatment intervention for clients with anorexia. Many clients use their control of their weight as a means of gaining control over their lives. Clients are taught appropriate problem solving and coping skills and taught to recognize that the behaviors associated with anorexia nervosa are not only inappropriate but can be life-threatening. They are also taught to improve self-esteem, assertiveness, life satisfaction, and interpersonal communication (American Psychological Association, 2013; Collingwood, 2018; Mayo Clinic, 2018c).

    Bulimia Nervosa

     Bulimia nervosa, commonly referred to as bulimia, is characterized by repeated episodes of binge-eating, which is defined as eating, in a specific period of time, an amount of food that is “definitely larger than most individuals would eat in a similar period of time under similar circumstances” (American Psychological Association, 2013, p. 345).  Binge-eating is followed by purging in order to prevent weight gain. Examples of purging behaviors include self-induced vomiting, excessive use of laxatives and/or diuretics, and excessive exercise. Persons suffering from bulimia nervosa feel a significant loss of control over these binging and purging behaviors (Psychological Association, 2013; Collingwood, 2018; Mayo Clinic, 2018d).

    Nursing Consideration:  Bulimia nervosa and anorexia nervosa can occur at the same time (American Psychological Association, 2013). When nurses are assessing clients for eating disorders, it is important that they be evaluated for both of these disorders. Not all healthcare professionals know that bulimia nervosa and anorexia nervosa can co-exist. It is important to help educate colleagues, as well as clients and families, about the possibility of this simultaneous occurrence.

     A factor that differentiates bulimia nervosa from anorexia nervosa is the fact that clients who have bulimia nervosa usually maintain a normal weight, while some affected persons are slightly overweight. However, like people with anorexia nervosa, bulimic clients are desperate to lose weight and are very unhappy with their body size and shape (American Psychological Association, 2013; Mayo Clinic, 2018d).

     Bulimia nervosa can lead to significant fluid and electrolyte imbalances, cardiac problems, and alterations in homeostasis (American Psychological Association, 2013; Mayo Clinic, 2018d).

     Research indicates that the most effective treatment for bulimia nervosa is cognitive behavioral therapy (CBT). This is an outpatient treatment intervention and requires a detailed strategy to guide treatment. Research indicates the need for highly detailed, manual-guided treatments of 18 to 20 sessions over a period of five to six months.  CBT should be conducted by a therapist who is an expert in CBT and who has experience treating persons with bulimia nervosa (Mayo Clinic, 2018e; Videbeck, 2017).

     The goal of CBT is to change the client’s cognition (thinking) and behaviors. Emphasis is on helping persons suffering from the disorder to identify unhealthy, negative beliefs, thoughts, and behaviors, and replace them with healthy, positive ones. Therapy is designed to stop the client’s focus on food and to interrupt the cycle of dieting, binging, and purging (Mayo Clinic, 2018e; Videbeck, 2017).

      Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) may be prescribed to treat depression and even if depression has not been diagnosed. Findings from research indicate that antidepressants were more effective than placebos in reducing the occurrence of binge-eating. These drugs also improved mood and reduced fixation on body shape and weight. Most people with bulimia nervosa recover. However, periods of binging and purging may come and go throughout the person’s life, depending on life circumstances such as periods of extreme stress (Mayo Clinic, 2018e; Videbeck, 2017).

    Binge-Eating Disorder

     Binge-eating disorder, also referred to by some health care providers as compulsive overeating, is a newly recognized eating disorder. It is characterized by the following (American Psychological Association, 2013; Mayo Clinic, 2018f):

    • As a serious mental illness.
    • By uncontrollable eating, in a discrete period of time, an amount of food that is larger than what most people would eat in a similar period of time under similar circumstances.
    • As similar to the binging that occurs in bulimia nervosa but without the accompanying inappropriate behaviors to rid the body of excess calories (purging).
    • As a way affected persons use to cope with depression, stress, or anxiety.

    Nursing Consideration:  Two of three people in the United States who have binge-eating disorder are obese (WebMD, 2019a). Thus, binge-eating can contribute to the already significant problem of obesity in the United States.

     Binge-eating disorder has only recently been recognized as a well-defined disorder (American Psychiatric Association, 2013). In the United States, it is estimated that about 5.6 million women and 3.1 million men have the disorder (WebMD, 2019a).

     People who are obese are at greater risk for developing binge-eating disorder, but those who are of normal weight can also have the disorder. About two of every three people in the United States who have the disorder are obese (WebMD, 2019a).

     Binge-eating disorder can lead to the same health hazards as obesity and requires significant treatment interventions, including psychotherapy and medication (WebMD, 2019a). Psychotherapy can be conducted in individual and/or group therapy sessions. Therapy may also include family members as indicated (Videbeck, 2017).

     Cognitive behavioral therapy (CBT) is generally recommended as a treatment initiative for persons with eating disorders. Cognitive therapy concentrates on immediate processing of thoughts and feelings. Emotions of sadness, depression, anxiety, and anger are reactions to the environment in which the person lives. Some facets of CBT, as they relate to binge-eating disorder and other eating disorders, include the following initiatives (Videbeck, 20017):

    • Identification of issues that trigger binge-eating episodes. Examples of such issues are negative feelings about one’s body, work, school, or family-related stressors, or co-existing conditions such as depression (Mayo Clinic, 2018f; Videbeck, 2017; WebMD, 2019a).
    • Learning coping strategies to deal with negative feelings and triggering stressors (Videbeck, 2017; WebMD, 2019a).
    • Learning ways to regain a sense of control over one’s life, including binge-eating behaviors (Mayo Clinic, 2018g; Videbeck, 2017; WebMD, 2019a).

     Interpersonal psychotherapy concentrates on the individual’s current relationships with other people, including family, friends, and co-workers. The goal of interpersonal psychotherapy is to improve interpersonal skills, meaning how one relates to others. This type of therapy may help to reduce binging that is triggered by poor communication skills, unhealthy patterns of interaction, and poor interpersonal relationships (Mayo Clinic, 2018g).

     Dialectical behavior therapy focuses on techniques to help increase stress tolerance. People learn to improve relationships and regulate emotions. This may help to decrease binge-eating episodes since triggering factors are often negative emotions and unhealthy relationships (Mayo Clinic, 2018g).

    Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) may be prescribed. These kinds of drugs may help to reduce feelings of depression and negative thought patterns (Mayo Clinic, 2018g; Videbeck, 2017; WebMD, 2019a).

    Nursing Interventions

     When health care professionals discuss nutritional problems, they may first think of the problems of those who are overweight and obese. However, the descriptions of the preceding eating disorders show that obesity is far from the only problem related to poor nutritional intake.

     Nurses must be careful not to equate thinness with good dietary habits. They must carefully measure height, weight, and BMI. They must ask patients and their families about dietary intake and food preferences and dislikes. Nurses must also assess mental health since obesity and eating disorders can be accompanied by mental health disorders.

    Self-Assessment #3

    Melanie is a popular high school junior who is the captain of the school’s prestigious cheerleading squad. She prides herself on her appearance and her leadership role among her classmates. However, a new student has recently joined the squad. She is pretty and very thin and soon becomes quite popular. Melanie overhears her telling some friends, “Melanie would be so much better at cheering if she would just lose a few pounds. She’s holding back the whole squad just because she can’t control her appetite!” Melanie vows she is not going to lose her leadership position and goes on a strict diet. Her friends and family initially praise her for her weight loss. Melanie vows to become the thinnest person on the cheerleading squad. She eats nothing but a few raw vegetables and is obsessed with getting thinner. Melanie is becoming dangerously thin and shows signs of developing anorexia nervosa.

    1. Melanie has been diagnosed with anorexia nervosa. Treatment initiatives should include
    2. antipsychotic medications.
    3. short-term CBT.
    4. electroconvulsive therapy (ECT).
    5. family therapy.

    Self-Assessment #4

    Dominique is a well-to-do investment banker. At 33 years of age, she is a partner in her investment firm, the wife of a prominent businessman, and the mother of two young children. She is also very attractive and has a slim figure that complements her designer clothes. Dominique is the envy of almost everyone who knows her. Her weight is within the normal range for her height and weight. However, Dominique is, in fact, far from healthy. She suffers from bulimia nervosa. Dominique eats enormous quantities of food in private and immediately takes laxatives and/or induces vomiting so that she will not gain weight. This dangerous cycle of binging and purging is increasing at an alarming rate.

    1. When assessing for bulimia nervosa, the nurse anticipates that the patient will be
    2. overweight.
    3. having feelings of control over their eating habits.
    4. desperate to lose weight.
    5. violent.

    Recommended Dietary Guidelines

    Dietary Guidelines from Health.gov

     The 2015–2020 Dietary Guidelines (8th ed.) were written to provide Americans with information they need to make healthy food choices (Health.gov., 2016a). Dietary principles that are part of these most recent guidelines include the following (Health.gov., 2015; 2016a; 2016b):

    • Americans should follow a healthy-eating pattern across their lifespan.
    • Eating patterns have a significant impact on health.
    • Healthy-eating patterns are adaptable.
    • Healthy eating should focus on variety, nutrient density, and amounts of food eaten.
    • Eating patterns should stay within appropriate caloric intake for age, sex, and activity level; they should meet nutritional needs, and be achievable and maintainable in the long term.
    • Healthy-eating patterns include nutrient-dense forms of the following:
    • A variety of vegetables – dark green, red, and orange in color, including legumes (beans and peas) and other starchy vegetables.
    • Fruits, especially whole fruits.
    • Fat-free or low-fat dairy, including milk, yogurt, cheese, and fortified soy beverages.
    • A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), soy products, and nuts and seeds.
    • Oils, including those from plants (e.g., canola, corn, olive, peanut, safflower, soybean, and sunflower) and oils that are naturally present in foods (nuts, seeds, seafood, olives, and avocados).
    • Note that the preceding foods are nutrient dense only if they are prepared with little or no added solid fats, sugars, refined starches, and sodium.
    • Calories from added sugars and saturated fats should be limited, and sodium intake should be reduced.
    • Added sugars should be limited to less than 10% of total daily calorie intake.
    • Saturated and trans fats should be limited to less than 10% of total daily calories by replacing them with unsaturated fats and limit trans fats to as low as possible.
    • Sodium intake should be limited to less than 2,300 mg daily (for adults and children 14 years and older).

    EBP Alert! Research shows that most Americans get 50% more sodium than recommended. Sodium is linked with hypertension and heart disease (Health.gov., 2015). Nurses must emphasize the importance of limited sodium intake to appropriate levels when counseling patients and families.

    • Alcohol intake should be limited to no more than one drink daily for women and no more than two for men.
    • Americans should shift to healthier food and beverage choices. Examples include a shift from the following:
    • Full-fat cheese or whole milk to low-fat cheese and milk.
    • White bread to whole-wheat bread.
    • Fatty cuts of meat to seafood or beans.
    • Butter to olive or canola oil.
    • Soft drinks to water.
    • Potato chips to unsalted nuts.
    • Eating patterns represent the totality of all foods and beverages consumed.
    • Nutritional needs should be met primarily from foods.
    • Healthy-eating patterns are adaptable.

     Healthy physical activity patterns are essential components of all healthy-eating patterns. Only 20% of adults meet the Physical Activity Guidelines for aerobic and muscle-strengthening activity (Health.gov., 2015). These Guidelines state the following (Health.gov., 2015; 2016a):

    • Regular physical activity is one of the most important things individuals can do to improve his or her health.
    • Adults need at least 150 minutes of moderate intensity physical activity per week and should perform muscle-strengthening exercises on two or more days each week.
    • Young people in the age range of 6–17 years old need at least 60 minutes of physical activity per day, including aerobic, muscle-strengthening, and bone-strengthening activities.
    • Strong evidence shows that regular physical activity helps people maintain a healthy weight, prevent excessive weight gain, and lose weight when combined with a healthy- eating pattern lower in calories.
    • Strong evidence shows that regular physical activity lowers the risk of early death, coronary heart disease, stroke, high blood pressure, adverse blood lipid profile, type 2 diabetes, breast and colon cancer, and metabolic syndrome.
    • Strong evidence shows that regular physical exercise reduces depression and prevents falls.

     These preceding principles and guidelines are updated every five years. Such regular updating requires ongoing research and evaluation. There are three stages involved in the update process (Health.gov., 2015; 2016a; 2016b):

    • Stage 1 – Review of Current Scientific Evidence: The secretaries of Health and Human Services and the United States Department of Agriculture appoint a 15-member external advisory committee to be sure that the federal government is getting reliable external scientific advice. Nominations from the public were sought for candidates to serve on the 2015 committee. The goal of the committee was to provide advice and make recommendations to the federal government on the current state of scientific evidence on nutrition and health. Their responsibilities were to review the 2010 edition of the Dietary Guidelines to determine the topics for which new scientific evidence was most likely to be available and to review that evidence to help in the development of the 2015–2020 edition. In order to fulfill their responsibilities, committee members completed the following:
    • Conducted original systematic reviews. The members systematically searched the scientific literature for relevant articles, assessed the methodology rigor of each article included in the process, and summarized, analyzed, and graded the evidence provided in each article.
    • Reviewed existing systematic reviews, meta-analyses, and reports by federal agencies or leading scientific organizations. This review involved applying a systematic process to assess the quality of the existing review or report and to ensure that it presented a comprehensive review of the question of interest.
    • Conduced data analysis. The committee members used national data from federal government agencies to address questions regarding chronic disease prevalence rates, food, and nutrient intakes of the population of the United States across age, sex, and other demographic characteristics, as well as questions regarding the nutrient content of foods.
    • Conducted food pattern modeling analyses. The committee members estimated the effects of diet quality on possible changes in types or amounts of foods in the United States Department of Agriculture Food Patterns that it was in consideration of recommending.
    • Stage 2 – Development of the Dietary Guidelines for Americans: In this stage, Health and Human Services and the United States Department of Agriculture developed the eighth edition of the Dietary Guidelines. The eighth edition was built upon the preceding edition, with scientific justification for revisions supported by the advisory committee report and information from public and federal agencies. The strength of the evidence that supported the 2015 recommendations was determined using the following criteria:
    • Strong Evidence: Reflects a large, high-quality and/or consistent body of evidence. Strong evidence indicates that there is a high level of certainty that the evidence is relevant to the population of interest and that additional studies are not likely to change conclusions based on this evidence.
    • Moderate Evidence: Reflects sufficient evidence to draw conclusions. However, the level of certainty may be constrained by limitations in the evidence presented in the studies.
    • Limited Evidence: Reflects either a small number of studies, studies of weak design or with inconsistent results, and/or limitations on the generalization of the findings.
    • Stage 3 – Implementing the Dietary Guidelines for Americans: Federal programs apply the Dietary Guidelines via food, nutrition, and health policies and programs, and in nutrition education materials for the public. For example, MyPlate is extensively used to promote the Dietary Guidelines.

     To date, the Dietary Guidelines focused on persons ages two and older in the United States, including those who are at increased risk of chronic disease. However, as research continues to demonstrate association between early nutrition to health outcomes throughout the life span, it is anticipated that future guidelines (beginning with the 2020–2025 edition) will expand to include guidance for persons under the age of two and for women who are pregnant (Health.gov., 2015; 2016a).

    Nursing Consideration: Nurses must be knowledgeable in how the Dietary Guidelines are developed and their content so that they can adequately provide patient/family education regarding these recommendations. Part of this knowledge is to be able to interpret MyPlate content and explain its recommendations to healthcare consumers.


     MyPlate was introduced by the United States Department of Agriculture in 2011. It is a visual guide designed to provide an easy, quick graphic of how to eat according to the Dietary Guidelines for Americans (Dairy Council of California, 2019).

     The MyPlate graphic divides a dinner plate into four sections. The fruits and vegetables sections make up half of the plate, emphasizing the guideline that recommends fruits and vegetables make up half of every meal. The second half of the plate is divided into two sections: one section for grains and one for protein. A smaller circle, separate from the plate, is for dairy (Dairy Council of California, 2019).

     Recommendations that are part of MyPlate include the following (Dairy Council of California, 2019):

    • Switching to fat-free or low-fat (1%) milk.
    • Making at least half of grain intake whole grains.
    • Choosing lean sources of protein.
    • Drinking water instead of sugary drinks.
    • Avoiding portions that are oversized.
    • Comparing the amounts of sodium (salt) in foods like soups, breads, and frozen meals, and choosing foods with the lesser amounts of sodium.

    MyPlate remains the federal government’s accepted graphic representation of healthy eating.

    Harvard Healthy Eating Plate

     In 2011, the Harvard Medical School published its own graphic representation of healthy eating guidelines. Harvard’s Healthy Eating Plate was also divided into four sections: vegetables, fruits, whole grains, and healthy proteins. Next to the plate was a glass representing water intake and a canister representing healthy oils (Harvard Health Publishing Harvard Medical School, 2017).

     Citing what they felt were inadequacies in MyPlate, Harvard experts encouraged the following healthy-eating habits (Harvard Health Publishing Harvard Medical School, 2017).

    • Choose whole grains, and limit refined grains, which act like sugars.
    • Choose healthy proteins such as fish, poultry, beans, or nuts. Limit red meat and avoid processed meat, since eating even small quantities of these foods on a regular basis increases the risk of heart disease, diabetes, colon cancer, and weight gain.
    • Eat a variety of vegetables. Americans are especially deficient in their vegetable intake except for potatoes and french fries, which contain large amounts of rapidly digested starch. Potatoes have the same effect on blood sugar as refined grains and sugars. Their consumption should be limited.
    • The Healthy Eating Plate places fruits beneath vegetables on the plate, since not as much fruit is needed each day as vegetables.
    • Choose healthy oils such as olive, canola, and other plant oils in cooking, on salads, and at the dining table. Butter and trans fat consumption should be limited.
    • Drink water. Avoid sugary drinks. Limit milk and dairy to one to two servings each day. Limit juice intake, even 100% fruit juice, as juice contains as much sugar and as many calories as sugary soda.
    • A figure at the bottom of the Healthy Eating Plate reminds people to stay active.

    For more information and to view the Healthy Eating Plate visit: https://www.health.harvard.edu/staying-healthy/healthy-eating-plate

    Healthy Eating and Food Groups

     Healthy-eating recommendations include various terms about food groups. It is important that nurses be able to teach their patients about the identified groups and what constitutes healthy choices within each group. A number of websites offer the following explanations about food groups (Health.gov., 2015; 2016a; 2016b):

    • Vegetables: A healthy diet includes a variety of vegetables from all of the five vegetable subgroups: dark green, red and orange, legumes (beans and peas), starchy, and other. These groups include all fresh, frozen, canned, and dried options in cooked or raw forms. These also include vegetable juices. Legumes are excellent sources of protein and fiber. Green peas and green (string) beans are not considered to be part of the legume subgroup because their nutritional components are not similar to legumes. Green peas are grouped with starchy vegetables, and green beans are grouped in the “other” vegetable subgroup, which also includes onions, iceberg lettuce, celery, and cabbage.
    • Fruits: Healthy eating includes eating fruits, especially whole fruits. The fruits group includes whole fruits and 100% fruit juice. Whole fruits include fresh, canned, frozen, and dried forms of fruit. One cup of 100% fruit juice counts as one cup of fruit. However, fruit juice can be high in calories and some have added sugars. When consuming fruit juice, 100% juice should be selected without added sugars. Half a cup of dried fruit is equivalent to one cup of fruit. Dried fruits can contribute to extra calories if sugars are added.
    • Grains: Grains are either whole or refined. The intake of refined grains should be limited. Examples of whole grains include brown rice and oats. Refined grains are those that have been processed to remove the dietary fiber, iron, and other nutrients. Examples of refined grains include products such as cookies, cakes, and some snack foods.
    • Dairy: Healthy dietary intake of dairy products includes fat-free and low-fat (1%) milk, yogurt, cheese, or fortified (with vitamins A and D) soy beverages. Products sold as milk but made from plants, such as almond, rice, and coconut milks, may contain calcium but are not included as part of the dairy group because their overall nutritional content is not similar to dairy milk and fortified soy beverages. Recommended amounts of dairy are based on age rather than calories.
    • Children ages two to three years: 2-cup equivalents of dairy per day.
    • Children ages four to eight years: 2 ½ cup equivalents of dairy per day.
    • Persons nine years of age and older: 3 cup equivalents per day.
    • Protein: A variety of protein foods are part of healthy-eating patterns. Examples of protein foods include a number of subgroups including seafood, meats, poultry, eggs, nuts, seeds, and soy products. Legumes may be considered to be part of the protein food group and the vegetable food group.
    • It is recommended that, for the general population, eight ounces of seafood should be consumed per week. However, mercury can be found in seafood in varying levels. It is recommended that women who are pregnant or who are breastfeeding and young children should eat seafood that is low in mercury. Examples of seafood that generally have lower levels of mercury include salmon, anchovies, herring, shad, sardines, Pacific oysters, trout, and Atlantic and Pacific mackerel.
    • Meat, also known as red meat, includes all forms of beef, pork, lamb, veal, goat, and nonbird game. Poultry includes all forms of chicken, turkey, duck, geese, guineas, and game birds. Lean meats should be chosen over processed meats and processed poultry.
    • Oils: Oils are not a food group, but are part of healthy-eating patterns because they are the major source of essential fatty acids and vitamin E. Healthy oils include those obtained from plant sources and not trans fats.

    Whole Foods Versus Processed Foods

     All forms of media communication discuss the benefits of “whole” foods. What exactly are whole foods? What makes them better? What is the difference between whole foods and processed foods?

     Whole foods are nutrient dense. Processed foods are energy dense. Nutrient-dense foods provide the consumer with nutrients critical to health, such as fiber, vitamins, and minerals with low added sugar and fat. Energy dense foods are often high in calories that have little nutritional value (Jones, 2013; Mission Health, 2018).

     Ideally, a whole food is one that consists of only one ingredient, such as an apple or a piece of chicken. These types of foods can help to reduce cholesterol and regulate blood sugar. Processed foods, on the other hand, contain more than one ingredient, and also contain added sugars, preservatives, dyes, and saturated and trans fats (Jones, 2013; Mission Health, 2018).

     Additional advantages of whole foods include the following (Health Agenda Nutrition, 2017):

    • Whole foods are rich in phytochemicals.
    • Whole foods contain more vitamins and minerals than processed foods.
    • Whole foods contain more fiber and beneficial fats than processed foods.
    • Whole plant foods contain combinations of nutrients that work together to protect the body from disease.

    Nursing Consideration: Examples of whole foods include those listed in healthy-eating guidelines, such as fresh fruits, and vegetables, fresh lean meats, and fresh eggs. Nurses must be able to differentiate among the nutritional value of whole versus processed foods and teach their patients the differences as well.

    • Stage 1: Review of Current Scientific Evidence: The Secretaries of Health and Human Services and the United States Department of Agriculture appoint an external Dietary Guidelines Advisory Committee. Appointing a committee is done in order to ensuicit

     Here are some reasons to avoid processed foods (Health Agenda Nutrition, 2017; Mission Health, 2018):

    • Processed foods contain additives and preservatives and are often high in sodium.
    • Processed foods may contain trans fats that elevate cholesterol.
    • Processed foods may contain hidden allergens that may be a threat to those who suffer from food allergies.
    • Some forms of processed foods contain large amounts of sugar. Examples include candy, sugared cereals, frozen desserts, and soft drinks.
    • Processed foods high in calories and low in fiber contribute to overeating and weight gain. Foods high in fiber make people feel fuller more quickly compared to processed foods.

     When people are shopping for groceries, they are often in a hurry and grab what is quickly and easily available, but it is worth taking the time to look for whole foods. Here are some tips for swiftly locating healthy, whole foods (Health Agenda Nutrition, 2017; Mission Health, 2018):

    1. Purchase seasonal fresh, whole foods from local farmers or farmers’ markets or through a community-supported agriculture (CSA) group.
    2. In grocery stores, shop around the perimeter of the store. That is where whole foods are located. Processed foods are in the aisles.
    3. Make a grocery list before leaving home. Make sure the list emphasizes shopping primarily around the periphery of the store for items such as fruits, vegetables, lean meats, and low-fat dairy items. People should travel into only one or two aisles per grocery store trip.

    Organic Foods     

     In the not so distant past, organic foods were found only in health food stores, and people who purchased them were viewed, by many others, as a bit unusual or overly concerned about their diets. Today, however, organic foods are readily available at most grocery stores. But do organic foods really provide more health benefits than conventionally grown food products? Do the benefits outweigh disadvantages to purchasing organic food? For example, organic foods frequently cost considerably more than their counterparts raised by nonorganic methods. Organic foods cost more because they may decompose faster, and they are more labor-intensive to produce. Organic meats are costly because the food required to feed the animals is more expensive than foods fed to animals raised by conventional methods. In some cases, organic foods costs twice as much as nonorganic foods (Mayo Clinic, 2018g).

    Organic refers to the way farmers grow and process agricultural products. Here are some facts about organically grown food (Mayo Clinic, 2018g):

    • Organic farming practices are intended to help conserve soil and water and reduce pollution.
    • Conventional methods of fertilization and weed control are not used by farmers who grow organic produce. Instead, natural fertilizers are used to feed soil and plants. Crop rotation or mulch is used to manage weeds.
    • The United States Department of Agriculture (USDA) has established an organic certification program that regulates how these foods are grown, handled, and processed.
    • Any product labeled as organic must be certified by the USDA. Food producers who sell less than $5,000 a year in organic foods are exempt from certification, but they are still required to follow the department’s standards for organic foods.
    • To be labeled as 100% organic, food products must be either completely organic or made of all organic ingredients.
    • To be labeled organic, food products must be at least 95% organic.
    • To be labeled made with organic, foods must be composed of at least 70% certified organic ingredients. If less than 70% of a multi-ingredient product is certified organic, it may not be labeled as organic or carry a USDA seal.
    • Only foods that are grown and processed according to the USDA standards may be labeled organic.

     A common barrier to buying organic foods is cost. Organic foods are usually more costly than conventional foods because, in part, the farming practices used are more expensive. Additionally, organic products may spoil quicker because they are not treated with preservatives (Maloney, 2019a; Mayo Clinic, 2018g).

    EBP Alert! There is a growing body of evidence that indicates some potential health benefits of organic foods including increased amounts of nutrients, higher levels of omega-3 fatty acids, and reduced exposure to toxic metals, pesticide residue, and bacteria (Maloney, 2019a).

     Individuals who buy organic foods express certain concerns about nonorganic foods, including the following (Maloney, 2019a; Mayo Clinic, 2018g):

    • Pesticide use: Conventional farmers spray pesticides that can leave residue on food products. Organic farmers use insect traps, disease-resistant crop selection, predator insects, or beneficial microorganisms to control crop-damaging pests. Thus, organic products typically carry significantly less pesticide residue than conventional food. Pesticide residue on both organic and nonorganic does not exceed government-identified safety thresholds.
    • Food additives: Organic regulations ban or significantly limit the use of food additives, processing aids, and fortifying agents that are commonly used in the production of nonorganic foods. Examples of fortifying agents include preservatives, artificial sweeteners, colorings and flavorings, as well as monosodium glutamate.
    • Environmental concerns: Organic farmers focus on reducing pollution and conserving water and soil quality.

    Nursing Interventions

     As noted throughout this education program, nurses play a critical role in educating patients about nutrition. There is an unlimited amount of information available on the Internet concerning nutrition, various types of diets, and how to use nutrition to improve health and wellness. Some of this information is accurate and helpful, while some can be downright dangerous to the uninformed consumer. Nurses must not only be able to provide accurate, current information about the latest Dietary Guidelines for healthy eating, but also help patients to differentiate between fact and fiction when it comes to healthy eating.

    Self-Assessment #5

    Monica is a busy mother of three, including Tracey, a 16-year-old health and fitness enthusiast. Tracey frequently criticizes her family’s eating habits and tells her mother that they should all eat more “organic” foods. Monica doesn’t really understand the difference between organic and nonorganic food products and doubts if Tracey really understands what she is proposing. One day, Monica asks Tracey to accompany her to the grocery store, and tells her, “Now you can show me why you think this organic stuff is so much better than what we’ve been eating for years!” What should Tracey tell her mother about organic foods?

    1. Tracey should tell her mother all of the following EXCEPT
    2. organic foods typically carry significantly less pesticide reside.
    3. organic foods are less expensive than conventional foods.
    4. organic farmers focus on reducing pollution and conserving water and soil quality.
    5. organic regulations ban or significantly limit the use of food additives.

    Specific Nutrients

     There are many nutrients that are obtained from various food sources. Some of them, such as soy, have been credited with abundant healing properties, as have some vitamins and minerals. The following material, although not all-inclusive, provides information to help the nurse relay accurate information to patients and families about nutrients.


     Phytonutrients or phytochemicals are natural chemicals found in plant foods. Good sources of phytonutrients are fruits, vegetables, whole grains, nuts, beans, and tea. Research suggests that phytonutrients may help prevent disease (WebMD, 2018c).

     There are more than 25,000 phytonutrients. Here are descriptions of six of the most important phytonutrients and how they may impact health (WebMD, 2018c):

    • Carotenoids: There are more than 600 carotenoids, which provide the yellow, orange, and red colors in various fruits and vegetables. Carotenoids function as antioxidants and convert alpha-carotene, beta-carotene, and beta-cryptoxanthin to vitamin A. They may help to lower the risk of prostate cancer and enhance eye health.
    • Ellagic Acid: Ellagic acid is found most often in berries such as strawberries, raspberries, and in pomegranates. Ellagic acid may help to slow the growth of cancer cells and help the liver to neutralize cancer-causing agents in the body.
    • Flavonoids: Sources of flavonoids include the following:
    • Green tea, which may help to prevent certain malignancies.
    • Citrus fruits, which work as antioxidants.
    • Apples, berries, kale, and onions, which may help to reduce the risk of asthma, some malignancies, and heart disease.
    • Resveratrol: Found in grapes, purple grape juice, and red wine, resveratrol acts as an antioxidant and anti-inflammatory.
    • Glucosinolates: Found in cruciferous vegetables such as brussels sprouts, cabbage, kale, and broccoli, glucosinolates may have some cancer prevention properties.
    • Phytoestrogens: Phytoestgrogens can cause estrogen-like effects, but can also block the effects of the body’s natural supply of estrogen. Isoflavones, a type of phytoestrogen, are found in soy foods and may be linked to a lower risk of endometrial cancer and a lower risk of bone loss in women.


     Antioxidants are synthetic or natural substances that may help to prevent or delay some types of cell damage. Vegetables and fruits are excellent sources of antioxidants. Research shows that people who eat more vegetables and fruits have lower risks of some diseases; however, it is not yet clear whether these results are linked to the amounts of antioxidants in vegetables and fruits, to other components of these foods, to other dietary choices, or to other lifestyle choices (National Center for Complementary and Integrative Health (NCCIH), 2016).

     Antioxidants have been found to counteract the effects of free radicals. Free radicals are very unstable molecules that are formed naturally when people exercise and when the body converts food into energy.  Free radicals also come from the environment in the form of air pollution, sunlight, and cigarette smoke. Free radicals can lead to what is referred to as oxidative stress, which is believed to play a part in the development of some diseases including cancer, heart disease, diabetes, Alzheimer’s disease, Parkinson’s disease, cataracts, and age-related macular degeneration (NCCIH, 2016).

     Although the benefits that come from eating fruits and vegetables may include antioxidant-associated benefits, the role of antioxidant supplements is less clear. High-dose supplements of antioxidants may actually be harmful in some cases. Some research findings indicate that the use of high-dose beta-carotene supplements is linked to an increased risk of lung cancer in smokers, and the use of high-dose vitamin E supplements may increase the risk of hemorrhagic stroke and prostate cancer (NCCIH, 2016).  

     There is also the danger of interactions between antioxidant supplements and some medications. For example, the ingestion of vitamin E supplements may increase bleeding risk in patients who are taking anticoagulants. There is contradictory evidence regarding taking antioxidant supplements while receiving treatment for cancer. Some study findings indicate that such supplements may be helpful, while other findings suggest that they may actually be harmful. Persons undergoing cancer treatment should talk to their health care provider before adding any supplements to their diets (NCCIH, 2016).

     For patients who are thinking about adding antioxidant supplements to their diets, it is recommended that they do the following (NCCIH, 2016):

    • Not use antioxidant supplements to replace the guidelines for a healthy diet, conventional medical care, or as a substitute for seeking medical help for a health problem.
    • Seek the advice of health care providers if they have age-related macular degeneration and are thinking about taking supplements. They should not take supplements without the advice of their health care providers.
    • Obtain accurate information from reliable healthcare resources (e.g., healthcare professionals) before adding supplements to their diets. Supplements can interact adversely with medications and other supplements.
    • Inform their health care providers about any complementary health care interventions they are thinking about trying. Seek their advice before starting any such interventions.


     Soy has gained great popularity as a health food. It has been part of the human diet for thousands of years. It is not certain if the proposed health benefits of soy come from its isoflavones or from a combination of isoflavones and other nutrients found in soy. Researchers are investigating whether or not soy can help to prevent hormone-related cancers such as breast, prostate, and uterine cancer. They are also investigating the impact soy has on menopausal symptoms and on bone and heart health. However, the results are not definitive (Messina, 2016; WebMD, 2019c).

     Here is a review of some of the research findings related to therapeutic uses of soy.

     Cholesterol Reduction. Some research findings indicate that soy may reduce the risk of heart disease by lowering LDL (bad) cholesterol levels. Evidence indicates that a decrease in LDL cholesterol in response to soy protein is greater in the hypercholesterolemic compared to persons with normal cholesterol levels (Messina, 2016). Some studies indicate that adding soy protein to the diet can help lower LDL cholesterol by four to six percent (WebMD, 2019b).

     Cancer. Findings related to soy as a cancer preventive agent are complicated. Most studies that found soy lowers the risk of breast cancer were conducted using Asian women as subjects, since these women generally eat a lot of soy. Additionally, study results suggest that a woman may receive the best protection if she eats a diet high in soy while young, rather than when she goes through menopause (Messina, 2016; WebMD, 2019b).

     Some studies suggest that soy consumption decreases the risk of prostate cancer, and others suggest that soy consumption is linked to a lower risk of lung cancer and improves survival chances in patients who have lung cancer. However, not all studies show such benefits (Messina, 2016; WebMD, 2019b).

    EBP Alert! Studies related to soy consumption and reduced cancer risk show mixed results. It is important that nurses stay current regarding soy research and its findings.

     Osteoporosis. Results from studies on the impact of soy on osteoporosis prevention are mixed. Not many studies have been conducted, but some that have been conducted indicate that women who are approaching menopause and eat isoflavone-rich soy protein are more likely to boost bone mineral density than those who do not. However, other studies show that soy isoflavones do not increase bone mineral density in early postmenopausal women (Messina, 2016; WebMD, 2019b).

     Menopause. As in other studies, results of whether or not soy reduces menopausal symptoms have been mixed. Studies with the most positive results show such results are associated with a daily intake of soy products with at least 15 mg of isoflavones (Messina, 2016; WebMD, 2019b).

     Precautions Concerning Soy Intake. The following issues describe situations that indicate soy should be consumed with caution (Messina, 2016; WebMD, 2019b).

    • Soy allergies: Persons allergic to soy and soy products should not consume soy or soy supplements.
    • Breast cancer: Some studies suggest that soy consumption in women who have already had breast cancer may not be safe. However, other studies indicate that soy consumption in such patients is not harmful. Health care providers should be consulted before adding soy to the diet.
    • Renal Disease: Soy contains more phosphorus and potassium than similar quantities of other protein sources, such as meat, poultry, and fish. Thus, persons with renal disease should consult with their health care providers before consuming soy products.
    • Hypothyroidism: Isoflavones can reduce the amount of iodine in the body. Insufficient amounts of iodine may lead to inadequate thyroid function.
    • Uterine cancer: Women who have had or who have uterine (endometrial) cancer should not consume large amounts of soy or soy supplements without first consulting with their health care providers.
    • Pregnancy and breastfeeding: Soy food consumption in women who are pregnant or who are breastfeeding is generally considered safe. However, these women should not take soy supplements without first consulting with their health care providers.


     Fats are nutrients that provide the body with energy and facilitate the absorption of the fat-soluble vitamins, D, E, K, and A. There are three types of fat: saturated, trans, and unsaturated (WebMD, 2019c).

     Saturated Fat. Saturated fat is solid at room temperature and is found primarily in animal related foods such as milk, cheese, and meat (red meat has more saturated fat than poultry and fish). Food products that are made with butter, margarine or shortening contain significant amounts of saturated fat. Since saturated fat can elevate cholesterol levels, a healthy diet should have less than 10% of daily calories from saturated fat (WebMD, 2019c).

     Trans Fat. Trans fat is hydrogenated, which increases its shelf life and makes it solid at room temperature. Trans fat is found in items such as processed foods, snack foods (e.g., potato chips), cookies, some margarines and salad dressings, and processed foods. This type of fat can also elevate cholesterol (WebMD, 2019c).

     Unsaturated Fat. Unsaturated fat, which is liquid at room temperature, is obtained primarily from plants. Unsaturated fats may actually reduce cholesterol levels. Types of unsaturated fat include the following (WebMD, 2019c):

    • Monounsaturated fat: Found in avocados, nuts, and vegetable oils, monounsaturated fat may actually help to reduce LDL (bad) cholesterol and help to maintain HDL (good) cholesterol.

    Nursing Consideration: It is important to teach patients that eating greater amounts of unsaturated fat without reducing intake of saturated fat will not help to reduce LDL cholesterol (WebMD, 2019c).

    • Polyunsaturated fat: Found primarily in vegetable oils such as safflower, sunflower, sesame, soybean, and corn oils, polyunsaturated fat is also the main fat in seafood. The two types of polyunsaturated fat are omega-3 and omega-6 fatty acids. Omega-3 fatty acids are found in foods from plants (e.g., soybean oil, walnuts, and flaxseed) and in fatty fish and shellfish such as salmon, anchovies, herring, sardines, trout, Pacific oysters, and Pacific mackerel. Guidelines for healthy diet recommend that eight ounces or more of these types of fish be consumed every week. Omega-6 fatty acids are found primarily in liquid vegetable oils.


     Carbohydrates are the body’s primary energy source. There are three main types of carbohydrates (Mayo Clinic, 2017a):

    • Sugar: Sugars are the simplest forms of carbohydrates. They occur naturally in foods such as fruits, vegetables, milk, and milk products. Sugars also include fruit sugar (fructose), table sugar (sucrose), and milk sugar (lactose).
    • Starch: Starch is a complex carbohydrate, which means that it is comprised of multiple sugars that are bonded together. Starch is found naturally in vegetables, grains, and cooked dry beans and peas.
    • Fiber: Fiber, also a complex carbohydrate, occurs naturally in fruits, vegetables, whole grains, and cooked dry beans and peas.

     Carbohydrates are important to good health. Dietary Guidelines for Americans recommend that carbohydrates make up 45–65% of the total daily caloric intake (Mayo Clinic, 2017a).

     Carbohydrates, important components of a healthy diet, must be chosen wisely. Here are some guidelines to incorporate healthy carbohydrates into the diet (Mayo Clinic, 2017a):

    • Choose fiber-rich fruits and vegetables. Choose whole, fresh, frozen, and canned fruits and vegetables without added sugar.
    • Choose whole grains. Whole grains are good sources of fiber and other important nutrients.
    • Choose low-fat dairy products. Dairy products are good sources of calcium and protein, but choose low-fat dairy products to limit saturated fat and calories.
    • Increase bean and legume intake. Legumes and beans are good sources of iron, protein, potassium, and magnesium as well as good fats and fiber. Legumes can be a healthy substitute for meat.
    • Limit the intake of added sugars. There is no health advantage to consuming added sugars, although consuming a small amount of added sugar will probably not have negative health impacts. However, consuming too much added sugar can lead to poor nutritional intake, weight gain, and tooth decay.


     Fiber has many health benefits. It can help maintain a healthy weight, lower the risk of heart disease and diabetes, and prevent or relieve constipation. Dietary fiber is found primarily in fruits, vegetables, and legumes (Mayo Clinic, 2018h).

     Dietary fiber is also known as roughage or bulk and includes the components of plant foods that the body is unable to digest. This means that it passes nearly intact through the stomach, small intestine, colon, and out of the body (Mayo Clinic, 2018h).

     There are two types of fiber: Soluble fiber, which dissolves in water to form a soft, gel-like material, is found in food such as oats, peas, beans, apples, and barley. It can help to reduce cholesterol and glucose levels. Insoluble fiber, found in whole wheat flour, wheat bran, nuts, beans and vegetables, facilitates digestive system movement, increases the bulk of stools, and helps to regulate elimination patterns (Mayo Clinic, 2018h). 


     Proteins are referred to as the building blocks of life. Every cell in the body contains proteins, which are made of up to 20 different types of amino acids. Proteins (Lawler, 2019) will do the following:

    • Provide energy.
    • Repair cells.
    • Stimulate the growth of new cells.
    • Promote growth and development in children, teenagers, and the fetus in pregnant women.

     Protein is found in both animal and nonanimal sources. Animal sources of protein include meat, poultry, fish, and eggs. Nonanimal sources of protein include soy products, beans, nuts, and some grains. The Institute of Medicine (IOM) recommends that adults obtain a minimum of eight grams of protein daily for every 20 pounds of body weight. Most adults need two to three servings of foods rich in protein every day (Lawler, 2019).

     Excessive amounts of protein, however, can cause certain adverse effects, including the following (Lawler, 2019):

    • Abdominal pain.
    • Eating pattern changes.
    • Hepatic complications.
    • Increased workload on the kidneys.

    Nursing Consideration: The amount of protein consumed as part of a well-balanced diet is generally considered to be adequate and safe (Lawler, 2019). Nurses must advise patients about protein sources and how protein should be consumed as part of a healthy diet.


    Vitamins are important to a state of health and wellness and are classified as water-soluble and fat-soluble.

     Water-Soluble Vitamins. Water-soluble vitamins travel throughout the body without inhibition, and excess amounts are typically excreted by the kidneys. It is unlikely that water-soluble vitamins will reach toxic levels (WebMD, 2018d). The following are important points about water-soluble vitamins (Medline Plus, 2019; WebMD, 2018d):

    • Thiamine (vitamin B1): This vitamin is important to nerve function and energy. It is found in pork, whole-grain or enriched breads and cereals, legumes, nuts, and seeds.
    • Riboflavin (vitamin B2): Vitamin B2 is needed not only for energy metabolism, but is also important for normal vision and integumentary health. Sources of this vitamin include milk and milk products, green leafy vegetables, whole-grain, enriched breads and cereals.
    • Niacin (vitamin B3): Also needed for energy metabolism, vitamin B3 is essential for the health of the nervous and digestive systems and integumentary health. Sources of vitamin B3 include meat, poultry, fish, whole-grain or enriched breads and cereals, leafy green vegetables, mushrooms, asparagus, and peanut butter.
    • Pantothenic acid: Needed for energy metabolism, pantothenic acid is found in many food sources.
    • Biotin: Biotin is needed for energy metabolism and is widespread in foods. It is also produced by bacteria in the intestinal tract.
    • Pyridoxine (vitamin B6): Vitamin B6 is a part of an enzyme essential for protein metabolism. It also helps in the manufacture of red blood cells (RBCs). Sources of this vitamin include meat, fish, poultry, vegetables, and fruits.
    • Folic acid: Folic acid is needed for the manufacture of DNA and new cells, red blood cells in particular. Folic acid is found in leafy green vegetables and legumes, seeds, orange juice, and liver. Folic acid is currently added to most refined grains.
    • Cobalamin (vitamin B12): Vitamin B12 is needed for the manufacture of new cells and is important for nerve functioning. It can be found in meat, poultry, fish, seafood, eggs, milk, and milk products. However, it is not found in plant foods.
    • Ascorbic Acid (vitamin C): Vitamin C is an antioxidant and is needed for the metabolism of protein. It facilitates iron absorption, and is important for a healthy immune system. Vitamin C is found only in fruits and vegetables, especially citrus fruits, vegetables in the cabbage family, cantaloupe, strawberries, tomatoes, potatoes, lettuce, papayas, mangoes, and kiwi.

     Fat-Soluble Vitamins. Fat-soluble vitamins are stored in body cells and are not excreted as quickly or easily as water-soluble vitamins. Excessive amounts of fat-soluble vitamins can lead to toxicity (Medline Plus, 2019; WebMD, 2018d). The following are important points about fat-soluble vitamins (Medline Plus, 2019; WebMD, 2018d):

    • Vitamin A: Vitamin A, important for vision, healthy skin and mucous membranes, the growth of bones and teeth, and a healthy immune system, is obtained from animal sources, fortified milk, cheese, cream, butter, fortified margarine, eggs, and liver. Vitamin A’s precursor is beta-carotene, which is obtained from leafy, dark green vegetables, dark orange fruits, and vegetables.
    • Vitamin D: Vitamin D is essential for adequate calcium absorption and is stored in the bones. Vitamin D is obtained from egg yolks, fatty fish, fortified milk, and fortified margarine. The skin can make vitamin D when it is exposed to adequate amounts of sunlight.
    • Vitamin E: Vitamin E is known for its antioxidant properties, which help to protect the walls of the body’s cells. Vitamin E is obtained from polyunsaturated plant oils, leafy green vegetables, wheat germ, whole-grain food products, liver, egg yolks, nuts, and seeds.
    • Vitamin K: Vitamin K is essential for the proper clotting of blood. It may be found in leafy green vegetables, vegetables in the cabbage family, and milk. It is also manufactured by bacteria that live in the intestinal tract.


     Calcium is essential for the healthy functioning of the heart, muscles, and nerves, as well as for the safe and appropriate clotting of blood. Research shows that insufficient amounts of calcium are associated with the development of osteoporosis, low bone mass, and high incidence of fractures (National Institute of Health (NIH) Osteoporosis and Related Bone Diseases National Resource Center, 2018).

     Adults between the ages of 18 and 50 need 1,000 mg/day of calcium. Men between the ages of 51 to 70 need 1,000 mg/day of calcium daily, and women between the ages of 51 to 70 require 1,200 mg daily (NIH Osteoporosis and Related Bone Diseases National Resource Center, 2018).

           It is essential that the body has enough vitamin D, which is needed to absorb calcium. Vitamin D leads to the formation of calcitriol, referred to as active vitamin D. In turn, inadequate amounts of vitamin D lead to insufficient absorption of calcium from the diet. If this occurs, the body takes calcium from the bones, which weakens the skeletal system and prevents new bone formation (NIH Osteoporosis and Related Bone Diseases National Resource Center, 2018).

    Nursing Consideration: Up to the age of 70, a daily intake of 600 IU (International Units) of vitamin D is recommended. Men and women over the age of 70 should increase their intake to 800 IU daily. Nurses should educate their patients about sources of vitamin D: through the skin, from diet, and from supplements. Foods rich in vitamin D include egg yolks, saltwater fish, liver, and fortified milk. People should consult their health care providers about the need for vitamin D supplements (NIH Osteoporosis and Related Bone Diseases National Resource Center, 2018).

    Self-Assessment #6

    A professor of nursing is preparing a class on nutrients. The professor wants students to comprehend the importance of nutrients to health and wellness.

    1. The professor will include which of the following in the class on nutrients?
    2. Vitamin A is important for vision, healthy skin, and a healthy immune system.
    3. Vitamin E is necessary for the absorption of calcium.
    4. Folic acid is stored in body cells.
    5. Niacin is vitamin B1.

    Types of Diets

     There are many types of diets in popular use today. Research shows that some are quite beneficial to health and wellness, while others, despite popularity in the media, have yet to be proven to enhance health. The following diets are widely discussed and have many proponents, as well as some critics.

    Paleolithic (Paleo) Diet

    Gloria is a college freshman. She has made a number of friends who are focused on dieting and losing weight. Several of them decide that the “caveman” diet is a surefire way to lose weight. When Gloria asks them what they mean, they explain, “It’s the way the first humans ate before all of these horrible preservatives and the junk they use to spray food crops were invented.” Gloria is planning on majoring in nursing and, although she is anxious to lose some weight herself, she decides that she needs to find out more about this diet before she joins her friends in adopting it.

     Gloria has made a sound decision. All diets should be carefully investigated for nutritional value before one decides to follow them. The so-called “caveman” diet is known as the paleo diet, the Paleolithic diet, the Stone Age diet, and the hunter-gatherer diet. Proponents of this diet believe that by eating like prehistoric humans, people will be thinner and less likely to develop diabetes, heart disease, and cancer (Mayo Clinic, 2017b; McMillen, 2018).

     The paleo diet is high in protein and fiber and is designed to help people lose weight without cutting calories. It is based on foods similar to what might have been eaten during the Paleolithic era (2.5 million to 10,000 years ago) (Mayo Clinic, 2017b; McMillen, 2018).

     Proponents of the paleo diet believe that the human body is better suited to eating the way prehistoric humans did prior to the diets that emerged with farming. Farming changed the way humans ate when dairy, grains, and legumes were added as important components of dietary intake. According to paleo enthusiasts, farming triggered rapid changes in nutritional intake, which did not allow the body enough time to adapt to these dietary changes. They believe that these overwhelming changes contribute to the current prevalence of obesity, cardiac disease, and diabetes (Mayo Clinic, 2017b; McMillen, 2018).

     These are the foods allowed by the paleo diet (Mayo Clinic, 2017b; McMillen, 2018):

    • Nuts and seeds.
    • Lean meats, particularly those that are grass-fed or wild game.
    • Fish, especially those that are rich in omega-3 fatty acids such as salmon, mackerel, and albacore tuna.
    • Oils from fruits and nuts such as olive oil or walnut oil.

    These foods are not allowed by the paleo diet (Mayo Clinic, 2017b; McMillen, 2018):

    • Any processed foods.
    • Grains such as wheat, oats, and barley.
    • Legumes such as beans, lentils, peanuts, and peas.
    • Refined sugar.
    • Refined vegetable oils such as canola oil.

     The paleo diet also stresses the importance of drinking water and being physically active every day (Mayo Clinic, 2017b; McMillen, 2018).

     Research findings regarding the benefits of the paleo diet are mixed. There are both positive and negative findings.

     Clinical trials of 12 weeks or less show that the paleo diet may provide some moderate health benefits when compared with diets of fruits, vegetables, lean meats, whole grains, legumes, and low-fat dairy products, including the following (Mayo Clinic, 2017b; McMillen, 2018).

    • Increased weight loss.
    • Improved glucose tolerance.
    • Improved blood pressure control.
    • Better management of appetite.

    EBP Alert! Short-term clinical trials do not provide enough data regarding the health benefits (or lack of benefits) concerning the paleo diet. Nurses should promote longer trials with large groups of participants who are randomly assigned to various diets to identify long-term, overall health benefits and possible risks of the diet. To date, there are no long-term clinical trials that identify benefits and risks of the paleo diet (Mayo Clinic, 2017b; McMillen, 2018).

     Some experts in nutrition argue that proponents of the paleo diet have oversimplified the components of the diet of the earliest humans. Their concerns include (Mayo Clinic, 2017b; McMillen, 2018). The evolution of the human diet would have depended on geography, climate, and food availability, not only on the shift to farming as a means of acquiring food.

    • Findings from archeological research show that early human dietary intake may have included wild grains as much as 30,000 years ago. This was well before farming existed.
    • Genetic research shows that significant evolutional changes continued after the Paleolithic era. These included changes in the body to help breakdown dietary starches and other food components.

     Strengths and Weaknesses of the Paleo Diet. Proponents of the paleo diet identify the following strengths (Mayo Clinic, 2017b; McMillen, 2018):

    • There is no counting of calories on the paleo diet. The consumption of fiber-rich foods, such as fruits, vegetables and lean meat, will make people feel fuller quicker.
    • There are no requirements for meetings (either in person or online).
    • People can follow this diet without the need for coaches or counselors. However, there are paleo diet forums online (and on social media) to network with other followers of this diet.
    • Eliminating grains, dairy, processed food and sugar will most likely lead to weight loss.
    • Proponents of the diet claim that there is evidence that shows following the paleo diet may lower the risk of heart disease, hypertension, and inflammation, reduce acne, and promote health and wellness.

    Weaknesses and/or criticisms of the paleo diet include the following (Mayo Clinic, 2017b; McMillen, 2018):

    • Wheat and dairy products are prohibited.
    • Processed foods and packaged meals are prohibited.
    • Followers of vegetarian or vegan diets will not be able to follow a paleo diet. Intake of meat, seafood, and eggs are essential to the paleo diet. Vegetarian sources of protein (e.g., beans and other legumes) are prohibited.
    • Cost may be an issue. Eating large quantities of meat and fish can increase the cost of groceries.
    • The paleo diet may be hard to follow long term because of dietary restrictions.
    • Dieters will need to stock up on approved foods and cook them from scratch. Therefore, they need to plan on incorporating shopping and cooking into their schedules.

    Nursing Consideration: The paleo diet has both advantages and disadvantages. Nurses should advise their patients to consult with their health care providers before starting this, or any other diet.

    Mediterranean Diet

    Jason is a 40-year-old high school football coach. He also has his own sports clinic when football season is over. He loves these jobs, but they are accompanied by a great deal of stress and long working hours. This makes it difficult for him to exercise as regularly as he would like, and he often grabs fast food instead of healthy meals. Jason’s family is concerned about some of his unhealthy lifestyle choices. Jason’s father died at the age of 50 from a massive heart attack. His mother has a history of hypertension and elevated cholesterol. Jason makes an appointment with the nurse practitioner at his family practice office. After doing some research, he is thinking of adopting the Mediterranean diet. But before doing so, he wants some advice and guidance.

     The Mediterranean diet has been known as a heart-healthy eating plan for some time. Research indicates that this type of diet can help to prevent heart disease, stroke, and premature death. The most positive impact seems to be correlated with adopting this diet early in life. However, newer studies indicate that adopting it during midlife also has positive results (Mayo Clinic, 2019a).

     Additional findings show that the Mediterranean diet is associated with a small reduction in the incidence of some breast cancer and a primary overall protection from colorectal cancer. The diet may be beneficial in reducing the risk of breast cancer and colorectal cancer (Schwingshackl, Schwedhelm, Galbete, & Hoffmann, 2017).

     What are the components of a Mediterranean diet? Here is a summary of its elements (Mayo Clinic, 2019a; Schwingshackl, Schwedhelm, Galbete, & Hoffmann, 2017):

    • Every meal should be based on plant-based foods, such as whole grains (rather than refined grains), fruits and vegetables, legumes, nuts, olive oil, seeds, herbs, and spices.
    • Butter should be replaced with healthy fats such as olive oil and canola oil.
    • Fruits and vegetables should be used as snack foods rather than highly salted foods, such as potato chips and crackers.
    • Herbs and spices should be used to flavor foods rather than salt.
    • Intake of red meat should be limited to no more than a few times a month.
    • Fish should be eaten at least twice a week.
    • Moderate portions of poultry and eggs should be eaten every two days or weekly.
    • Moderate portions of cheese and yogurt should be consumed daily to weekly. Dairy products should be fat-free or low-fat.
    • Plenty of water should be consumed every day.

     The focus of the Mediterranean diet is on making wise choices about what is eaten. For example, the following are good choices (Mayo Clinic, 2019a):

    • Grains in the Mediterranean region are generally whole grain and contain very few unhealthy fats.
    • Bread is an important part of the diet in this region. However, bread is eaten either plain or dipped in olive oil, not with butter or margarine that contain saturated or trans fats.
    • Olive oil, a monounsaturated fat that can help reduce LDL cholesterol, is the primary source of fat.
    • Nuts are an important part of the Mediterranean diet. Nuts are high in unsaturated fat and calories, so they should not be eaten in large amounts. No more than a handful a day should be consumed.
    • Fatty fish (e.g., salmon, albacore tuna, lake trout, herring, sardines, and mackerel) are rich in omega-3 fatty acids and are eaten as a regular part of the Mediterranean diet.

     Consumption of red wine is also part of the Mediterranean diet. Recent claims have surfaced regarding the heart health benefits of red wine. Red wine contains antioxidants called polyphenols that may help to prevent heart disease by increasing HDL (good cholesterol) levels and protecting arteries from damage, which, in turn, may prevent blood clots (Mayo Clinic, 2019b).

    EBP Alert! Various studies have shown that moderate amounts of all types of alcohol can benefit the heart, not just alcohol found in red wine. It may be that alcohol has these benefits: (1) raises HDL cholesterol; (2) reduces formation of blood clots; (3) helps to prevent arterial damage caused by high levels of LDL cholesterol; and (4) may improve the function of cells that line blood vessels (Mayo Clinic, 2019b).

     There are other foods that contain resveratrol, such as grapes, peanuts, blueberries, and cranberries. It is not yet known if consuming these foods are comparable to red wine concerning heart health benefits (Mayo Clinic, 2019b).

     Both the American Heart Association and the National Heart, Lung, and Blood Institute do not recommend that people start drinking alcohol to prevent heart disease. Alcohol can lead to addiction problems or exacerbate other health problems (Mayo Clinic, 2019b).

     Some of the problems associated with too much alcohol intake include the following (Mayo Clinic, 2019b):

    • Elevation of blood pressure.
    • Hepatic damage.
    • Elevation of triglycerides.
    • Some cancers.
    • Lack of coordination leading to accidents.

     Too much alcohol has been associated with a weakening of the cardiac muscle and heart failure. People with heart failure or cardiomyopathy (weakened muscles of the heart) should not drink alcohol at all. Alcohol should not be consumed by pregnant women (Mayo Clinic, 2019b).

     A drink of alcohol is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80 proof distilled spirits. In healthy adults, this means that women of all ages and men older than 65 years of age should limit their alcohol intake to no more than one drink per day. Men 65 years of age and younger should drink no more than two drinks per day. The limit for men is higher than for women because men usually weigh more and have more of the enzyme that metabolizes alcohol than do women (Mayo Clinic, 2019b).

    Dash Diet

    High blood pressure runs in Jeffrey’s family. His parents and siblings all take medication to control their blood pressure, and Jeffrey, although only 28 years old, has just been prescribed an antihypertensive agent as well. Concerned about Jeffrey’s health, he and his wife decide to adopt a healthier lifestyle, including changing their eating habits. After discussing their concerns with Jeffrey’s health care provider, they decide to follow the DASH diet, which is designed to help treat or prevent elevated blood pressure.

     DASH stands for Dietary Approaches to Stop Hypertension. The DASH diet is designed as a lifelong approach to healthy eating. Its goal is to help prevent or reduce hypertension (Asay, 2019; Mayo Clinic, 2019c).

     According to information published by the Mayo Clinic, people who follow the DASH diet may be able to reduce their blood pressure by a few points in just two weeks. By following it over a period of time, systolic blood pressure could drop by as much as 8–14 points (Mayo Clinic, 2019c).

     The DASH diet has a number of health benefits in addition to lowering blood pressure. The DASH diet’s components are complementary with dietary recommendations to prevent osteoporosis, cardiac disease, some cancers, stroke, and diabetes (Mayo Clinic, 2019c).

      DASH diet, like many recommendations for healthy-eating patterns, focuses on consumption of vegetables, fruits, and low-fat dairy foods, and on moderate amounts of whole grains, fish, poultry, and nuts. It also stresses reduction in sodium intake (Asay, 2019; Mayo Clinic, 2019c).

     There are two versions of the DASH diet: a standard version and a lower sodium DASH diet. The standard DASH diet allows for the consumption of up to 2,300 mg of sodium a day. The lower sodium DASH limits sodium consumption to 1,500 mg a day. Either version significantly reduces the amount of sodium that is generally consumed in a typical American diet, which may consist of 3,400 mg of sodium a day or more. The standard DASH diet is in accordance with the Dietary Guidelines for Americans, which recommend that sodium intake be limited to less than 2,300 mg per day (Mayo Clinic, 2019c).

     The DASH diet is low in saturated fat, total fat, and cholesterol. It allows for the consumption of small amounts of red meat, sweets, and fats. Total caloric consumption is 2,000 calories per day according to the following guidelines (Asay, 2019; Mayo Clinic, 2019c).

    • Grains: The DASH diet allows for six to eight servings of grains per day. The focus is on whole grains such as brown rice instead of white rice, whole-grain bread instead of white bread, and whole wheat pasta instead of regular pasta. Consumers are urged to read the labels of food products. Appropriate examples are “100% whole grain” or “100% whole wheat.” Whole grains are low in fat. To maintain this low level of fat, consumers are urged to avoid adding butter, cream, and/or cheese to grains. An example of one serving of grains is one slice of whole wheat bread or one-half cup of cooked cereal, rice, or pasta.
    • Vegetables: Four to five servings of vegetables per day should be consumed when following the DASH diet. Vegetables contain high amounts of fiber, vitamins, and minerals. Ways to increase the amount of vegetables consumed per day include using vegetables as main dishes. For example, spread vegetables over brown rice or whole wheat pasta as a main dish. Both fresh and frozen vegetables are appropriate food sources. Examples of one serving of vegetables include one cup of raw leafy green vegetables or one-half cup of cooked vegetables.
    • Fruits: Like vegetables, the recommended number of servings of fruits is four to five servings per day. Fruits can be part of meals or consumed as snacks. Most fruits are low in fat and high in fiber. One serving of fruit is defined as one medium fruit, one-half cup of fresh, frozen, or canned fruit, or four ounces of fruit juice. It is recommended that the peels remain on fruit whenever possible. Peels of fruits such as apples contain significant amounts of nutrients and fiber. Persons eating canned fruit or fruit juices should read the labels to be sure that they contain no added sugar.

    Nursing Consideration: Some citrus fruits can interact with various medications, so persons following the DASH diet should consult their health care providers regarding intake of citrus fruits. For example, persons taking the cholesterol-lowering agent simvastatin (Zocor) should avoid consuming grapefruits or grapefruit juice (Comerford & Durkin, 2020).

    • Dairy: The DASH diet allows for two to three servings of dairy products per day. For example, one serving of dairy is one cup of skim or 1% milk or 1½ ounces of part-skim cheese. Persons following the DASH diet should choose dairy products that are low in fat or fat-free. Dairy products are excellent sources of calcium, vitamin D, and protein. Lactose-free products are available for persons that have difficulty digesting dairy products. Over-the-counter products that contain the enzyme lactase can help to reduce or prevent symptoms of lactose intolerance.
    • Lean meat, poultry, and fish: The DASH diet recommends six servings or less per day of lean meat, poultry, and fish. When eating meat, consumers should choose those that are lean and eat no more than six ounces a day. Poultry and meat should be baked, broiled, grilled, or roasted and not fried in fat. When choosing fish, people should eat heart-healthy fish such as salmon, herring, and tuna. These types of fish are high in omega-3 fatting acids, which can help to reduce total cholesterol levels.
    • Nuts, seeds, and legumes: Examples of this food group in the DASH diet include almonds, sunflower seeds, kidney beans, peas, and lentils. These types of foods are rich in minerals, fiber, and phytochemicals. These foods are also high in calories and should be eaten only a few times per week (four to five servings a week). For example, one serving is the equivalent of one-third cup of nuts or one-half cup of cooked beans or peas.
    • Fats and oils: The recommended number of servings of fats and oils is two to three servings a day. Fats are important to the absorption of essential vitamins and the maintenance of a healthy immune system. However, excessive amounts of fat increase the risk of obesity, diabetes, and cardiac disease. The DASH diet limits total fat intake to less than 30% of daily calories from fat, and intake should focus on healthy monosaturated fats. Consumers should be taught to read food labels so that they can select fats and oils that are lowest in saturated fat and without trans fats.
    • Sweets: The DASH diet does not prohibit sweets, but limits them to five servings or less per week. One serving of a sweet includes such items as one tablespoon of sugar or jelly, or one-half cup of sorbet. When choosing sweets, people should choose those that are fat-free or low in fat.

    Raw Food Diet

    Gloria is a breast cancer survivor. She completed treatment 10 years ago and there is no evidence of cancer at this time. She is very interested in nutrition and how diet can impact health. She is especially interested in how diet can help to prevent cancer or facilitate its treatment. One of her friends is an advocate of the raw foods diet, and she tells Gloria, “this is really the only way to eat. If you want to stay healthy you need to check it out!” Gloria has never heard of a raw foods diet and can’t imagine what it would be like to eat only raw foods. Could it help her to stay healthy?

     The raw food diet is just what it sounds like; it consists of raw fruits, vegetables, and grains. The theory behind the raw foods diet is that heating food destroys its nutrients and naturally occurring enzymes, which enhance digestion and help to prevent chronic diseases. Proponents of this diet claim that it can prevent headaches, cure allergies, enhance the working of the immune system, and improve arthritis and diabetes (Robinson, 2019).

     What foods are allowed on the raw foods diet? Allowed foods are uncooked, unprocessed, and mostly organic. Staples of this diet are raw fruits, vegetables, nuts, seeds, and sprouted grains. Some people also eat unpasteurized dairy foods, raw eggs, meat, and fish. Foods can be cold or slightly warm, as long as the food temperature does not go above 118 degrees. Blenders, food processors, and dehydrators can be used in food preparation (Robinson, 2019).

      Advantages of the Raw Foods Diet. There are a number of potential advantages associated with the raw foods diet (Robinson, 2019):

    • The diet is acceptable to vegetarians and vegans. However, a dietician should be consulted to ensure that nutritional needs are met.
    • Persons who need to follow a gluten-free diet can follow the raw foods diet since most raw foods are naturally free of gluten.
    • The raw foods diet is low in sodium. This might decrease the risk of stroke, heart failure, osteoporosis, cancer of the stomach, and renal disease.
    • Eating a great deal of vegetables and fruits can help to lose weight and help to manage type 2 diabetes.
    • The raw foods diet is high in fiber, and many vitamins and minerals, as well as in phytochemicals.

     Disadvantages of the Raw Foods Diet. There are also a number of disadvantages associated with the raw foods diet, such as the following (Robinson, 2019):

    • Preparing raw foods can take a great deal of time. For example, the time needed for blending and dehydrating foods and germinating nuts and sprout seeds can be extensive.
    • Some uncooked and unpasteurized foods are associated with foodborne illnesses. Thus, foods must be thoroughly washed, especially foods most often associated with foodborne illnesses, such as sprouts, raspberries, green onions, and lettuce.
    • Due to the risk of foodborne illness, the raw foods diet is not recommended for pregnant women, young children, older adults, people whose immune systems are compromised, and people who have chronic medical conditions, such as renal disease.
    • It may be expensive to follow the raw foods diet. Organic foods are typically more expensive than conventionally grown foods. Appliances used to prepare food such as juicers, blenders, and dehydrators can be expensive.
    • The raw foods diet is deficient in some essential nutrients, such as protein, iron, calcium, and vitamin B12.
    • Cooking foods can help to prevent foodborne illnesses and can even boost certain nutrients such as beta-carotene.

    Nursing Consideration:  Before deciding to follow a raw foods diet, one should consult his or her health care providers to ensure that adequate recommended nutrients are being received.

    Gluten-Free Diet

    Amanda has a family history of celiac disease. Amanda, now in her early 20s, is starting to have periods of intense abdominal cramping, diarrhea, and weakness. In consultation with her health care provider, Amanda is going to adopt a gluten-free diet.

     Gluten is a protein found in grains such as wheat, barley, and rye. Primarily used to treat celiac disease, gluten-free eating has been gaining popularity among persons who do not have the disease as well. Adopting a gluten-free diet requires a significant change in one’s diet. However, it can have a positive impact on gastrointestinal symptoms and enhance the quality of life of people who react negatively to gluten (Mayo Clinic, 2017c).

     As the popularity of gluten-free eating has grown, so has the number and variety of gluten-free foods that are available. Various gluten-free breads and pasta products are available, as well as items such as gluten-free pizza (Mayo Clinic, 2017c).

     Many foods that are tasty and healthy are naturally gluten-free. Examples of such foods include the following (Mayo Clinic, 2017c):

    • Natural and unprocessed beans, seeds, and nuts.
    • Fresh eggs.
    • Fresh meats, fish, and poultry as long as they are not breaded, marinated, or coated with batter.
    • Fruits and vegetables.
    • The majority of dairy products.

    Foods that should be avoided include the following (Mayo Clinic, 2017c):

    • Food products that contain barley including malt, malt flavoring, and malt vinegar.
    • Triticale (a cross between wheat and rye).

     It is important that nurses provide persons who are on gluten-free diets with adequate education regarding its guidelines and facilitate consultation with a dietician as needed. Some important patient and family education tips include the following (Mayo Clinic, 2017c):

    • Read labels on all food products before purchasing and/or eating them. Be sure that they are specifically labeled gluten-free or are made with corn, rice, soy or other gluten-free grains.
    • Avoid oats and oat products unless they are clearly labeled as gluten-free.
    • Check food labels for the addition of food additives that contain gluten, such as malt flavoring and modified food starch.
    • Check for use of gluten as a binding agent in medications and vitamins.
    • Be wary of cross-contamination. For example, cross-contamination can take place when gluten-free foods come into contact with foods that contain gluten. This can occur during the manufacturing process if the same equipment is used to make many types of foods. Cross-contamination can occur in the home if foods are prepared on common surfaces or with the same utensils. Even using a toaster for gluten-free and regular bread can be problematic.
    • Be cautious when eating in restaurants. Ask how gluten-free items are prepared and what steps are taken to avoid cross-contamination.
    • Ask your health care provider or dietician how to obtain nutrients that are not readily provided in a gluten-free diet. Examples of these nutrients are iron, calcium, fiber, thiamin, riboflavin, niacin, and folate.

    The Zone Diet

    Trudy and her college friends are anxious to lose weight and have obtained information from the Internet about numerous diets, many of which promise significant weight loss. One diet in particular captures their interest. This is the Zone diet; whose proponents say that followers can burn fat as they sleep. Trudy and her friends think that this is the diet for them!

     What is the Zone diet? Created by the biochemist, Barry Sears, PhD, the Zone diet was designed to reset the metabolism in order to prevent or reduce the risk of heart disease, diabetes, and other chronic health conditions. The premise of the Zone diet is that by balancing the amount of fat, carbohydrates, and protein in the diet, the body will burn fat, even during sleep (Levitt & Zelman, 2018; Stoppler, 2018).

     This diet restricts calorie intake to 1,200 calories a day for women and 1,500 for men.  Specifically, 30% of these calories are to come from fat, 30% come from protein, and 40% from carbohydrates (Levitt & Zelman, 2018; Stoppler, 2018).

     No food is completely banned on the Zone diet, which includes three meals and two snacks a day. Each of these meals/snacks includes a mix of low-fat protein (e.g., skinless chicken or fish) and a small amount of healthy fat, such as avocado or olive oil. This diet recommends that bread, pasta, grains, and other starches be considered as condiments instead of main or even side dishes (Levitt & Zelman, 2018).

     There are a number of benefits to the Zone diet, such as the following (Levitt & Zelman, 2018; Stoppler, 2018):

    • Variety of food sources: The Zone diet offers considerable variety in comparison to other high-protein diets.
    • Easy to follow: After understanding the design of this diet, it is relatively easy to adhere to.
    • Frequent meals: The Zone diet recommends eating small meals and snacks throughout the day.
    • Healthy fats: The Zone diet is not a low-fat diet. However, it discourages the use of saturated and trans fats and encourages the intake of healthy fats.
    • Sugar management: Refined sugars are limited and the intake of whole grains, proteins, fruits, and vegetables is emphasized.
    • Realistic, achievable weight loss: Most people who adhere to its guidelines can lose weight on the Zone diet. The goal of the Zone diet is a weight loss of 1–1.5 pounds per week. The National Institutes of Health (NIH) recommends a good weight-loss program, aiming for the loss of one to two pounds per week.
    • Vegetarian friendly: Since the Zone diet consists of a large intake of fruits and vegetables, the Zone diet can work for vegetarians.
    • Gluten-free friendly: It is easy to adapt the Zone diet to the needs of those who must eat gluten-free, since it strongly discourages eating wheat, barley, and rye products.
    • Low-salt friendly: The Zone diet emphasizes the intake of fresh ingredients rather than high-sodium, processed foods. This facilitates the maintenance of a low-sodium diet.

     There are also some concerns related to the Zone diet, including the following (Levitt & Zelman, 2018; Stoppler, 2018):

    • Calcium intake: The Zone diet does not encourage the intake of dairy products. It can be hard to acquire adequate amounts of calcium on this diet. A number of nondairy products contain calcium, but individuals who follow the Zone diet must monitor their calcium intake carefully.
    • Missing nutrients: Zone diet food restrictions can lead to insufficient intake of fiber, vitamin C, folic acid, and some minerals.
    • Strict dietary balances: The Zone diet breakdown of caloric intake of 30% from fat, 30% from protein, and 40% from carbohydrates is recommended for everyone who follows the Zone diet. However, most individuals have different health needs and are in different states of health and wellness. Therefore, The Zone diet may not be appropriate for people who require a different nutritional balance to lose weight and be healthy.
    • Renal risk: The Zone diet is high in protein, which can be stressful on the renal system. Such stress can be dangerous to some people with impaired renal function.
    • Cost: Purchasing quantities of food recommended by the Zone diet may be costly for some people.
    • Moderate to high-fat content: The fats recommended by the Zone diet are, in general, healthy fats. However, the American Heart Association warns that this diet may be too high in fat for persons who need to monitor their blood pressure and cholesterol levels.
    • Calorie restrictions: Those who strictly adhere to the Zone diet will be eating less than 1,200 calories per day. This can lead to feelings of hunger and trouble adhering to the diet.
    • Long-term challenges: The Zone diet may be difficult to follow for long periods of time, since it restricts a number of common foods such as rice and pasta, as well as calorie intake.

     The Zone diet also recommends regular physical exercise as part of its weight-loss program. Its recommendations are closely aligned with those of the American Heart Association (Levitt & Zelman, 2018; Stoppler, 2018).

    Vegetarian Diets

    Sharon is the nurse manager of a large surgical unit and has a hectic work schedule. She is married and is the mother of three teenagers, who range in age from 13 to 18. One evening as she, her husband, and two of her children are preparing dinner, her 16-year-old daughter, Amy, walks in the door and apologizes for being late.  She is explaining that her orchestral practice took longer than expected when she stops abruptly in the middle of a sentence. “Is that a steak you expect me to eat? The body of some harmless animal that was slaughtered? I have decided to become a vegetarian! We’ve been discussing animal rights activist activities in current events class. From now on, I will not eat meat or anything that comes from animals!” Sharon shakes her head and realizes that it is going to be a long evening. Sharon must now explain to her daughter that simply giving up meat and animal food products can have serious health consequences, unless the vegetarian diet includes adequate amounts of essential nutrients, such as calcium and protein. Becoming a vegetarian is not going to be as easy as Amy thinks it will be. Sharon will support Amy’s decision as long as she consults with the family’s health care provider and adopts a vegetarian diet that includes adequate amounts of essential nutrients.

     Vegetarian diets are becoming increasingly popular. There are a number of reasons cited by vegetarian diet devotees, such as health benefits, reduction of risk for certain diseases, and the promotion of animal rights. With adequate planning, a vegetarian diet can meet the needs of people of all ages, including pregnant or breastfeeding women. The goal is to incorporate adequate amounts of recommended nutrients into the vegetarian’s daily diet (Mayo Clinic, 2019d).

     What some people do not realize is that there are a number of types of vegetarian diets, each of which has certain restrictions. The important thing is to know what nutrients are required and how to get them on a vegetarian diet. Here are some types of vegetarian diets:

     Lacto-Vegetarian Diet. Sharon is a senior year nursing student. She is preparing to develop a power point presentation for posting on the nursing department’s website on vegetarian diets. She is feeling a bit overwhelmed by all of the different types of vegetarian diets. Sharon decides to talk to a friend who is a vegetarian. He explains that he is a lacto-vegetarian and does not eat meat, fish, poultry, and eggs as well as foods that contain them. He does, however, consume dairy products such as milk, cheese, yogurt, and butter.

    The term lacto-vegetarian is derived from the Latin word lactis, meaning milk. The lacto-vegetarian diet excludes the following foods (Link, 2019; Mayo Clinic, 2019d):

    • Foods that contain meat, fish, poultry, and eggs.

     In addition to fruits, vegetables, grains, soy products, and plant-based proteins, lacto-vegetarians DO eat the following (Link, 2019; Mayo Clinic, 2019c):

    • Dairy products.

     Consumption of dairy products is the main factor that differentiates lacto-vegetarians from vegans. However, lacto-vegetarians do not eat dairy products made with gelatin (e.g., some puddings and custards) because most gelatins contain pulverized animal hooves, bones, or marrow. They also do not eat dairy products that contain animal-based rennet, which consists of a collection of enzymes that cheese-makers generally obtain from calves (Link, 2019; Mayo Clinic, 2019d).                                                                                                                                                                                                                                                                                                                                                         

     Some studies show that following a lacto-vegetarian diet may improve heart health and facilitate weight loss or the maintenance of a healthy weight (Link, 2019; Mayo Clinic, 2019d).

     Ovo-Vegetarian Diet. An ovo-vegetarian diet excludes meat and dairy products but does include eggs. Very few people follow this type of vegetarian diet. Typically, the individuals who adopt this particular diet do so because they wanted to follow a vegetarian diet but are also lactose intolerant and cannot eat dairy products (Hill, 2019; Mayo Clinic, 2019d).

     An ovo-vegetarian diet includes the following (Hill, 2019):

    • Spices and fresh herbs.
    • Eggs and products including eggs, such as mayonnaise, egg noodles, and some baked goods.

     The following food products are excluded in the ovo-vegetarian diet (Mayo Clinic, 2019d):

    • Dairy products.

     Lacto-Ovo Vegetarian Diet. The lacto-ovo vegetarian diet excludes meat, fish, and poultry but does allow dairy products and eggs. This particular vegetarian diet makes it easier for its followers to meet nutrient needs than people who do not eat eggs and dairy products (Mayo Clinic, 2019d; Spiridakis, 2019).

     Pescatarian Diet. Nicole’s friends know that she is a vegetarian. However, she eats fish, which offends some of her friends who exclude both meat, poultry, and fish from their diets. Mark, a friend who is not a vegetarian, asks Nicole to explain what kind of vegetarian she is. Nicole replies that she follows a pescatarian diet.

     A pescatarian is someone who does not eat any meat or animal flesh with the exception of fish and seafood such as shrimp, clams, crabs, and lobster. Pescatarians also exclude eggs and dairy products from their diets (Mayo Clinic, 2019d).

     Technically, a pescatarian is not a vegetarian, since a vegetarian diet excludes all animals and fish. Pescatarians often believe that consuming moderate amounts of fish or fish oils are necessary for optimum health because fish are high in omega-3 fatty acids (Hackett, 2019).

     Research indicates that the pescatarian diet may increase life expectancy and may reduce the risk of heart disease, type 2 diabetes, and breast cancer (Maloney, 2019b).

     There are, however, some potential dangers associated with the pescatarian diet. Fatty fish, although high in “good” fats, contain low levels of pollutants that can accumulate in the body over time. Excessive exposure to these pollutants can increase risk of cancer, diabetes, and thyroid disease. Pregnant women who consume excessive amounts of fish containing these pollutants are at risk for delivering low-birth weight infants and children who experience developmental delays (Maloney, 2019b).

     Mercury is also found in fish in various amounts. Mercury is a natural element that fish process into a toxic substance (methylmercury). Intake of large amounts of mercury-containing fish can increase exposure to the toxin, which, in turn, can affect the nervous system and cause significant development delays in infants who were exposed to mercury in the womb. Recommendations for consumption depend on the type of fish being eaten. Sardines, herring, and tilapia have low amounts of mercury and can be eaten without worry. Bluefin, Chilean sea bass, and yellow fin tuna have high levels of mercury, and their consumption should be limited. (Maloney, 2019b).

     Vegan Diet. Is a vegan different from being a vegetarian? A vegetarian does not eat meat, fish, or poultry. Vegans, in addition to being vegetarians, do not use other animal products and by-products including eggs, dairy products, honey, leather, fur, silk, wool, cosmetics, and soaps that are obtained from animal products. The key to adopting a vegan diet is to include a variety of foods to obtain necessary nutrients (Mayo Clinic, 2019d).

     People choose to adopt a vegan lifestyle for a variety of reasons including improving their health status, protecting the environment, or ethical reasons concerning the treatment of animals. A healthy vegan diet includes fruits, vegetables, leafy greens, whole-grain products, nuts, seeds, and legumes (Mayo Clinic, 2019d).

      The more restrictive the vegetarian diet, the more challenging it can be to get all necessary nutrients. A vegan diet eliminates natural food sources of vitamin B-12 and milk products, which are excellent sources of calcium (Mayo Clinic, 2019d).

     Vegetarians and vegans can enjoy a healthy diet and healthy lifestyle as long as they make sure to incorporate adequate amounts of nutrients in their diets. The following are some suggestions for obtaining these nutrients (Mayo Clinic, 2019d; Petre, 2016):

    • Calcium: Calcium is necessary for the development and maintenance of strong bones and teeth. Milk and dairy foods have the highest amounts of calcium. For vegetarians who do not consume milk and dairy products, dark green vegetables are good plant sources of protein when eaten in adequate amounts. Calcium-enriched and fortified products such as juices, cereals, soy milk, soy yogurt, fortified veggie meats (e.g., veggie burgers), and tofu are other good options.
    • Vitamin D: Vitamin D is essential to the absorption of calcium. Vitamin D is added to some brands of soy and rice milk and some cereals and margarines. If not enough fortified foods are eaten and sun exposure is limited, a vitamin D supplement (one made from plant sources) may be necessary.
    • Vitamin B12: This vitamin is necessary for the production of red blood cells and the prevention of anemia. Vegans and vegetarians can find it difficult to get enough vitamin B12 as it is found almost exclusively in animal products. Vitamin-enriched cereals, veggie meats, and soy-based beverages can be good sources of vitamin B12. However, it may be necessary to consume vitamin supplements to ensure adequate levels of vitamin B12.

    Nursing Consideration: Vitamin B12 deficiency may go unnoticed in vegans since the vegan diet is rich in folate, which may conceal such a deficiency until severe problems occur (Mayo Clinic, 2019d).

    • Protein: Protein is essential for the maintenance of healthy skin, bones, muscles, and organs. Eggs and dairy products are good protein sources, but vegans need to acquire protein from other sources, such as soy products, meat substitutes, legumes, lentils, nuts, seeds, and whole grains.
    • Omega-3 Fatty Acids: Omega-3 fatty acids are important for a healthy cardiovascular system. Diets that exclude fish and eggs are usually low in active forms of omega-3 fatty acids. Alternative sources of essential fatty acids include canola oil, soy oil, walnuts, ground flaxseed, and soybeans. Unfortunately, conversion of plant-based omega-3 fatty acids to forms usable by people is inefficient. Therefore, vegans and vegetarians should consider fortified products or supplements, or both.
    • Iron: Iron is essential for the production of red blood cells (RBCs). Sources of iron for the vegan and vegetarians include dried beans and peas, lentils, enriched cereals, whole-grain products, dark leafy green vegetables, and dried fruit. Iron is not as easily absorbed from plant sources as from animal sources. Thus, it is recommended that vegans and vegetarians eat food rich in vitamin C to help the body absorb iron. Examples of such foods include strawberries, citrus fruit, tomatoes, cabbage, and broccoli. Eat these foods at the same time as consuming iron-containing foods.
    • Zinc: Zinc helps to boost immune system functioning and is important to the process of cell division and protein formation. It is found in ample amounts in soybeans, soy milk, veggie “meats,” whole grains, legumes, nuts, and wheat germ. If dairy products are consumed, cheese is also a good source of zinc.
    • Iodine: Iodine is an essential component of thyroid hormones. These hormones help to regulate metabolism and the growth and functioning of critical body organs. Vegans may not get enough iodine. This puts them at risk for iodine deficiency and thyroid dysfunction. Just one fourth of a teaspoon of iodized salt per day offers a significant amount of iodine.
    • Riboflavin: Riboflavin (vitamin B2) helps to convert carbohydrates into glucose. Acceptable vegan and vegetarian sources of riboflavin include almonds, fortified cereals, yogurt, mushrooms, soy milk, and vitamin B2 fortified foods.

     In summary, by being alert to sources of nutrients that may not be available in vegan and vegetarian diets in sufficient quantities, it is possible to supplement these nutrients to maintain a healthy diet that provides adequate amounts of nutrients and allows vegans and vegetarians to follow their desired lifestyles and dietary choices.

    Keto Diet

     The ketogenic (keto) diet is a very low-carb, high-fat diet. It involves drastically reducing carbohydrate intake and replacing it with fat, which leads to ketosis. During ketosis the body becomes very efficient at burning fat for energy. Keto diets can cause large reductions in blood sugar and insulin levels. Research suggests that this diet can help in the prevention/treatment of epilepsy, cancer, and Alzheimer’s disease (Mawer, 2018).

     There are some disadvantages to the keto diet. There is little evidence to show that this diet is effective or safe for the long term for anything other than epilepsy. Additionally, very low carbohydrate diets have higher rates of side effects such as constipation, headaches, and halitosis. The keto requirements can also make it a challenge to meet micronutrient needs (Mayo Clinic, 2019e).

    Nursing Interventions

     Nursing interventions should focus on assessment and patient/family education. Nurses have an obligation to remain objective and provide adequate information about the diets patients and families have chosen. It is essential that nurses have knowledge of various diets and be able to provide guidance regarding how to obtain adequate nutrition while following them.

    Self-Assessment #7

    Denise is a 30-year-old college professor. Her parents both died before the age of 60 due, in part, to cardiovascular disease and high blood pressure. Denise’s blood pressure has been gradually increasing over the past few years, and her health care provider is advising her to change her eating habits.

    Which of the following diets is best for Denise to adopt, based on having the goal of preventing or reducing hypertension?

    1. Raw food diet.
    2. Gluten-free diet.
    3. DASH diet.
    4. Keto diet.

    Nutritional Needs for Specific Populations

    The Older Adult

     Alice is studying to become a nurse practitioner. Her focus is on gerontology, a specialty she loves. Alice is especially interested in how nutritional needs change as a person ages and how nutrition can impact the older adult’s state of health and wellness.

     As the body ages, it becomes less efficient at absorbing some key nutrients. The sensation of taste diminishes, leading to a decrease in appetite. Digestion becomes less efficient as well, making it difficult for the older adult’s body to digest foods. Loss of teeth or ill-fitting dentures may make it difficult for food to be chewed (Mayo Clinic, 2019f; Wolfram, 2018). It is imperative that nurses know how age affects the body’s ability to acquire adequate nutrition and to provide appropriate patient/family education regarding how diet impacts the health and wellness of the older adult.

     Age-Related Changes to the Digestive Tract. Many age-related changes may occur in the digestive tract of the older adult including changes in appetite and hydration status. These changes can lead to inadequate nutritional intake (Mayo Clinic, 2019f).

     Oral Health Changes.  Missing or loose teeth, poorly fitting dentures, and poor dental hygiene can have an adverse impact on the older adult’s nutritional status (Mayo Clinic, 2019f).

     Senses of Taste and Smell. The older adult’s senses of taste and smell (olfactory) decrease with age. Inability to smell and/or taste food interferes with the ability to enjoy meals. This can lead to a decrease in appetite, nutritional intake, and overall health status (Boltz, Capezuti, Fulmer, & Zwicker, 2016; Mayo Clinic, 2019f).

     Thirst Mechanism. The thirst mechanism also diminishes with age as does the kidney’s ability to concentrate urine. These issues increase the risk for dehydration in the older adult (Boltz et al., 2016; Mayo Clinic, 2019f).

     Nursing Consideration: Nurses should teach older adults and their families about the potential for dehydration and how to recognize its signs and symptoms. They should also encourage adequate fluid intake.

     Vision Changes. Age-related changes in vision can make it difficult to prepare and even consume food. Problems such as cataracts and macular degeneration can exacerbate these problems and interfere with the older adult’s adequate nutritional intake (Boltz et al. 2016; Mayo Clinic, 2019f).

     Changes in the Stomach. The older adult may also have to deal with a decrease or lack of hydrochloric acid production. Important nutrients such as iron and vitamin B12 must have an acid environment to begin the absorption process. Unless the body produces enough hydrochloric acid, these nutrients will not be properly absorbed and supplements may be needed (Boltz et al., 2016; Mayo Clinic, 2019f; Wolfram, 2018).

     Social and Economic Issues. Older adults are often on fixed incomes. They may choose foods that are inexpensive rather than those that provide proper nutrition. Older adults may need financial assistance in order to purchase healthy foods (Boltz et al., 2016; Mayo Clinic, 2019f).

     Older adults may also be affected by a lack of social interaction during mealtimes. Traditionally, mealtimes are times for social interaction with families and friends. Older adults who live alone may skip meals or eat poorly (Boltz et al., 2016; Mayo Clinic, 2019f). Nurses need to assess the older adult’s social support system when evaluating nutritional status.

     Older Adults and Nutritional Deficits. There are several important nutrients that are especially likely to be missing or in low quantities in the diets of older adults. Here are the nine top nutrients to monitor for the older adult:

     Vitamin B12. Vitamin B12, essential to red blood cell production and the maintenance of healthy nerve function, is one of the nutrients most often lacking in the older adult. Even if their diets contain enough vitamin B12, problems with absorption may necessitate a need for a B12 supplement. However, supplements should not be taken unless under the direction of a health care provider. Foods rich in this vitamin include eggs, milk, milk products, fish, meat, and poultry (Boltz et al., 2016; Mayo Clinic, 2019f; Wolfram, 2018).

     Calcium. Calcium is essential for the formation of strong bones and teeth. Inadequate dietary calcium intake causes the body to utilize calcium from bones, leaving them brittle. This increases the risk of fractures. Older adults should consume three servings a day of low-fat milk and dairy products. Kale and broccoli and calcium-fortified juices are also good sources of calcium (Boltz et al., 2016; Mayo Clinic, 2019f; Wolfram, 2018).

    Nursing Consideration: Nurses should recommend foods that have high-calcium content and are appealing to an older adult. Smoothies made with yogurt, fruit, and vegetables can be a good source of calcium for older adults. This is especially true for those older adults who have a decreased appetite, trouble chewing, or dry mouths.

     Vitamin D. Vitamin D is essential for the body to absorb calcium, maintain bone density, and prevent osteoporosis. Research has associated vitamin D deficiency with an increased risk for falls. Few foods naturally contain vitamin D. Foods that do contain this vitamin include salmon, tuna, and eggs. Some cereals, milk, yogurts, and juices are fortified with vitamin D. The skin produces Vitamin D when it is exposed to sunlight (Boltz et al., 2016; Mayo Clinic, 2019f; Wolfram, 2018).

     Potassium. Potassium is critical for proper body cell functioning. Many older adults do not acquire enough potassium from their daily diets. Good sources of potassium include fruits and vegetables, including bananas, prunes, plums, and potatoes with their skin. However, people should not take potassium supplements without authorization from their health care providers. Too much potassium is just as dangerous as too little (Boltz et al., 2016; Mayo Clinic, 2019f; Wolfram, 2018).

     Magnesium. Magnesium plays many roles in health and wellness including immune system functioning and cardiovascular health. Magnesium absorption decreases with age. Compounding this problem is that some medications (e.g., diuretics) often taken by older adults further reduce magnesium absorption. Therefore, older adults should make sure that their diets contain foods that are good sources of magnesium, such as fresh fruits and vegetables, nuts, whole grains, beans, and seeds (Boltz et al., 2016; Mayo Clinic, 2019f).

     Fiber. Fiber is necessary for the adequate functioning of the digestive process. Whole grains, beans, fruits, and vegetables are high in fiber. Nuts and beans are also good sources of fiber. Fiber supplements are also available. Older adults should consult with their health care providers about taking a fiber supplement (Boltz et al., 2016; Mayo Clinic, 2019f; Wolfram, 2018).

     Water. Water, although technically not an essential nutrient like vitamins or minerals, is absolutely essential to health and wellness. As previously mentioned, older adults are at risk for becoming dehydrated because of a reduction in the thirst mechanism and taking certain types of medications, such as diuretics. Experts recommend that people consume eight glasses of fluids every day unless medically contraindicated (Boltz et al., 2016; Mayo Clinic, 2019f; Wolfram, 2018).

    Nursing Consideration: Some older adults may reduce their fluid intake because of concerns about incontinence. Nurses must educate older adults and their families about the importance of adequate hydration. They can help to alleviate incontinence concerns by suggesting that older adults limit their fluid intake after the evening meal and by initiating a bladder training program as needed.

    Nutritional Needs of the Cancer Patient

     Nancy is undergoing chemotherapy for an aggressive type of breast cancer. She has no appetite and struggles with nausea and periods of vomiting. Her family is very concerned. They remember when Nancy’s father was receiving chemotherapy for prostate cancer; he lost a great deal of weight and had to be hospitalized in order to receive adequate nutrition. Nancy and her family consult the adult oncology nurse practitioner for advice about diet and nutrition.

     Unfortunately, malnutrition is a common problem in cancer patients. It has been associated with the following (National Cancer Institute, 2019):

    • Increased morbidity and mortality.
    • Poor prognosis.
    • Increased incidence and severity of treatment side effects.
    • Increased risk of infection.

     The phrase “nutrition impact symptoms” refers to symptoms that interfere with oral intake. Such symptoms include anorexia, nausea, vomiting, diarrhea, constipation, stomatitis, mucositis, dysphagia, pain, depression, anxiety, and changes in taste and smell (National Cancer Institute, 2019). Nurses must promote the early recognition and detection of malnutrition risk and nutrition impact symptoms to promote adequate nutritional intake for cancer patients.

     Alterations in the sense of taste may be different among patients with a cancer diagnosis. Food may lack flavor or taste metallic. Food may also taste too sweet or too salty. Fortunately, these alterations are usually temporary. However, until then, it is important to take steps to maintain appropriate nutritional intake (Mayo Clinic, 2018i).

     The Mayo Clinic has published a number of suggestions for selecting and preparing foods for patients with cancer (Mayo Clinic, 2018i):

    • If the patient’s mouth or throat is sore, spices, acidic foods, and hot foods or beverages should be avoided since such foods can further irritate the mouth and throat.
    • When preparing foods, different sauces and seasonings should be used to add flavor. Examples of alternative sauces and seasonings include
    • ketchup;
    • barbecue sauce;
    • extracts;
    • meat marinades;
    • mustards;
    • soy sauce;
    • spices and herbs;
    • vinegar;
    • wine;
    • teriyaki sauce;
    • bacon bits;
    • chopped green or red bell peppers, onion, or garlic;
    • nuts; and
    • cheese (particularly sharp cheese).
    • Add sugar or syrup to foods. For example, the taste of cereal may be enhanced by the addition of brown sugar, maple, syrup, honey, cinnamon, or raisins instead of white sugar.
    • Salty foods may have more taste. Cured meats and cheeses may help to stimulate appetite.
    • If foods taste too sweet, the addition of a little salt or lemon juice can help. Beverages that are less sweet, such as lemonade, milk, or sports drinks, should be selected.
    • If foods taste too salty, a little sugar may decrease the saltiness. Processed foods, which are high in sodium, should be avoided. When cooking, salt should not be added nor should seasonings be used that contain salt.
    • If meat is properly cooked and still does not taste “right” to a patient, other foods that are high in protein may be served. Such foods include
    • beans or peas,
    • cheese,
    • custard,
    • eggs,
    • eggnog,
    • fish,
    • instant breakfast drinks or other types of nutrition beverages,
    • lentils,
    • macaroni and cheese,
    • milkshakes,
    • nuts,
    • peanut butter,
    • poultry,
    • pudding,
    • tofu, and

    Nursing Consideration: Individuals who are being treated for cancer and were previously following a special diet, such as the low-sodium or low-fat diet, may need to alter their restrictions during treatment and find ways to stimulate their appetites. Patients should talk to their health care providers about easing restrictions before doing so (Mayo Clinic, 2018i).

    Nutrition During Pregnancy

     A woman’s body undergoes many physical and hormonal changes during pregnancy. It is imperative that pregnant women eat a healthy, well-balanced diet to ensure their health and the health of their babies.

     Most women who are pregnant can meet the increased nutritional needs of pregnancy by eating a diet that includes a variety of healthy foods.

     Specific nutrients provide specific benefits. The following are examples of the benefits from different food groups (Mayo Clinic, 2019g):

    • Whole grains are excellent sources of energy.
    • Fruits and vegetables provide fiber, vitamins, and antioxidants.
    • Meats, nuts, and legumes provide protein, folate, and iron.
    • Dairy products provide calcium and (when fortified) vitamin D.

     The pregnant woman’s body uses specific nutrients in specific ways for her health and the health of her baby. For example, the following are beneficial nutrients (Mayo Clinic, 2017d):

    • Protein: Essential for the growth of fetal tissue and growth of the mother’s breast and uterine tissue during pregnancy.
    • Calcium: Calcium is necessary for development of the baby’s bones.
    • Iron: Iron increases blood flow and ensures that both mother and unborn baby are adequately oxygenated.
    • Folate: Folate (folic acid) helps to decrease the risk of neural tube defects, which are major birth defects affecting the baby’s brain and spinal cord.
    • Vitamin D: Vitamin D promotes bone strength and helps to build the baby’s bones and teeth.

    Health care providers should be consulted before adding any supplement to a pregnant woman’s diet. Typically, a daily prenatal vitamin (ideally begun at least three months before conception) is prescribed (Mayo Clinic, 2017d).

    Nutrition for Women

     Good nutrition is essential for women of all ages. Diet and nutrition tips for women include the following (Help Guide, 2019):

    • Calcium: Calcium is essential for healthy bones, teeth, regulation of the heart’s rhythm, and nervous system functioning. For women between the ages of 19–50, the recommended daily allowance is 1,000 mg/day. For women over 50, the recommendation is 1,200 mg/day.
    • Magnesium: Magnesium increases calcium absorption from the bloodstream into the bones. The recommended daily allowance for magnesium is 320 to 400 mg/day.
    • Vitamin D: Vitamin D is also necessary for proper calcium metabolism, and the daily recommended amount is 600 IU daily.
    • Iron: Many women do not get enough iron. This is often because one of the best sources of iron is red meat, which many women avoid because of the high saturated fat content. Other good sources of iron include poultry, seafood, dried fruit, beans, green leafy vegetables, and fortified cereals, breads, and pastas. For women 14–18 years old, the recommended daily amount is 15 mg. For women 19–50, the recommendation is 18 mg/day. For women 51 and older, the recommendation is 8 mg.

    Nutrition for Men

     Typically, most men need 2,000 to 3,000 calories a day. Protein needs of men are usually based on body weight and activity levels. The recommended dietary allowance (RDA) for men is 55 grams of protein a day. Men who exercise regularly require up to 1.3 grams of protein per pound of body weight daily (Coleman, 2019).

     Men should obtain 45% to 65% of their calorie intake from carbohydrates, and 20% to 35% from dietary fat. Men who eat 2,500 calories a day should aim for 281 to 406 grams of carbohydrates and 56 to 97 grams of fat. Healthy high-carbohydrate foods are vegetables, fruits, whole grains, low-fat milk, nuts, seeds, and legumes. Healthy fats should be obtained from plant-based oils, fish oils, nuts, seeds, olives, and avocados (Coleman, 2019).

    Following a well-balanced meal plan generally provides appropriate amounts of vitamins and vegetables. However, (especially as one ages) health care providers should be consulted about adding any necessary supplements to their diets (Coleman, 2019).

    Nutrition for People with Heart Disease

     The American Heart Association points out that adopting a healthy diet and lifestyle are the best ways to combat cardiovascular disease (American Heart Association, 2019b).

     The American Heart Association makes the following diet and lifestyle recommendations to prevent or limit the extent of cardiovascular disease (American Heart Association, 2019b):

    • Use up at least as many calories as are taken in.
    • Strive for at least 150 minutes of moderate physical activity or 75 minutes of vigorous physical activity (or a combination of both) every week.
    • Adopt a healthy dietary pattern that includes the following:
    • A wide variety of fruits and vegetables.
    • Whole grains.
    • Low-fat dairy products.
    • Skinless poultry and fish.
    • Nuts and legumes.
    • Non-tropical vegetable oils.
    • Limit saturated fat, trans fat, sodium, red meat, sweets, and sugar-sweetened beverages.
    • Limit intake of foods that are high calorie, high fat, and/or low in nutrition.
    • Limit foods that are high in sodium.
    • Drink alcohol only in moderation. This means no more than one drink per day for women and no more than two drinks per day for men.
    • Do not smoke.
    • Avoid second-hand smoke.

    Nutrition for People with Chronic Obstructive Pulmonary Disease (COPD)

     People who have COPD need more energy to breathe than those without lung disease. The muscles they use during respiration can require up to 10 times more calories than those of people without COPD (Cleveland Clinic, 2018). 

     The Cleveland Clinic makes the following recommendations regarding nutritional guidelines for people living with COPD (Cleveland Clinic, 2018):

    • Monitor weight at least once a week unless told by health care providers to do so more often. Individuals with COPD who take diuretics or steroids should weigh themselves every day.
    • Drink at least six to eight eight-ounce glasses of caffeine-free beverages every day. Some people may be on fluid restrictions due to other health conditions. Therefore, it is wise to consult with health care providers about fluid intake.
    • Limit caffeine.
    • Incorporate high-fiber foods into the diet. The goal is to consume about 20 to 35 grams of fiber every day.
    • Limit sodium intake. Use herbs and spices as food flavoring. Do not have the salt shaker on the table, and do not add salt when cooking. Check with health care providers before using salt substitutes, which can contain other ingredients that may be harmful.
    • Avoid foods and beverages that cause gas and bloating, which can make breathing difficult. Examples of such foods and beverages include carbonated beverages, fried or greasy foods, heavily spiced foods, apples, beans, and peppers. Many fruits and vegetables can cause gas but are part of a healthy diet. Consult health care providers regarding foods that can cause gas and bloating.

     The Cleveland Clinic also offers the following tips for persons with COPD who are short of breath while eating or immediately after eating (Cleveland Clinic, 2018):

    • Clear airways at least one hour prior to eating.
    • Eat slowly.
    • Take smalls bites and chew foods thoroughly and slowly. Breathe deeply while eating.
    • Choose easily chewed foods.
    • Eat five or six small meals rather than three large ones.
    • Drink liquids at the end of meals rather than during meals. Drinking during meals may increase feelings of fullness and feeling bloated.
    • Sit up to eat.
    • Use pursed lip breathing.

    Nutritional Needs of People with Gout

     Gout is a painful type of arthritis that occurs when high levels of uric acid in the blood cause crystals to form and accumulate around a joint (Mayo Clinic, 2018j). Gout can affect any joint, but most often affects those in the feet and legs. Attacks of gout follow an intermittent course and can leave patients free from symptoms for years between such attacks. Gout can lead to chronic disability or incapacitation. However, prognosis is good with treatment (Gersch, Heimgartner, Rebar, & Willis, 2017).

     Part of the treatment for gout includes some dietary restrictions and modifications. These include the following (Gersch et al., 2017; Mayo Clinic, 2018j):

    • Lose weight if overweight or obese, which can increase the risk of developing gout. Losing weight lowers uric acid levels and reduces the number of attacks of gout.
    • Eat more complex carbohydrates, such as fruits, vegetables, and whole grains.
    • Avoid foods such as white bread, cakes, candy, sugar-sweetened beverages, and products with high-fructose corn syrup.
    • Stay hydrated. Research suggests that an increase in water consumption is associated with fewer attacks of gout. It is suggested that people drink 8–16 glasses of fluids every day with at least half of this amount as water.
    • Reduce the amount of saturated fats consumed from red meat, fatty poultry, and high-fat dairy products.
    • Limit daily proteins from lean meat, fish, and poultry to 4–6 ounces.
    • Add protein sources, such as low-fat or fat-free dairy products. These are linked to reduced uric acid levels.
    • Allow high-purine vegetables to be part of the diet, including asparagus, mushrooms, spinach, peas, and cauliflower. Once thought that such foods increased the risk of gout or the number of attacks, research now shows that this is not accurate. A healthy diet includes a variety of lots of fruits and vegetables and can include high-purine fruit and vegetables products.
    • Avoid organ and glandular meats, such as liver and kidneys, which can contribute to high blood uric acid levels.
    • Avoid seafood that is high in urines, such as anchovies, herring, sardines, mussels, scallops, trout, haddock, mackerel, and tuna.
    • Review alcohol intake. Alcohol metabolism is believed to increase the production of uric acid and contribute to the risk of dehydration. Beer is linked to an increased risk of gout and the number of gout attacks as are distilled liquors to some extent. Discuss alcohol intake with health care providers.
    • Consider taking a vitamin C supplement. Vitamin C may help to reduce uric acid levels. Discuss the helpfulness of adding a vitamin C supplement to the diet.
    • Consider drinking coffee in moderate amounts. The results of some studies suggest that moderate coffee consumption (especially coffee with caffeine) may reduce the risk of gout. Discuss coffee consumption with health care providers.
    • Consider eating cherries. There is some indication from research results that eating cherries is associated with a reduced risk of gout attacks.

    Nutritional Needs for People with Compromised Immune Systems

     Various health problems, such as cancer and HIV/AIDS, can weaken the body’s immune system. The American Cancer Society offers the following recommendations when preparing foods and grocery shopping to avoid possible foodborne illnesses, which can be devastating for people with weakened immune systems (American Cancer Society, 2019):

    • Handle food carefully by taking the following actions:
    • Wash hands with warm water and soap for at least 20 seconds before and after preparing food and before eating.
    • Refrigerate foods at or below 40 degrees Fahrenheit.
    • Thaw meat, fish, or poultry in the microwave or refrigerator. Place thawing foods in dishes to catch possibly contaminated drippings. Do not thaw foods at room temperature.
    • Use defrosted foods promptly.
    • Do not refreeze foods.
    • Refrigerate perishable foods within two hours of buying them or preparing them. Dishes with eggs, cream, and/or mayonnaise should not be left unrefrigerated for more than one hour.
    • Wash fruits and vegetables thoroughly under running water before peeling or cutting them.
    • Rinse the leaves of leafy vegetables under running water one leaf at a time.
    • Do not consume raw vegetable sprouts.
    • Discard fruits or vegetables that have mold or appear to be slimy.
    • Do not buy produce that has been cut at the grocery store.
    • Wash the tops of canned foods with soap and water before opening.
    • Use different utensils for stirring and tasting foods.
    • Throw away eggs with cracked shells and foods that look strange or have a strange odor.
    • Avoid cross-contamination by following these suggestions:
    • Using a clean knife to cut different foods.
    • Store raw meats by tightly sealing them and placing them away from ready-to-eat foods.
    • Use separate cutting boards for cooked and raw foods.
    • Carefully clean counters and cutting boards with hot, soapy water or disinfecting wipes that can be used around food products.
    • When cooking or buying food, take the following steps:
    • Cook meats to a temperature of 160 degrees Fahrenheit. Use a meat thermometer to accurately measure temperature.
    • Cook poultry to 180 degrees Fahrenheit. Use a meat thermometer for accurate temperature measurement.
    • Check expiration dates on all food before buying them. Purchase only the freshest food products.
    • Never buy products that are outdated.
    • Never purchase damaged, swollen, rusted, or deeply dented cans.
    • Avoid eating deli foods.
    • Avoid purchasing cream or custard-containing products sold in unrefrigerated areas.
    • Avoid eating yogurt and ice cream from self-serve machines.
    • When eating out, people with compromised immune systems should do the following:
    • Eat early to avoid crowds.
    • Ask for freshly prepared foods at fast food restaurants.
    • Avoid self-serve condiment containers.
    • Avoid eating from sources thought to be high risk, such as buffets, potlucks, salad bars, and sidewalk vendors.
    • Make sure that utensils are set on a napkin or clean tablecloth or clean placemat instead of directly on the table.
    • When taking home leftovers, ask for a container and put the food in yourself. Do not allow the server to take food to the kitchen to box the food.

    Nutrition for People with Irritable Bowel Syndrome (IBS)

     Irritable bowel syndrome (also referred to as spastic colon and spastic colitis) is a common health problem. It is characterized by chronic or periodic episodes of diarrhea and moderate to severe abdominal cramping. The episodes of diarrhea may alternate with constipation. Treatment is generally supportive and focuses on avoiding foods that trigger the problem and controlling or avoiding emotional stress, which can exacerbate the condition (Gersch et al., 2017).

     The goals of treatment are to relieve symptoms, identify triggers, and investigate stress reduction strategies (Gersch et al., 2017).

     The National Institute of Diabetes and Digestive and Kidney Diseases has published the following recommendations regarding dietary changes that can help relieve the symptoms of IBS (National Institute of Diabetes and Digestive and Kidney Diseases, 2017):

    • Increase fiber intake: Fiber may help to improve constipation since it helps to soften stool and facilitate bowel movements. Soluble fiber (found in beans, fruit, and oat products) is thought to be more helpful in IBS symptom relief than insoluble fiber (found in whole-grain products and vegetables). Fiber should be added to the diet gradually to allow the body to assimilate.
    • Avoid gluten: Gluten is a protein found in wheat, barley, and rye. Foods that contain gluten include most cereals, grains, pasta, and many processed foods. Health care providers may recommend that gluten be removed from the diet to see if IBS symptoms improve.
    • Eat a low FODMAP diet: Health care providers may suggest trying the FODMAP diet. This diet requires that certain foods are avoided or eaten in smaller amounts. These foods are generally carbohydrates called FODMAPS. Examples of these foods include the following:
    • Fruits such as apples, apricots, cherries, nectarines, pears, plums, and watermelon.
    • Canned fruit in natural fruit juice, or large amounts of fruit juice or dried fruit.
    • Vegetables such as artichokes, asparagus, cauliflower, garlic, onions, and mushrooms.
    • Dairy products such as milk, milk products, soft cheeses, yogurt, custard, and ice cream.
    • Wheat and rye products.
    • Honey and foods with high-fructose corn syrup.
    • Products such as candy and gum and sweeteners ending in “ol” such as sorbitol, mannitol, and maltitol.

    Nutrition for People with Inflammatory Bowel Disease

    Stephanie is undergoing a number of diagnostic tests as part of an evaluation for periodic attacks of bloody diarrhea, which also contains pus and mucus. She also experiences abdominal pain, anorexia, weakness, nausea, and weight loss. The results of a sigmoidoscopy and colonoscopy confirm a diagnosis of ulcerative colitis.

     Mark visits his family physician complaining of weakness and fatigue that is accompanied by right lower quadrant abdominal pain, diarrhea with an average of six stools per day, and weight loss. Sometimes his stools are bloody. Stool studies show that his feces contain excessive amounts of fat (steatorrhea). There is no indication of parasites or infectious agents in his stools. A barium enema shows the characteristic string sign (marked narrowing of the bowel) of Crohn’s disease.

     Inflammatory bowel disease (IBD) is a general term used to refer to two separate diseases, Crohn’s disease and ulcerative colitis. Crohn’s disease is a chronic inflammatory disease that can affect any part of the digestive tract. Inflammation can affect the entire intestinal wall leading to diarrhea, strictures, fistulas, malabsorption, and the need for surgical restrictions Mayo Clinic, 2017e).

    Ulcerative colitis is an inflammatory disease of the colon. It is often accompanied by diarrhea. The inflammation caused by ulcerative colitis does not affect the entire intestinal wall, so it does not lead to the development of fistulas. Unfortunately, if the inflammation is extensive, it may ultimately lead to surgical removal of the affected area (Mayo Clinic, 2017e).

    No specific diet has been identified that treats or prevents inflammatory bowel disease. There are, however, some dietary recommendations that may help to control symptoms (Mayo Clinic, 2017e; UCSF Health, 2017).
    Ulcerative Colitis. During an ulcerative colitis flare up, these dietary recommendations may help to control symptoms (Mayo Clinic, 2017e; UCSF Health, 2017):

    • Follow a low-residue diet (limit foods that are high in fiber and increase bowel activity).
    • Avoid foods that increase the amount of stool production, such as fresh fruits and vegetables, prunes, and beverages that contain caffeine.
    • Decrease the amount of concentrated sweets that are eaten. These types of foods draw water into the intestine, which may lead to watery stools.
    • Decrease the amount of alcohol that is ingested.
    • Eat more omega-3 fatty acids, which may have an anti-inflammatory effect.
    • Eat smaller, more frequent meals rather than three large meals. This type of eating pattern is often better tolerated.
    • Discuss the need for nutritional supplements with health care providers. Their use may be indicated if appetite is poor and nutritional intake is decreased.

    Crohn’s Disease. During a flare up of Crohn’s disease, the following recommendations may help to control symptoms (Gersch et al., 2017, Mayo Clinic, 2017e; UCSF, 2017):

    • Follow a low-residue diet.
    • Avoid nuts, seeds, beans, and kernels. This is especially important if strictures are present.
    • Avoid high-fiber foods, such as fresh fruits and vegetables, prunes, and beverages that contain caffeine. These kinds of foods and vegetables increase the amount of stool produced.
    • Consider eating cold foods since these may help reduce bouts of diarrhea.
    • Adhere to a lactose-free diet if lactose intolerant.
    • Be alert to signs of fat malabsorption, which is characterized by oily and foul-smelling stools. People with this problem should follow a low-fat diet and discuss the problem with their health care providers.

     A low-residue diet should be followed since a variety of foods should only slowly be reintroduced into the dietary pattern. Examples of foods to be initially reintroduced include diluted juices, applesauce, canned fruit, oatmeal, plain chicken, turkey or fish, mashed potatoes, rice or noodles, and bread (sourdough or white). Fiber should be added to the diet gradually as tolerated (Gersch et al., 2017; Mayo Clinic, 2017e; UCSF, 2017):

    Nursing Consideration: Corticosteroids have often been used to treat moderate to severe flares of inflammatory bowel disease. These medications can decrease calcium and phosphorus absorption and increase protein needs (Gersch et al., 2017; Mayo Clinic, 2017e; UCSF, 2017).  Nurses must be aware of how medications influence diet for persons with inflammatory bowel disease.

     There are some nutritional deficiencies specific to each type of inflammatory bowel disease (Gersch et al., 2017; Mayo Clinic, 2017e; UCSF, 2017).

     Patients who have ulcerative colitis may have increased needs for the following nutrients (Gersch et al., 2017; Mayo Clinic, 2017e; UCSF, 2017):

     It is imperative that patients discuss the need for nutritional supplements with their health care providers.

     Patients who have Crohn’s disease may be at risk for deficiencies of the following nutrients (Gersch et al., 2017; Mayo Clinic, 2017e; UCSF, 2017):

    • Vitamin B12.
    • Vitamins D, E, and K.
    • Vitamin A.

     Patients, families, and health care providers should discuss the need for nutritional supplements to combat potential or actual deficiencies.        

    Nursing Interventions

     Nurses have considerable responsibilities when it comes to knowing how to facilitate acquisition of proper nutrition for patients with various health problems. They need to educate patients and families regarding how nutritional needs are affected by disease processes. They must also be able to help patients and families establish dietary patterns that meet their nutritional needs.

    Self-Assessment #8

     Kate is a 25-year-old graphics designer. For the past year, she has been troubled by recurrent bouts of lower abdominal pain and diarrhea; the periods of pain and diarrhea alternate with periods of normal bowel functioning. Kate notices that she is more likely to suffer from these symptoms during periods of emotional stress and after eating particular foods, such as raw peppers or drinking unusually large amounts of caffeine containing beverages. She undergoes a number of diagnostic tests, including a colonoscopy. Inflammatory bowel disease, celiac disease, diverticulitis, lactose intolerance, and colon cancer have been ruled out. A differential diagnosis of irritable bowel syndrome is made.

    1. When evaluating Karen’s state of health, health care professionals recognize all of the following EXCEPT
    2. IBS is characterized by periodic episodes of diarrhea that may alternate with constipation.
    3. patients are advised to increase their fiber intake.
    4. proper administration of corticosteroids can lead to a cure for IBS.
    5. emotional stress can exacerbate IBS.

    Self-Assessment #9

     A nurse practitioner is working with a patient to enhance his nutritional status. This patient has COPD.

    1. Nursing interventions to help the patient with COPD improve their nutritional status include which one of the following?
    2. Telling patients who are taking diuretics that they should weigh themselves on a weekly basis.
    3. Drink 6 to 8 glasses of beverages with caffeine to help increase energy levels.
    4. Increase sodium intake to stimulate the sense of taste.
    5. Consume about 20 to 35 grams of fiber every day.

    Intent to Change Practice

     There are numerous indications for practice changes in the way nurses and other healthcare professionals can enhance nutritional health. Ways to do this include the following:

    • Be sure to stay up-to-date regarding nutritional recommendations, how nutrition affects health and wellness, and how to appropriately counsel patients regarding nutrition.
    • Incorporate nutritional guidance into every plan of patient care.
    • Make nutrition an interdisciplinary team effort to help patients improve their nutritional status.

    Self-Assessment #10

     A nurse is considering practice changes after participating in a course about nutrition. She wants to use knowledge gained to improve patient outcomes.

    1. It is appropriate for a nurse to change practice in all of the following ways EXCEPT
    2. use knowledge from current education resources to improve patient outcomes.
    3. incorporate nutritional guidance in patients who are overtly malnourished.
    4. make sure that nutrition improvement is an interdisciplinary effort.
    5. improve nutritional counseling.


    Meeting nutritional needs is often a complex process. These needs vary depending on gender, age, and health status. Nurses must be sure to include nutritional assessment as part of all of their physical and emotional assessments. They must also explore how nutritional needs are affected by changes in health status and how to help patients adjust to necessary changes in their diets based on such changes.


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    Mayo Clinic. (2018e). Bulimia nervosa: Diagnosis and treatment. Retrieved from  https://www.mayoclinic.org/diseases-conditions/bulimia/diagnosis-treatment/drc-  20353621

    Mayo Clinic. (2018f). Binge-eating disorder: Overview. Retrieved from  https://www.mayoclinic.org/diseases-conditions/binge-eating-disorder/symptoms-  causes/syc-20353627

    Mayo Clinic. (2018g). Organic foods: Are they safer? More nutritious? Retrieved from  https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-    depth/organic-food/art-20043880

    Mayo Clinic. (2018h). Nutrition and healthy eating. Dietary fiber: Essential for a healthy diet.     Retrieved from https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-    eating/in-depth/fiber/art-20043983

    Mayo Clinic. (2018i). Eating during cancer treatment: Tips to make food tastier. Retrieved from  https://www.mayoclinic.org/diseases-conditions/cancer/in-depth/cancer/art-20047536

    Mayo Clinic. (2018j). Gout diet: What’s allowed, what’s not. Retrieved from  https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gout-   diet/art-20048524

    Mayo Clinic. (2019a). Nutrition and healthy eating. Mediterranean diet: A heart-healthy eating   plan. Retrieved from https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-      eating/in-depth/mediterranean-diet/art-20047801

    Mayo Clinic. (2019b). Red wine and resveratrol: Good for your heart? Retrieved from  https://www.mayoclinic.org/diseases-conditions/heart-disease/in-depth/red-wine

    Mayo Clinic. (2019c). Nutrition and healthy eating. DASH diet: Healthy eating to lower your       blood pressure. Retrieved from https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/dash-diet/art-20048456 

    Mayo Clinic. (2019d). Vegetarian diet: How to get the best nutrition. Retrieved from  https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-    depth/vegetarian-diet/art-20046446

    Mayo Clinic. (2019e). The truth behind the most popular diet trends of the moment. Retrieved     from https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/the-truth-behind-     the-most-popular-diet-trends-of-the-moment/art-20390062

    Mayo Clinic. (2019f). Senior health: How to prevent and detect malnutrition. Retrieved from  https://www.mayoclinic.org/healthy-lifestyle/caregivers/in-depth/senior-health/art- 20044699

    Mayo Clinic. (2019g). Pregnancy nutrition: Healthy-eating basics. Retrieved from  https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-  depth/pregnancy-nutrition/art-20046955

    McMillen, M. (2018). The Paleo Diet. Retrieved from https://www.webmd.com/diet/a-z/paleo-    diet

    Medline Plus. (2019). Vitamins. Retrieved from https://medlineplus.gov/ency/article/002399.htm

    Messina, M. (2016). Soy and health update: Evaluation of the clinical and epidemiologic literature. Nutrients, (9(12) 754. DOI: 10.3390/nu8120754. Retrieved from  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5188409/

    Mission Health. (2018). What are you putting in your body? The difference between whole and    processed foods. Retrieved from https://blog.mission-health.org/2018/07/26/whole-     processed-foods-health/

    National Cancer Institute. (n.d.). Obesity and cancer. Retrieved from     https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-    sheet#r23

    National Cancer Institute. (2019). Nutrition in cancer care (PDQ®)  Health professional version.  Retrieved from https://www.cancer.gov/about-cancer/treatment/side-effects/appetite- loss/nutrition-hp-pdq

    National Center for Complementary and Integrative Health (NCCIH). (2016). Antioxidants: In     Depth. Retrieved from https://nccih.nih.gov/health/antioxidants/introduction.htm

    The National Institute of Diabetes and Digestive and Kidney Diseases. (2017). Eating, diet, &     nutrition for irritable bowel syndrome. Retrieved from https://www.niddk.nih.gov/health-    information/digestive-diseases/irritable-bowel-syndrome/eating-diet-nutrition

    Institute of Health (NIH) Osteoporosis and Related Bone Diseases National Resource Center. (2018). Calcium and vitamin D: Important at every age. Retrieved from https://www.bones.nih.gov/health-info/bone/bone-health/nutrition/calcium-and-vitamin-d-important-every-age

    New York Times. (2011). Nutrition plate unveiled, replacing food pyramid. Retrieved from  http://www.nytimes.com/2011/06/03/business/03plate.html?_r=0

    Obesity Medicine Association. (2019). Obesity and obstructive sleep apnea. Retrieved from  https://obesitymedicine.org/obesity-and-sleep-apnea/

    O’Neil, E. (2019). What is adult learning theory? Retrieved from   https://www.learnupon.com/blog/adult-learning-theory/

    Petre, A. (2016). 11 foods healthy vegans eat. Retrieved from  https://www.healthline.com/nutrition/foods-vegans-eat

    Robinson, K. M. (2019). Raw foods diet. Retrieved from https://www.webmd.com/diet/a-z/raw-   foods-diet

    Schwingshackl, L., Schwedhelm, C., Galbete, C., & Hoffmann, G. (2017). Adherence to Mediterranean Diet and risk of cancer: An updated systematic and meta-analysis.     Nutrients, 9(10), 1063. DOI: 10.3390/nu910063. Retrieved from    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5691680/

    Shan, Z., Rehm, C. D., Rogers, G., Ruan, M., Wang, D., Hu, F. B., M. … Bhupathiraju, S. N. (2019). Trends in dietary carbohydrate, protein, and fat intake and diet quality among US adults, 1999–2016. The Journal of the American Medical Association (JAMA), 322(12), 1178–1187. DOI: 10.1001/jama.2019.13771

    Spiridakis, N. (2019). Lacto-ovo vegetarian meal plans. Retrieved from  https://www.livestrong.com/article/353025-lacto-ovo-vegetarian-meal-plans/

    Stoppler, M. C. (2018). Medical definition of Zone Diet. Retrieved from  https://www.medicinenet.com/script/main/art.asp?articlekey=64062

     UCSF Health. (2017). Nutrition tips for inflammatory bowel disease. Retrieved from  https://www.ucsfhealth.org/education/nutrition-tips-for-inflammatory-bowel-disease

    United States (U.S.) Department of Agriculture. (n.d.). Agency history. Retrieved from  https://www.fsa.usda.gov/about-fsa/history-and-mission/agency-history/index

    Videbeck, S. L. (2017). Psychiatric-mental health nursing (7th ed.). Philadelphia, PA: Wolters    Kluwer.

    WebMD. (2019a). Binge eating disorder. Retrieved from https://www.webmd.com/mental- health/eating-disorders/binge-eating-disorder/binge-eating-disorder-medref#1

    WebMD. (2019b). Health benefits of soy. Retrieved from    https://www.webmd.com/diet/ss/slideshow-soy-health-benefits

    WebMD. (2019c). What types of fat are in food? Retrieved from     https://www.webmd.com/diet/guide/types-fat-in-foods#1

    WebMD. (2018a). Health risks linked to obesity. Retrieved from  https://www.webmd.com/diet/obesity/obesity-health-risks#2

    WebMD. (2018b). Causes of obstructive sleep apnea. Retrieved from    https://www.webmd.com/sleep-disorders/sleep-apnea/obstructive-sleep-apnea-causes#1.

    WebMD. (2018c). Phytonutrients. Retrieved from    https://www.webmd.com/diet/guide/phytonutrients-faq#1

    WebMD. (2018d). Food sources of vitamins and minerals. Retrieved from  https://www.webmd.com/food-recipes/vitamin-mineral-sources#

    Wolfram, T. (2018). Special nutrient needs of older adults. Retrieved from  https://www.eatright.org/health/wellness/healthy-aging/special-nutrient-needs-of-older-     adults

    World Health Organization (WHO). (2018). Obesity and overweight. Retrieved from  https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

    Zdziarski, L, A,, Wasser, J. G., & Vincent, H. K.  2015). Chronic pain management in the       obese patient: A focused review of key challenges and potential exercise solutions.     Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4332294/

    Self-assessment Answers and Rationales

    1. The correct choice is a. Americans consume more than the recommended amounts of sodium in their diets. They should eat less saturated fats and increase the amount of whole grains that they eat. From 1999–2016, there were significant increases of consumption of plant products.
    2. The correct choice is c. Obesity has been linked to the development of a number of cancers, including breast cancers. The ideal goal for weekly weight loss is one to two pounds per week. To reduce symptoms of obstructive sleep apnea people should lose 10% of their body weight.
    3. The correct choice is d. Family therapy is the only evidence-based therapy for anorexia nervosa.
    4. The correct answer is c. Persons who have bulimia nervosa are usually of normal weight. They are, however, desperate to lose weight and feel that they have no control over binging and purging behaviors.
    5. The correct answer is b. Organic foods are usually more expensive than conventional foods because, in part, the farming practices used are more expensive.
    6. The correct answer is a. Vitamin A is important for vision, healthy skin and mucous membranes, growth of bones and teeth, and a healthy immune system. Vitamin D is necessary for calcium absorption. Folic acid is water-soluble, not fat-soluble. Niacin is vitamin B3.
    7. The correct answer is c. The DASH diet is designed as a lifelong approach to healthy eating. Its goal is to help prevent or reduce hypertension. According to information published by the Mayo Clinic, people who follow the DASH diet may be able to reduce their blood pressure by a few points in just two weeks.
    8. The correct answer is c. Treatment of IBS is generally supportive and focuses on avoiding foods that trigger IBS. Corticosteroids are used in the treatment of inflammatory bowel disease, not IBS.
    9. The correct answer is d. High fiber should be incorporated into the diet. The goal is to consume about 20 to 35 grams of fiber every day. Sodium should be limited as well as caffeine intake.
    10. The correct answer is b. Nutritional guidance should be part of every patient care plan.

    Test Questions



    Answer A

    Answer B

    Answer C

    Answer D



    Using data on current patterns, a nurse would tell a patient all of the following EXCEPT:

    Research shows that Americans have increased the percentage of energy intake from high-quality carbohydrates.

    Reducing sodium consumption by 1,200 will save up to $200 billion a year in medical costs.

    Empty calories from added sugars and solid fats contribute to 40% of total daily calories for 2- to 18-year-olds.

    The typical American diet exceeds the recommended intake of calories from whole grains, sodium, added sugars, and solid fats.



    An obese patient is being seen by the nurse practitioner. The patient has a history of heart disease. The nurse practitioner would anticipate:

    Lower HDL cholesterol.

    A reduction in triglyceride levels.

    Orthostatic hypotension.

    A reduction in LDL cholesterol.



    Theories of why obesity increases the risk for some cancers include:

    Fat tissues reduce estrogen, which is associated with some female reproductive organ cancers.

    Obese patients often have high levels of subacute inflammation which increases cancer risk.

    Obese people have decreased blood levels of insulin, which is associated with colon cancer.

    Adipokines in fat cells has no effect on cell growth.



    Pregnant women who are obese face an increased risk of all of the following EXCEPT:

    Emergency C-section.

    Gestational diabetes.


    Excessive vomiting.



    In order to follow the recommendations that are part of MyPlate, a person should:

    Switch to 2% milk.

    Make at least 25% of grain intake whole grains.

    Compare the amounts of sodium in foods.

    Increase consumption of beef.



    Vitamin ____is important to nerve function and energy.



    Folic acid.

    Ascorbic Acid.



    All of the following foods are allowed on the lacto-vegetarian diet EXCEPT:







    Pathophysiological changes associated with poor nutrition in older adults include:

    An over-active thirst mechanism.

    Increased production of hydrochloric acid.

    Decreased sense of taste and smell.

    Decreased sense of touch.



    When counseling patients about the Keto diet, the nurse would say:

    There is little evidence to show that the Keto diet is effective for long-term use except for patients with epilepsy.

    The Keto diet is both low-carb and low-fat.

    Research suggests that the Keto diet may exacerbate Alzheimer s disease.

    The Keto diet causes increases in blood insulin levels.



    A nurse is working with a male patient to help him enhance his nutritional status. The man should:

    Ingest 4,000 to 5,000 calories daily.

    Obtain 33% of calorie intake from carbohydrates.

    Obtain half of his calories from fat as advised for men.

    Obtain healthy fats  from plant-based oils.


  • Emerging Infectious Diseases

    Emerging Infectious Diseases

    6 Contact Hours

    Released:  March 3, 2021

    Expires: March 3, 2024

    Faculty: Bradley Gillespie, PharmD

    About the Author: Trained as a clinical pharmacist, Dr. Gillespie has practiced in an industrial setting for the past 25+ years. His initial role was as a Clinical Pharmacology and Biopharmaceutics reviewer at FDA, followed by 20 years of leading Early Development programs in the pharma/biotech/nutritional industries. In addition to his industrial focus, he remains a registered pharmacist and enjoys mentoring drug development scientists and health professionals. He also leads workshops and develops continuing education programs for pharmacy, nursing, and other medical professionals.

    Reviewer: Dianne L. Haas, PhD, RN

    About the Reviewer: Dr. Haas is a tenured professional with over 45 years of experience in healthcare, serving in clinical, administrative, public health, educational, research, and consulting roles. Her passion, experience, and education provide her with a strong background in the provision of high-quality client consulting and advisement services. Relevant to this review, she has been a member of several Pharmacy and Therapeutics and Infection Control Committees in both Pediatric and Adult hospitals and has administered hospital-based infection control programs. She was a first lieutenant with the National Disaster Medical System, National Nurse Response Team, USDHHS, from 2001-2006. This body is charged with responding to national health crises such as pandemics. She is a current member of the Michigan Medical Care Advisory Council, whose members serve as policy advisors to the state’s Medicaid Director and program staff, who are currently responding to the coronavirus pandemic.

    Purpose Statement

    Nurses in every practice setting must be aware of the effects of emerging infectious diseases (EID). Case in point: the COVID-19 pandemic, which has influenced nearly every facet of life. As a result, nurses, at the center of the healthcare system, must understand the scientific as well as sociological aspects of infectious disease (ID). This course is designed to provide an overview of EID, offering useful historic and scientific underpinnings, as well as an introduction to the less obvious consequences of rapidly spreading infections. It is expected that this will empower nurses to best serve their patients, despite the challenges projected by EID-associated disruptions. In broad strokes, this educational program provides the following:

    • General ID and EID information.
    • Consequences of a pandemic.
    • An overview of how governments and organizations prepare for EID.
    • Methods to combat the spread of ID.
    • Descriptions of specific nursing approaches useful to prevent and manage EID.

    Evidence-Based Practice is summarized, where appropriate, to supplement material provided. Nursing Considerations are included to further aid in the implementation of this information to practice.

    Learning Outcomes

    Upon completion of this course, the learner will be able to:

    • Provide two historic examples of a global pandemic.
    • Describe a potential consequence of antimicrobial resistance.
    • Explain how R0 can change over the course of an epidemic.
    • Detail a scenario that could permit an outbreak of a previously eradicated ID in the United States.
    • Identify one reason why some people refuse to vaccinate themselves and/or their children.
    • Understand the relationship between a pandemic and the human need to assign blame.
    • Name three components of hygiene efforts useful to counter the spread of ID.
    • Acknowledge the role of public health agencies in the management of contagious ID.
    • Identify two elements needed to support effective contact tracing efforts.
    • Explain two practices that nurses can teach their patients that are effective in reducing the spread of contagious diseases.


    How to Receive Credit

    • Read the entire course online or in print which requires a 6-hour commitment of time.
    • Complete the Self-Assessment Quiz Questions either integrated throughout or all at the end of the course.
      • These questions are NOT GRADED. The questions are included to help affirm what you have learned from the course.
      • The correct answer is shown after the question is answered. If the incorrect answer is selected, a Rationale for the correct answer is provided.  
    • At the end of the course, answer the Yes/No Affirmation question to indicate that you have completed the educational activity.
    • Specific to Florida: A mandatory Final Examination with a passing score of 70% or higher is required. Exam questions link content to the course Learning Objectives as a method to enhance individualized learning and material retention.
    • If requested, provide required personal and payment information.
    • Complete the mandatory Nursing Course Evaluation.
    • Print your Certificate of Completion.


    CE Broker Reporting 

    Elite, provider # 50-4007, reports course completion results within 1 business day to CE Broker.  If you are licensed in Arkansas, District of Columbia, Florida, Georgia, New Mexico, South Carolina, or West Virginia, your successful completion results will be automatically reported for you.

    Accreditations and Approvals

    Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center’s (ANCC) Commission on Accreditation.  

    Individual State Nursing Approvals 

    In addition to states that accept ANCC-accredited courses, Elite is an approved provider of continuing education in nursing by: Alabama, Provider #ABNP1418 (valid through February 2, 2025); California Board of Registered Nursing, Provider #CEP17480 (valid through January 31, 2022); California Board of Vocational Nursing and Psychiatric Technicians (LVN Provider # V15058, PT Provider #15020; valid through December 31, 2021); District of Columbia Board of Nursing, Provider #50-4007; Florida Board of Nursing, Provider #50-4007; Georgia Board of Nursing, Provider #50-4007; and Kentucky Board of Nursing, Provider #7-0076 (valid through December 31, 2021). This CE program satisfies the Massachusetts States Board’s regulatory requirements as defined in 244 CMR5.00: Continuing Education.

    Activity Director

    Shirley Aycock, DNP, RN

    Executive Director of Quality and Accreditation  



    Resolution of Conflict of Interest

    In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.




    Sponsorship/Commercial Support and Non-Endorsement

    It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.


    The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition ©2021: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up-to-date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.

    Course Verification

    All individuals involved have disclosed that they have no significant financial or other conflicts of interest pertaining to this course. Likewise, and in compliance with California Assembly Bill No. 241, every reasonable effort has been made to ensure that the content in this course is balanced and unbiased. 


    The world’s struggle with the novel coronavirus has brought the term Emerging Infectious Disease into everyday use in scientific and clinical vernacular. While the use of this terminology has only recently become more common, the phenomenon of EID has likely plagued humans for many centuries. Over the past several years, though, the occurrence of EID seems to have greatly accelerated, becoming an existential threat to humankind. The changes leading to an increased incidence of EID are likely multi-faceted, with linkages to modifications in land use, enhanced intercontinental travel, climate change, and antimicrobial resistance. Whatever the reason, EID pose significant challenges for public health and science. While the impact of some EID may be blunted by immunization programs, antimicrobial therapeutics, and active immunity, it can be anticipated that, in many cases, EID will overwhelm global public health systems.

    While the COVID-19 pandemic was the most important global EID at the time that this program was developed, the focus of this educational program is EID agnostic. Nonetheless, because of the massive scale of the current crisis, thousands of examples related to COVID-19 are available that work well to illustrate the general concepts of EID.

    Infectious Disease

    Microorganisms, such as parasites, bacteria, viruses, and fungi, live inside, on, and around animal and human bodies. While many are harmless and, in some cases, even helpful, others are pathogenic and can cause ID. Some ID are not easily transmissible between animals and people, while others can be quite contagious. In some cases, infectious microorganisms are spread by insects or other animals (vectors), while at other times, transmission is via environmental exposure or by consumption of contaminated food or water. Manifestations of ID are variable, depending on a variety of factors, perhaps most importantly, the organism causing the infection. Despite symptomatic diversity, ID are often associated with fever and fatigue. Additional symptoms may include diarrhea, arthralgia, and coughing. While mild infections may respond well to rest and home remedies, others may be life-threatening and require urgent medical attention. Many historically devastating ID, such as measles, can be prevented by timely immunizations. In addition, many other ID can be prevented by employing thorough sanitation practices, such as handwashing and cloth face masks. While anyone exposed to a virulent pathogen can contract an ID (Mayo Clinic, 2019), there are risk factors that may increase the odds of illness through immunosuppression resulting from the following (Mayo Clinic, 2019):

    • The use of medications or therapies such as chemotherapy, chronic use of corticosteroids, or post-transplant anti-rejection medications.
    • Human Immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS).
    • Cancer or disorders impacting the immune system.
    • Other medical conditions, such as malnutrition and advanced age.

    Some ID are associated with long-term risks of contracting cancer and other disease states. For example, the human papillomavirus has been linked to an increased risk of cervical cancer; Helicobacter pylori is a known cause of peptic ulcer and stomach cancer; while both hepatitis B and C are associated with liver carcinoma. Furthermore, a number of pathogens can cause disease and then go dormant, only to reappear later in life. An example of this is varicella zoster virus (VZV), which can initially cause chicken pox, and then present itself decades later as shingles (Mayo Clinic, 2019).

    In order for an infection to occur, a pathogen must enter the body, replicate to a critical mass, and then cause a reaction (Centers for Disease Control and Prevention [CDC], 2017). In order for this to occur, three elements are required:

    1. A source where the infectious agent can exist, for example, human skin or household surfaces.
    2. Susceptible person, that is, a person with an accessible entry point.
    3. Transmission route – a way that the pathogen can access the susceptible person (CDC, 2017).

    It is critical to note that pathogens do not move themselves; rather, they depend on help from people or the environment (CDC, 2017). There are a few general ways that infectious agents can be transmitted, such as the following:

    • Contact (touching). As an example, a person’s hands become infected by contact with a high-touch area and then spread, if proper hygiene (handwashing) is not performed before coming into contact with a susceptible person.
    • Sprays and splashes are often associated with coughs and sneezes from an infected person. In this case, droplets are created carrying germs that are able to travel short distances (thought to be approximately 6 feet) before deposition on a susceptible person’s eyes, nose, or mouth. Pertussis and meningitis are known to be transmitted in this way (CDC, 2017).

    Nursing Consideration

    Nurses need to teach their patients how to properly cover their mouth and nose while sneezing. Patients should either cough or sneeze into their shirt sleeve at the elbow or use a tissue. If a tissue is used, it should be disposed of immediately after use. No matter the technique, individuals should be taught to wash their hands with soap and water (or hand sanitizer, as appropriate) as soon as possible after coughing or sneezing.

    • Inhalation of aerosolized pathogenic material. Unlike sprays and splashes from coughs and sneezes, when aerosolized, infectious agents can survive and be carried long distances (relative to the range of particles carried by coughs and sneezes) by air currents to reach a susceptible person. If conditions allow, aerosolization can result when infected patients cough, talk, or sneeze. As examples, tuberculosis and measles are known to be transmitted this way. Additionally, aerosolization can be caused by some types of medical equipment or can be contained within dust emanating from construction. Such examples include aspergillus and some mycobacteria (CDC, 2017).

    Evidence-Based Practice

    Traditional hypotheses about the transmission of airborne ID have largely focused on the roles of coughing and sneezing – dramatic examples of expiration sometimes resulting in visible droplets, as well as copious amounts of particles too small to be visualized. Nevertheless, it has been acknowledged that normal speech is also capable of generating invisible particles that are still able to ferry a variety of contagious respiratory pathogens. Asadi and colleagues conducted a series of experiments designed to link the amplitude (loudness) of speech with the rate of particle emission. Results obtained from this work showed that the number of particles increased from an average of one particle per second at low amplitudes to 50 at high speech amplitudes. Of significant importance were the individuals that they identified as “speech superemitters,” who consistently released particles in an order of magnitude greater than their peers. This phenomenon could not be completely explained by either specific speech structures or amplitude. Asadi and colleagues suggested that there must be unknown physiologic factors that vary considerably between individuals. In conclusion, they hypothesized that these findings may help explain the existence of “superspreaders,” who are disproportionately responsible for airborne ID outbreaks (Asadi et al., 2019).

    • Injuries such as those incurred by accidental needlesticks may lead to certain infections such as HIV and hepatitis B or C (CDC, 2017).
    • Animal to person transmission can occur if a human is bitten or scratched by an infected animal, to include pets. In addition, disease can be transmitted via animal waste (cat litter boxes have been associated with toxoplasmosis infection).
    • Mother to child – in some cases, pregnant women may pass certain pathogens through the placenta or breast milk. Also, vaginal germs can infect a baby during birth.
    • A variety of infectious agents rely on insect vectors such as mosquitos, fleas, lice, or ticks. Examples include the malaria parasite carried by mosquitos and Lyme disease carried by deer ticks.
    • Food or water contamination can facilitate the transmission of disease-carrying agents between people. A common example of this is Escherichia coli (E. coli), a bacterium sometimes present in undercooked ground meat or unpasteurized fruit juice (Mayo Clinic, 2019).

    Emerging Infections Disease

    The term “emerging infections” was defined in a 1992 report published by the Institute of Medicine as “new, reemerging, or drug-resistant infections whose incidence in humans has increased within the past two decades or whose incidence threatens to increase in the near future” (Watkins, 2018, p. 86). In addition to providing this definition, the report identified the following six factors contributing to EID (Watkins, 2018):

    1. Changes in human demographics and behavior.
    2. Technology advances and modifications of industry practice.
    3. Changes in land-use patterns and economic development.
    4. Significant changes in the amount and speed of international travel and commerce.
    5. Microbial evolution (including resistance to antimicrobial agents).
    6. A disruption in public health capacity.

    Furthermore, such infections are often linked to agents that, while previously identified, have come to be associated with novel disease states (Baylor College of Medicine [BCM], 2020).

    A majority of EID discovered to date are of animal origin, with that trend projected to continue. Another commonality is the type of pathogen: most are viral. EID are often costly, both in terms of human life and economically. As a result of the devastation wrought by EID, the World Health Organization (WHO) has prioritized a number of pathogens as requiring urgent research and development in an effort to curb severe outbreaks. While some of these diseases have already been manifested, others have a high likelihood of causing future outbreaks (Watkins, 2018).

    In 2007, WHO warned that the emergence of ID is occurring at a rate never seen in previous history. Since the 1970s, at least 40 novel ID have been discovered, to include: severe acute respiratory syndrome (SARS), Middle East Respiratory Syndrome (MERS), Ebola, chikungunya, avian flu, swine flu, Zika, and, recently, a new coronavirus associated with COVID-19. Although many of these diseases resulted from the factors described previously by Watkins, the potential also exists for diseases to emerge as a result of intentional introduction of pathogens to human, animal, or plant populations as bioterrorism agents. Examples of such pathogens include anthrax, smallpox, and tularemia (BCM, 2020).


    When a disease is typically present in a community at baseline exposure frequencies, it is termed endemic. It is critical to note that, although incidences of disease may exist in the background, this is not to say that this is always at a desired level. If adequate interventions are not taken and the incidence is not so high as to exhaust all susceptible people, the disease will continue to spread indefinitely. In this scenario, the baseline level of disease may come to be expected in that population. The rarity of a disease in a population may govern its treatment. For example, a single case of a relatively rare ID, such as rabies, may warrant an epidemiologic investigation in an effort to control further spread. In other cases of more common pathologies (for example, malaria, in some parts of the world), investigations may be triggered when the frequency of disease occurs outside the norm. While the term endemic is used to describe the constant and usual presence of a disease, at least two other terms are sometimes used to further describe endemic conditions. Sporadic diseases are those that occur with infrequency and irregularity. Hyperendemic diseases occur persistently and with sometimes relatively high levels of incidence (CDC, n.d.).


    If an unexpected increase in the incidence of a disease in a specific geographic area occurs, this may signal the beginning of an epidemic, which is defined as a rise in cases beyond baseline levels in a defined geographic area. Epidemics can occur because of a variety of causes, to include the following:

    • When an infectious agent rapidly becomes more common in an area where it already existed (endemically).
    • A pathogen spreads through a region that was previously naïve to that agent.
    • When human susceptibility somehow changes, allowing people to become sickened by agents that they previously tolerated.

    (Joy, 2020)

    The term epidemic has been present for some time, with possibly the first reference occurring in Homer’s Odyssey, where it appeared to be used similarly to how the word endemic is now used (Joy, 2020). The first occurrence of the word epidemic being used in a way similar to its contemporary meaning was in 430 BCE by Hippocrates in his writings, Epidemics, which is a collection of clinical observations that would go on to form the underpinnings of modern medicine (Martin & Martin-Granel, 2006).


    The word pandemic stems from a construct formed from the Greek words pan, meaning all, linked to demos, which refers to the population, thus forming the contraction pandemos, referring to all of the people (Shiel, n.d.).

    When a novel infectious agent emerges, the majority of people lack immunity to counter the resultant ID. If conditions permit, this susceptibility may result in a rapid spread of disease between people, sometimes covering major swaths of the population. The spread of a viral pandemic can be characterized by the following six distinct phases (Lockett, 2020):

    • Phase 1 – viruses are transmitted within animal populations. Since they have not been shown to enter humans, these pathogens are not considered a threat.
    • Phase 2 – a new virus appears in animals that is shown to be transmissible to humans. As a result, this presentation may signal the potential risk of an epidemic or pandemic.
    • Phase 3 – Initial clusters of human disease crop up as a result of animal-to-human transmission. Nonetheless, at this point, the rate of transmission is too low to result in significant community outbreaks. Although humans are considered to be at risk, the occurrence of a pandemic is unlikely.
    • Phase 4 – The rate of human-to-human transmission accelerates to the point that community outbreaks are documented. This escalation marks the presence of a high risk of pandemic development.
    • Phase 5 – When there is transmission of the virus to at least two countries, a global pandemic is considered to now be inevitable.
    • Phase 6 – If a virus has spread to at least three countries, a global pandemic is officially present.

    (Lockett, 2020)


    Although not well documented, history suggests that communicable diseases have been present for thousands of years – at least as far back as the so-called hunter-gather days of possibly two million years ago. A major change in the way people lived occurred approximately 10,000 years ago, as a shift to more agrarian lifestyles took hold. During this era, communities were created. These increases in population density facilitated the occurrence of transmissible disease, to include malaria, tuberculosis, leprosy, influenza, and smallpox. The civilization of humans was coupled with the building of larger cities, increased trade, and war between other peoples. These interactions fueled the likelihood of pandemics (History.com, 2020). Some key examples of ID have emerged over time.

    Great Plague of Athens, 430 BCE

    The first written account of a pandemic was rooted in 430 BCE Athens, in conjunction with the Peloponnesian War. Thucydides, an exiled Athenian general, was responsible for documenting the disease from a firsthand perspective. The malady was suspected, but not confirmed, to be typhoid fever, manifesting as fever, thirst, bloody throat and tongue, red skin, and lesions. It significantly weakened the Athenian army and likely contributed to their defeat at the hands of the Spartans. Although the Spartans had laid siege to Athens, the disease managed to spread beyond the walls of the city, ultimately impacting Libya, Ethiopia, and Egypt. Thucydides estimated that as much as two-thirds of the affected population ultimately died as a result of the disease. It was apparent that overcrowding in Athens, associated with inadequate housing and sanitation allowed the disease to rapidly spread and contributed to its lethality. Thucydides, himself, fell victim to the plague, but was able to recover. Perhaps, it was because of his own experience that he was able to understand fear and self-interest as it related to the disease, how it drove individual motivations and the subsequent fate of Greece. Through this lens, he recognized the practical and moral weaknesses that the disease was able to exploit. In addition to observations of inadequate infrastructure, Thucydides also criticized personal principles, noting that morally weak individuals, when they become afraid, regressed to lawlessness and sacrilege: “For the violence of the calamity was such that men, not knowing where to turn, grew reckless of all law, human and divine” (Kelaidis, 2020).

    Antonine Plague, 165 CE

    This early manifestation of smallpox apparently was initiated within a population of Huns, who infected the Germans, who shared it with the attacking Roman army. Upon return to Rome, troops quickly spread it throughout the Roman Empire. Infected people suffered fever, chills, dyspepsia, and diarrhea that evolved from red to black in a week’s time. Victims reportedly developed black pocks over their entire bodies, both inside and out. In those that survived, these sores then scabbed over, leaving disfiguring scars. In many cases, the suffering continued for 2 to 3 weeks. Of the approximately 75 million people residing in the Roman Empire, it is reported that 10% died. So shaken by this insult to their people, the town of Hierapolis erected a statue to the god, Apollo Alexikakos, the Averter of Evil, to protect their people from the disease as it spread throughout the Empire (Watts, 2020). The Antonine plague persisted until about 180 CE, even claiming the life of Emperor Marcus Aurelius (History.com, 2020).


    Leprosy, sometimes called Hansen’s disease, is caused by infection with the bacterium Mycobacterium leprae. Leprosy, if diagnosed and treated early, is a curable disease, allowing the afflicted to work and lead a normal life. If untreated, it can impact nerves, skin, eyes, and nasal mucosa, resulting in paralysis and blindness. Historically, leprosy was feared as both highly contagious and devastating (CDC, 2017a).

    In medieval times, the disabling consequences of leprosy were apparent throughout England, afflicting both rich and poor, in rural areas as well as in cities. By 1050, leprosy was considered to be a regular consequence of life. In its most extreme form, it could cause the loss of fingers and toes. It is crucial to note the complicated reaction that people had to the disease. Because some saw it as punishment for sinful behavior, being afflicted could result in various moral judgements or ostracization. Alternatively, others saw it as akin to the suffering endured by Christ. In this light, leprosy was considered to be purgatory on earth, providing a direct conduit to heaven upon death. Sufferers of leprosy, in some circles, were considered to be closer to God than others (HistoricEngland.org, 2020).

    Black Death, 1350 CE

    The term Black Death was given to a deadly plague associated with the bacterium Yersinia pestis, which ran rampant in Europe during the 14th Century. It is thought that it originated in Asia, arriving in Europe in late 1348. Up until recently, it was understood that Y. pestis was transmitted to humans through bites from rats. Nonetheless, forensic archaeology work conducted in 2014 generated evidence concluding that the infection relied on airborne routes of transmission (coughs and sneezes), with the reasoning that this was the only mechanism that could have been responsible for such a rapid spread. Initial evidence of contracting the plague included lumps in the groin or armpit regions. In due course, black spots appeared on the body. Many of the afflicted died within 3 days of exhibiting symptoms, with few people recovering. At the time, existing medical knowledge was no match for the plague, which killed six of every 10 Londoners by the spring of 1349. Remnants of the Black Death recurred six more times by the end of the century (Trueman, 2015).

    It appears likely that people’s ignorance of contagious diseases at the time contributed greatly to the plague’s ability to infect and kill so many people. Perhaps if they were more knowledgeable, they might have avoided close contact with others, especially when ill, and may have made better efforts to cover their mouth and nose when sneezing or coughing. Instead, the lack of information resulted in people trying most anything to escape the disease. One extreme example was the case of the so-called flagellants. Adherents to this philosophy whipped themselves in hopes that God might forgive them of their sins, and thus spare them of the Black Death (Trueman, 2015).

    The Columbian Exchange, 1492

    The Columbian exchange was a term used to describe massive transfers between the Old and New world. This process, marked by the arrival of Christopher Columbus to America in 1492, continues to this day. While many people may think of this colonization as mainly impacting plants, animals, and culture, all manners of life were sent in both directions across the Atlantic and, subsequently, to all corners of the world. One historian, Alfred Crosby, noted that European colonization of the New World depended not so much on guns, steel, and brutality, but more on the lifeforms that accompanied the early colonists. Some of the most critical were microbes that decimated the native peoples. For example, it is estimated that European small pox ultimately killed one-half of the indigenous American population, with the initial outbreak recorded in 1520-1521. In addition to the fatal efficacy of the virus, those that survived were weakened, and thus more susceptible to the diseases that followed, to include measles, bubonic plague, influenza, and typhus (History of Science in Latin America and the Caribbean [HOSLAC], n.d.).

    Fiji Measles Epidemic, 1875

    In October 1874, the chief of Fiji made an official state visit to Australia. Unfortunately, cases of measles had just started occurring in Sydney. The entire Fijian delegation caught the disease. The Australians provided attentive care, with most recovering by the time they returned home in January 1875. Nonetheless, the virus was not eradicated. Within a week, residents of the island began to be struck down by a disease that they could not understand. Despite the assurances of British administrators, some Fijians grew suspicious, believing that they were victims of sorcery. There was a widely held belief that the British had taken their chief to Australia with the intention of poisoning him. People became increasingly hostile and refused all conventional treatments for measles, leaving their immune systems alone to battle this serious illness. In the end, this measles outbreak was the worst disaster in the history of Fiji, resulting in the death of one-third of the island’s population of 150,000. The British government scapegoated the ship’s doctor and captain for not placing their passengers in quarantine upon their return to Fiji (Devestatingdisasters.com, n.d.).

    Spanish Flu, 1918

    The most severe pandemic to impact the world in the recent past was the influenza pandemic of 1918, sometimes called the Spanish Flu. It is thought that the virus infected approximately 500 million people globally, resulting in the death of over 50 million. In the United States (US), it is estimated that one-fourth of the total population was afflicted by the virus that killed approximately 675,000 Americans. In the US, the pandemic was thought to have decreased the average life expectancy by 12 years. At that time there was no vaccine available to prevent influenza. Instead, people were encouraged to exercise good sanitation, isolate, and quarantine as appropriate and strictly limit their social interactions (National Archives, 2020).

    Zika Virus, 1952

    Zika virus is a flavivirus transmitted by infected mosquitos. Initially identified in Ugandan monkeys in 1947, the first known transmission to humans occurred in 1952. Since that time, outbreaks of Zika have been noted in Africa, the Americas, and the Pacific. During the 1960s to 1980s, outbreaks were rare and sporadic, typically associated with mild illness. Larger outbreaks occurred in countries and territories of the Pacific beginning in 2013. In 2015, a major outbreak was reported in Brazil. During this outbreak, Zika was associated with Guillain-Barré syndrome and the incidence of microcephaly of children born to infected mothers. Outbreaks accelerated after this time. To date, infections have been reported in 86 countries and territories. Symptoms usually occur within 3 to 14 days of infection. In most individuals, the disease is mild and asymptomatic. In those that exhibit symptoms, the most common signs are mild and include fever, rash, conjunctivitis, muscle and joint pain, malaise, and headache, usually lasting 2 to 7 days.

    Ebola Virus Disease (EVD), 1976

    EVD can result from infection with a variety of viruses within the genus ebolavirus. The first observation of Ebola was near the Ebola River, in what is now the Democratic Republic of Congo. Since that time, viral outbreaks have occurred sporadically in a number of African countries. Although not with certainty, it is thought that the most likely source of Ebola was either bats or nonhuman primates. The initial spread to humans was likely through direct contact with infected blood, body fluids, or tissues of animals. The virus  then could easily spread to other people through contact with body fluids of other people who are sick with or have died from EVD. Viral entry is typically through broken skin, mucous membranes, or by sexual contact. The appearance of symptoms can occur anytime between 2 to 21 days after exposure to the virus. Usually, initial symptoms include fever, aches and pains, and fatigue, progressing to diarrhea and vomiting as the patient becomes sicker. Those that survive Ebola infections may experience lingering symptoms such as tiredness, muscle aches, eye and vision problems, and stomach pain (CDC, 2019).

    HIV/AIDS, 1981

    Although the virus causing AIDS had likely been present for some time, it was first characterized in 1981. AIDS is not, in itself, fatal. Rather, left untreated, it destroys a person’s immune system (largely t-cells), leaving them vulnerable to a variety of diseases that the body could normally fight off. After infection by HIV, people generally experience fever, headache, and enlarged lymph nodes. After a time, these symptoms may subside, leaving those afflicted infectious to others. While AIDS was initially seen primarily in gay American communities, it is thought that it originally stemmed from a west African chimpanzee virus in the 1920s, moving through Haiti in the 1960s and arriving in New York and San Francisco in the 1970s. Although a variety of therapeutics have been developed that effectively slow the progression of disease, no cure or vaccine has been found. To date, over 35 million people worldwide have died of AIDS since its discovery in 1981 (History.com, 2020).

    Severe Acute Respiratory Syndrome (SARS), 2003

    SARS is a viral respiratory illness caused by a coronavirus called SARS-associated coronavirus (SARS-CoV). Initial reports of SARS occurred in Asia in early 2003. The sickness spread to more than 25 countries in the Americas, Europe, and Asia before the pandemic could be contained (CDC, 2013). Generally, SARS is initially associated with flu-like symptoms, to include fever, chills, muscle aches, headache, and occasionally diarrhea. Approximately a week later, most people suffering from SARS will have a fever of at least 100.5⁰F, dry cough, and shortness of breath (Mayo Clinic, 2019). At this time, there are no known actively transmitted cases of SARS anywhere in the world. In 2004, human infection linked to laboratory-acquired infections in China were reported (CDC, 2013).

    Severe Acute Respiratory Syndrome Coronavirus 2 (COVID-19), 2019

    The term coronavirus is used to describe a family of viruses that have the potential to cause illness, ranging from the common cold to deadly diseases such as SARS. In 2019, a novel coronavirus identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first appeared in China. Infection with SARS-CoV-2 results in the disease COVID-19. Although some people with COVID-19 will remain asymptomatic throughout the course of disease, others may experience serious and even fatal outcomes. The most common signs and symptoms associated with COVID-19 appear within 2 to 14 days of exposure and may include fever, cough, and fatigue. In many cases, infected individuals may experience a loss of taste and/or smell. Other symptoms include a shortness of breath, arthralgia, chills, sore throat, rhinitis, headache, chest pain, and conjunctivitis. The severity of symptoms runs the gamut, ranging from very mild to severe. It appears that older individuals may be at a heightened risk of severe COVID-19. Additionally, it is evident that certain comorbidities, including heart disease, diabetes, obesity, pulmonary disease, and immunodeficiency put individuals in a higher risk category. In March 2020, WHO declared that the COVID-19 outbreak was a pandemic (Mayo Clinic, 2020).

    While the world is awaiting the broad availability of a vaccine to prevent COVID-19, there are well-acknowledged steps that can be taken to reduce the risk of infection. Key concepts include avoiding close contact with other people; frequent handwashing; prodigious use of face coverings; covering of mouth and nose when coughing or sneezing; avoidance of touching eyes, mouth, and nose; frequent cleaning and disinfecting of high-touch surfaces; and staying home when sick (Mayo Clinic, 2020).

    History of EID: A Summary

    From the 430 BCE Plague of Athens to our present struggle with COVID-19, it is uncanny, despite the passage of nearly 2,500 years and great advances in medicine, how many aspects remain the same:

    • Vaccines and therapeutics are often not available in time to stop a fast-spreading pandemic.
    • Failure to maintain adequate distance from people allows microbial transmission.
    • Contagion is often linked to poor sanitation.
    • Stigma and misinformation are able to enhance the spread of disease.

    Efforts to Manage EID

    The concept of emerging infectious diseases has been discussed in a variety of scientific publications since at least the early 1960s. It required a major outbreak of genital herpes, followed by the emergence of HIV/AIDS in the 1970s and early 1980s, to raise awareness and concern of EID, making the term widespread. A number of subsequent landmark events and publications aroused interest in the subject, deepening the funding channels, permitting increased levels of research and publication of seminal articles. This is not to say that previous to this, clinicians were ignorant to the potential harms of EID. As an example, in 1888, the Institut Pasteur (IP) opened in Paris as one of the original centers dedicated to supporting research to prevent, diagnose, and control outbreaks of EID. A number of laboratories were established to study the epidemiology of pathologies such as malaria and sleeping sickness. Such efforts led to the development of early vaccines intended to counter smallpox, rabies, and the plague. Meanwhile, the mission of the IP expanded, forming a close alliance with WHO and establishing centers in nine African countries. Currently, the IP remains a major player, entwined in almost every EID outbreak (Ndow, 2019).

    In response to the heavy toll that yellow fever was inflicting on the US Military, the Yellow Fever Commission was formed in 1900 to evaluate the cause and transmission of yellow fever. This effort was initially led in Cuba by Major Walter Reed. In its initial year of existence, the commission confirmed that yellow fever was communicated via mosquito bites. This was proven by deliberately infecting 30 men with mosquito bites. The commission then initiated control programs in Cuba revolving around enhanced sanitation, fumigation with insecticides, and endeavoring to eliminate standing water to prevent breeding. Their efforts were rewarded with a dramatic decrease in the incidence of yellow fever. These control programs were implemented just in time to preserve the Panama Canal project. Early in the project, it was estimated that approximately 85% of canal workers required hospitalization as a result of contracting malaria or yellow fever, resulting in the death of tens of thousands. President Theodore Roosevelt funded an effort to keep the construction progressing. A total of 4,000 workers traveled to Panama and spent a year working to prevent mosquitos from laying their eggs. To this end, they employed fumigation and spread oil on standing water. These efforts were effective, with the last victim of yellow fever in the Panama Canal zone succumbing to disease in 1906. By the end of World War II, most parts of the world had adopted dichlorodiphenyltrichloroethane (DDT) as its weapon of choice to eradicate mosquitos, and thus control yellow fever. Shortly thereafter, a vaccine for yellow fever was developed that ultimately provided lifetime immunity for 99% of people who were immunized. In the past 30 years, limited clusters of yellow fever have emerged in Africa and South America (National Public Radio [NPR], 2019).

    The Medical Research Council (MRC) laboratory in Gambia was formed in 1947 when a World War II British Army hospital was handed over to the United Kingdom (UK) based MRC. This institution is, and always has been, funded by the UK government and is their largest investment in medical research based in a developing country. With a keen focus on ID threatening Gambia and the greater continent of Africa, its objective was to reduce the burden of death, both there and in all of the developing world. The laboratory made significant contributions toward the prevention of pathologies to include malaria, tuberculosis, and Haemophilus influenza. To this day, it remains deeply engaged in research focused on ID, conducted at the bench as well as in clinical trials. Its reputation is excellent and it is thus able to attract international funding and the recruitment of superior investigators (Perform, 2020).

    In the timeframe spanning the 1950s to 1970s, a number of African nations created and supported research centers throughout the continent designed to improve health and quality of life. Examples include the South African Medical Research Centre (SAMRC), Kenya Medical Research Institute (KEMRI), the National Research Centre (NRC) of Egypt, the National Institute for Medical Research (NIMR) in Tanzania, the Medical Research Council of Zimbabwe (MRCZ), and the Medical Research Council of Nigeria. Many of these organizations conducted research intended to characterize the transmission of EID in ways designed to better understand the evolution of antimicrobial resistance and best inform procedures to counter disease outbreaks (Ndow, 2019).

    The National Center for Emerging and Zoonotic Infectious Diseases, a component of the US CDC, is tasked with protecting people from health threats, both global and domestic (CDC, 2017b). Some of their areas of interest include the following:

    • Waterborne and foodborne disease.
    • Hospital- and institution-based infections.
    • Antimicrobial-resistant infections.
    • Fatal diseases such as Ebola, anthrax, and COVID-19.
    • Illnesses that tend to impact travelers, immigrants, and refugees.
    • Diseases resulting from contact with animals.
    • Diseases that spread by fleas, mosquitos, and ticks.

    WHO endeavors to provide an integrated global alert and response system for epidemics and other public health emergencies by partnering with national health systems, resulting in a coordinated and effective response. WHO identifies their core functions as the following (WHO, 2020c):

    • Supporting their member states in a way to implement national capacities for epidemic preparedness and response, to include laboratory capacity, early warning alerts, and response schemes.
    • Support of training for epidemic (to include influenza) preparedness and response.
    • Generate standardized schemes supporting readiness and response to known epidemic diseases, such as meningitis, plague, and yellow fever.
    • Reinforce biosafety, biosecurity, and readiness for outbreaks of dangerous and emerging pathogenic outbreaks, such as SARS, COVID-19, and viral hemorrhagic fevers.
    • Maintain global operational platforms to support outbreak response.

    Current status of EID

    As of October 24, 2020, the CDC (2020c) reported a total of 12 US-based ID related outbreaks:

    • Salmonella infections from pet bearded dragons (October 2020).
    • Salmonella infections from wood ear mushrooms (September 2020).
    • Salmonella infections from pet hedgehogs (September 2020).
    • Salmonella infections from peaches (August 2020).
    • Salmonella infections from onions (August 2020).
    • Salmonella infections from backyard poultry (May 2020).
    • COVID-19 (January 2020).
    • Multidrug-resistant Campylobacter infections from pet store puppies (December 2019).
    • Lung injury associated with vaping (August 2019).
    • Drug-resistant Brucella infections from raw milk (February 2019).
    • Measles (January 2019).
    • Hepatitis A among people who are homeless and use drugs (March, 2017).

    It is evident that while the US faces a variety of perils, the greatest current challenge is that of managing COVID-19. In addition, the CDC (2020a) reported an outbreak of Ebolavirus in the Democratic Republic of the Congo beginning in May 2018. WHO more broadly focuses across all global outbreaks and is currently monitoring a much more extensive portfolio of ID. As of October 24, 2020, the WHO (2020b) list of pandemic and epidemic diseases included the following:

    • Crimean-Congo haemorrhagic fever.
    • Ebola virus disease.
    • Hendra virus infection.
    • Influenza (pandemic, seasonal zoonotic).
    • Lassa fever.
    • Marburg virus disease.
    • MERS-CoV.
    • Nipah virus infection.
    • Novel coronavirus (2019-nCoV).
    • Rift Valley fever.
    • Yellow fever.
    • Zika virus disease

    Drivers of EID

    In the last 60 years, the emergence of ID has occurred at an increased rate. In many cases, outbreaks seem to appear without warning, complicating public and animal health as diseases spread across regions. In order to best manage this evolving threat, it is critical to understand the driving force of these phenomena. When the basis of disease is characterized, it may be possible to develop solid measures designed to prevent and mitigate their spread. As long as EID are able to run rampant across the world, health security and sustainable development will remain in jeopardy (Machalaba & Karesh, 2017).

    Climate Change

    Human’s relentless drive to expand their global footprint is a major factor in driving the risk of EID. Population expansion linked to environmental impacts are acknowledged as linkages to some outbreaks of ID (Machalaba & Karesh, 2017).

    When ID appear in new hosts and/or in new regions, the cause of climate change must be considered. With climate change now nearly universally acknowledged, the emergence of novel ID can be expected. Changes in climate drive shifts in habitats, putting wildlife, crops, and humans into contact with pathogens that they have never been exposed to, and are thus typically susceptible. One example was recorded in Costa Rica. In this case, humans hunted capuchin and spider monkeys to the point of extinction in some regions of the country. With no host, native lungworm parasites moved to howler monkeys that, because of changes in climate, occupied a broader habitat, beginning a new path of migration. Over time, by hitchhiking on a variety of hosts inhabiting increasing ranges, lungworms have moved as far north as the arctic, ultimately taking up residence in Canadian caribou and muskoxen. For over 100 years, scientists did not believe that parasites could jump so rapidly between species. This has recently been proven otherwise with pathogens shifting to new hosts relatively quickly, given the right circumstances. To make matters worse, in many cases, the new hosts, which have not yet developed resistance, are often extremely susceptible to illness and get much sicker than the previous host. In cases where resistance to the pathogen does develop, the acute disease simply becomes a chronic problem. This is illustrated by West Nile Virus. Although West Nile is no longer an acute issue for animals or people in North America, it is well established and is here to stay (University of Nebraska-Lincoln, 2015).

    One potential approach to at least partially countering the impact of climate change on EID is to enhance the level of interaction between the public, veterinary health communities, and the biologists that study and classify evolving life forms. While the treatment of human cases of ID and development of vaccines to protect against them is needed, these fundamental approaches usually come too late. A more proactive approach would increase the study of pathogens carried by nonhuman reservoirs and predict which ones are likely to make the jump to humans and/or domesticated animals. If scientists could develop increased knowledge focused on the geographic distribution and behavior of nonhuman reservoirs of pathogens, better public health strategies could be developed to reduce the risk of spreading infections. While it is unlikely that pathogens can be eradicated from host species, human awareness of infected animals could lead to reduced contact and thus decrease the incidence of resultant ID (University of Nebraska-Lincoln, 2015).

    Evidence-Based Practice

    Parasites typically can exist within broader temperature ranges than their hosts. This is thought to occur because the smaller parasitic organisms can acclimate more readily because of higher metabolic rates. When there is a thermal mismatch, for example, a host organism is present in an environment at the higher edge of what they can tolerate, they may be more susceptible to parasitic infestation. Cohen tested the thermal mismatch hypothesis by measuring the temperature-dependent susceptibility of amphibian species to the fungal pathogen Batrachochytrium dendrobatidis. To this end, they assessed a total of 15,410 animals in 598 distinct populations. Their results showed that the greatest susceptibility of cold- and warm-adapted hosts occurred at relatively warm and cool temperatures, respectively. Investigators suggest that as climate change occurs, hosts find themselves out of their optimum environments, and thus more susceptible to parasitic infestation. These efforts help associate disease outbreaks with the extreme weather shifts common to climate change (Cohen et al., 2017).

    Antimicrobial Resistance (AMR)

    AMR asserts itself when bacteria, viruses, fungi, and parasites evolve to the point where they are no longer sensitive to medications previously able to counter them. AMR can then result in making infections more difficult to treat, thus permitting them to spread more easily. AMR happens naturally, typically as a result of genetic changes. AMR can occur in humans, animals, food, plants, and the environment. AMR pathogens can spread from persontoperson or between people and animals. Although there are a variety of causes of AMR, the largest drivers are the misuse and overuse of antimicrobial medications, poor sanitation, a lack of clean water, inadequate knowledge, and poor enforcement of guidelines designed to prevent it (WHO, 2020a).

    Case Study 1

    Melissa is a 14-year-old girl who has been brought to her Advanced Practice Nurse (APN), Laura, because she has been complaining of a sore throat, fever, and body aches. Although she does not feel especially unwell, she is concerned because she has a history test later that week and does not want to miss it. Her mother suggests that Laura prescribe a course of azithromycin because she is confident that this will help Melissa get better more quickly. While Laura considered the idea of offering an antibiotic, she was aware of a recent surge of viral infections in the community presenting similarly to Melissa’s. Based on this, Laura was leaning toward a diagnosis of viral pharyngitis. Based on her experience, there was not likely to be an effective treatment, so she suggested that her mother provide supportive care to address Melissa’s symptoms. Melissa’s mother was persistent though and had come to expect the provision of antibiotics whenever she or her family pursued medical care for a variety of complaints, to include fever, sore throat, and even diarrhea. Laura, fairly confident that Melissa was suffering from a viral infection, strongly suspected that antibiotics would serve no purpose. Even worse, she was aware that indiscriminate antibiotic usage could contribute to antibiotic resistance. Instead, Laura took the time to help Melissa’s mother understand the difference between bacterial and viral infections and the potential harm that can result from inappropriate antibiotic usage. Laura’s patience and persistence appeared to be a good investment of time – before long, Melissa’s mom was nodding in appreciation of Laura’s words. After Laura ensured that they had no further questions, Melissa and her mother left for the pharmacy to stock up on ibuprofen and orange juice.

    Self-Assessment Quiz Question 1

    Regarding antimicrobial resistance (AMR), which of the following statements is false?

    1. Antimicrobial resistance can render antibiotics ineffective against some previously susceptible microorganisms.
    2. In many cases, AMR facilitates the treatment of bacterial infections.
    3. AMR pathogens can sometimes spread between people.
    4. A major driver of AMR is the misuse of antibiotic products.

    According to the U.S. Agency for International Development (USAID), AMR and zoonotic rooted diseases account for 95% of all EID recorded in the second half of the 20th century. Examples include tuberculosis, HIV, and malaria. It is estimated that 700,000 people die annually as a result of AMR variants of these three diseases. USAID projects that, unless something is done to curb the escalation of AMR frequency, drug-resistant infections are on course to kill 10 million people per year by 2050 (USAID, 2019).

    Nursing Consideration

    Unfortunately, the inappropriate use of antibiotics in the treatment of viral disease is common. In fact, many patients have come to expect a prescription to be issued when they visit their clinician for treatment of an illness, even in cases of viral-based sicknesses. Nurses have a critical responsibility to explain the difference between viral and bacterial disease, and work to dissuade both these patients and their prescribers  to avoid using antibiotics in these instances, in an effort to combat the development of antibiotic-resistant bacteria.


    R0 (pronounced R naught) is a mathematical construct that describes the contagiousness of an ID. A synonym for R0 is reproduction number. Both terms characterize the reproduction of an infection, providing insights into how it spreads. R0 indicates the average number of people who will contract an infection from a single contagious person. This scenario is qualified by the population being totally susceptible, i.e., not immune to it, either through previous infection, vaccination, or otherwise protected. These conditions would allow for uncontrolled spread of a virulent pathogen. As an example, if a certain disease carries an R0 of 12, it can be expected that, in a vulnerable population, 12 additional people will ultimately be infected. R0 values, then, demonstrate that every disease has the following three spreading scenarios (Ramirez, 2016):

    1. In cases where R0 is less than one, each infection will result in less than one afflicted person. In this case, the incidence of disease will fade and eventually disappear.
    2. When R0 equals one, each infected person will cause one additional person to become ill. In this situation, the disease will remain stable, but an outbreak or epidemic is not expected. This is aligned with endemic conditions.
    3. If R0 is greater than one, each infection will result in more than one new infection. The disease will spread, potentially leading to epidemic conditions (Ramirez, 2016).

    Fortunately, the conditions needed to support an ID with an R0 greater than one are relatively uncommon because of advances in public health and medicine. Many deadly, contagious ID of the past have been largely contained (Ramirez, 2016).

    To put things in perspective, the R0 of the influenza virus of the 1918 Spanish Flu was estimated to range from 1.4 to 2.8, while the swine flu of 2009 was likely 1.4 to 1.6 (Ramirez, 2016).

    In the midst of the coronavirus pandemic, one of the most commonly argued issues is that of its R0. Both the media and public opinion remain focused on this epidemiological metric and its relationship to spreading potential. In some cases, R0 has even been defined as the “fatal number”: the higher it goes, the greater the mortality. Early on in the COVID-19 pandemic, at the time it was declared by WHO, that organization assigned an R0 ranging from 1.4 to 2.5. This degree of infectivity is, however, controversial. As of February 2020, the literature contained references to R0 ranging from 1.5 to 6.7, with average values reported of 3.28. If, indeed, this R0 was accurate, the coronavirus would exceed the reproductive potential of SARS. The diversity in estimating R0 is likely driven by discordant assumptions and modeling approaches. It is critical to understand that R0 is not an intrinsic value of the pathogen, rather it is calculated based on at least the following three variables, all of which may vary between the studies designed to estimate R0 (Viceconte & Petrosillo, 2020):

    1. Duration of contagiousness.
    2. Likelihood of infection per contact.
    3. Economic, social, and environmental factors of the recipient population.

    These differences are compounded by the use of different modeling approaches used to estimate R0. Further to this, it is generally assumed that there is no variation of secondary infections generated by a single infected case. This is known to be false because of the understanding of superspreader events in which a single individual may infect a large number of subjects. This phenomenon has been observed in cases of SARS, MERS, and the novel coronavirus. As a result, available models are not able to fully appreciate the large degree of heterogeneity in the transmission of and susceptibility to an infectious pathogen. Furthermore, R0 is constantly modified over the course of an epidemic because of mitigation approaches that are designed to reduce R0, specifically the duration of contagiousness, the likelihood of infection, and the rate of contact between infected and susceptible individuals (Viceconte & Petrosillo, 2020).

    Despite its potential flaws, R0, will continue to be used to describe contagions. In addition to difficulties in estimating this parameter, it is critical to note that R0 is not related to an infection’s potential lethality. As an example, Ebola (R0 ranging from 1.5 to 2.5) is far more deadly than the more contagious influenza in its regular form (R0 ranging from 2 to 4). The most contagious pathogens, pertussis and the measles, with R0 on the magnitude of 12 to 18, are well controlled by efficacious immunization strategies (Rodrigue, n.d.).

    Reemergence of ID That Had Significantly Declined in the Past

    Causes of the reemergence of so-called “old” ID are numerous. In some instances, pathogens may become more virulent through evolution over time, but in the majority of cases, it is a result of human behavior. An example of this is provided through examination of the changing interface between humans and the global environment. Over the course of the past century, populations have grown, people have migrated to cities, international travel has increased, and poverty, war, and destructive ecological changes have all occurred as a result of economic development and increases in land use (BCM, 2020).

    As with the initial emergence of an ID, reemergence depends on at least the two following factors:

    1. The infectious agent must come into contact with a susceptible population.
    2. Ready transmission of the agent must exist, allowing rapid spread from persontoperson, causing disease (BCM, 2020).

    In addition, the disease must be self-sustaining to allow more and more people to become infected. It is acknowledged that a number of IDs are passed from animals to people. So, when humans move into new environments, it becomes more likely that they may come into contact with species of animals that are hosts to IDs. Increases in population density and mobility both facilitate the reemergence of disease that had been previously vanquished. Another critical factor in the reemergence of IDs is increased rates of AMR. As microorganisms evolve, they are sometimes able to develop a resistance to the drugs that were once effective against them. This resistance can allow once dormant diseases to flourish (BCM, 2020).

    Lastly, a key contributor to reemergence is a decline in the use of immunizations (BCM, 2020). There is a growing population of people who refuse to vaccinate themselves and/or their children. In many cases, this is driven by controversial studies linking measles vaccinations and autism (BCM, 2020).

    Measles (United States)

    WHO states that the definition of measles elimination is “the absence of endemic measles virus transmission in a defined geographic area (e.g., region or country) for at least 12 months in the presence of a surveillance system that has been verified to be performing well” (Masresha et al., 2018, p. 1). In 2000, measles, according to the WHO definition, was no longer a presence in the US. According to the CDC, this means that because of substantial levels of immunizations, the risk of Americans contracting measles is low. Nonetheless, there is an expectation that measles will remain present in the US because of importation of the virus from other countries. The risk incurred by this reality is that these few cases of measles can spread among people who are not vaccinated, leading to outbreaks. The CDC fears that if such an outbreak is able to be sustained for a year or more, the US risks losing its measles elimination status. As a result, the US remains vigilant and prepared to respond to any incidence of measles (CDC, 2020a).

    The achievement and maintenance of measles elimination required monumental effort, reliant on substantial investments in time and resources. To lose elimination status would lead to efforts to reestablish this status, consuming valuable resources that could be better deployed elsewhere. It is well acknowledged that the key to preventing this threat is to ensure adequate levels of vaccination in all communities. It is especially important that children adhere to measles, mumps, and rubella (MMR) vaccination schedules and that international travelers confirm their immunization status before departure (CDC, 2020a).

    Measles outbreaks are defined as chains of transmission involving three or more cases that are linked in time and place. Such assessments are determined by local and state health department led investigations. Internationally imported cases of measles can be surmised in cases where at least part of the exposure period (usually 7 to 21 days before the onset of rash) occurred outside of the US and the rash began appearing within 21 days of reentry to the US with no known exposure to measles in the US during the exposure period (Patel, 2019).

    During the first three-quarters of 2019, a total of 22 measles outbreaks in 17 states, encompassing a total of 1,163 individuals, were recorded in the US. An additional 86 cases were not associated with a defined outbreak. Not only was this the second highest number of outbreaks since the 2000 elimination of the measles, it was the largest number of cases in a single year since 1992. Of those infected, 89% were patients who had not been properly immunized or whose vaccination status was not known. Furthermore, a total of 119 patients (10%) developed serious enough illness to require hospitalization. Transmission continued for nearly 1 year in closely related New York State outbreaks. The majority of these outbreaks (934, 75%) were rooted in large, closely knit Orthodox Jewish communities. Fortunately, a vigorous response effectively halted the transmission of disease before the 1-year mark, preserving US elimination status. In efforts to maintain the current lull in cases, continued vigilance and collaboration between public health officials and communities with high rates of undervaccination continues (Patel, 2019).

    As has been observed in most US outbreaks since the 2000 elimination of measles, the majority of the 2019 outbreaks were of limited scale and duration because of high population immunity and the rapid application of outbreak measures by public health authorities. Of note, there were two more sustained outbreaks in New York that persisted for a longer period of time because of the following three critical risk factors (Patel, 2019):

    1. Areas of low vaccination coverage and, in general, a variable acceptance of vaccinations.
    2. High population density in the impacted communities coupled to relatively closed social behavior.
    3. Repeat cases of measles importation by unvaccinated individuals traveling internationally.

    Responses to the outbreaks were multipronged and included the administration of approximately 60,000 doses of MMR vaccine, specialized communication strategies, partnering with religious leaders, physicians, health centers, and advocacy groups (Patel, 2019).

    Evidence-Based Practice

    In an effort to better understand a measles outbreak involving 649 confirmed cases in a New York Orthodox Jewish community, Yang modeled the transmission dynamics of the outbreak in an effort to identify root causes. To this end, he used a model based on age to estimate important epidemiological factors, including initial susceptibilities, the reproductive number (R0), contributors to spread of measles, and the proportions of infection attributable to each age group. Lastly, an effort was made to assess the impact of vaccination campaigns on modulating the outbreak. Findings from this work indicated that the delayed vaccination of children aged 1 to 4 years enabled the spread and enhanced infectious transmission. Approximately one-half of infants were susceptible at age 1 year and suffered many infections. Data obtained suggested that the vaccinations that did occur were effective: in the total absence of vaccinations, the number of infections may have been as much as 10-fold greater than experienced. These estimates are supported by an observed effective R0 ranging from 1 to 1.5 (compared to 12 to 18 in a totally susceptible population). Yang concluded that vaccination campaigns are critical to temper measles outbreaks and that enhanced public health education is needed to reduce unneeded exposure of children to measles and other infectious agents (Yang, 2020).

    Case Study 2

    A 7-year-old boy, Roger, recently returned from Taiwan, was feeling a bit unwell. Nonetheless, he attended a matinee film. 9-year-old twin girls attended the same movie. It was ultimately determined, after a week’s time, that Roger had contracted the measles, likely when visiting Taiwan. Before his diagnosis, Roger also infected his older sister Mary, just before she left to visit her grandparents in Iowa. 2 weeks after the chance theater meeting, the first of the twin girls developed a febrile rash, often associated with the measles.

    Upon development of the first twin’s rash, her mother took the girl to see their usual pediatrician, Dr. Steve. Despite the presence of a rash, because of the rarity of measles, Steve did not test the child for measles. Steve was puzzled by the presentation and consulted his colleague, Dr. Tanya. The idea of measles crossed Dr. Tanya’s mind, but again, the uncommon occurrence of measles led her not to pursue the possibility. Steve concluded that the rash could be treated with 1% topical hydrocortisone cream and sent the twin home. Roger and both girls continued to attend school and participated in a variety of extracurricular activities. Within a week the second twin developed the same mysterious rash.

    An attentive school nurse noticed a pattern of fever, rash, and cough in a number of children and grew suspicious. As part of her investigation, she reviewed the school’s student immunization status records. Her detective work showed that a total of six students were not properly vaccinated for measles. Despite taking all of these students, and another who was immunocompromised out of school, a total of five of the six unvaccinated students, including the twin girls, Roger, and his sister Mary, ultimately contracted the measles. One of the infected students was a member of a traveling soccer team. After diagnosis, all of the team members and parents were advised of the case of measles among the team. 2 weeks after this, one of the adult trainers (born in the 1960s) developed symptoms consistent with the measles. Although he notified his doctors that he had been exposed to measles, like the twin, he was not tested. The disease was more serious for the adult, requiring a brief hospitalization. Since his immunization status was unclear, blood was drawn in an attempt to assess immunity. Results indicated that he was not properly protected.

    The trainer, a truck driver, had been driving about making deliveries while infectious. Additionally, he was married to a woman who was 39 weeks pregnant. Serologic testing showed that she had been properly vaccinated and was immune to measles. Unfortunately, the male trainer had attended several Lamaze classes with his wife while infectious. While no efforts were made to identify the contacts he had encountered while working, exhaustive tracing was undertaken to ensure that all of the people that he contacted at the Lamaze classes had been properly vaccinated. Meanwhile, the public health department had been notified and the man was ordered into quarantine. Unfortunately, he was still in isolation when his wife went into labor, and he missed the birth of his first son.

    Including Roger, the twins, Mary, the soccer trainer, and the other two students, at least seven people contracted measles in this outbreak.

    Self-Assessment Quiz Question 2

    Although CDC has stated that the chances of getting measles in the US are low, occurrences of measles can happen. Which of the following is the most likely scenario that might allow a measles outbreak, such as that described in this case study, to occur?

    1. Comprehensive vaccination programs and travel to developed countries.
    2. Incomplete vaccination efforts and travel to developing countries.
    3. Genetic mutations conferring susceptibility to measles infection.
    4. High vaccine acceptance rates.

    Self-Assessment Quiz Question 3

    If a measles outbreak in the US is sustained for a period of at least 1 year, what is one potential outcome?

    1. Enough people will be infected to create a new level of immunity, halting spread of the outbreak.
    2. The chances of contracting pertussis will increase.
    3. The US risks losing its measles elimination status.
    4. It can be expected that such outbreaks will be more common in rural than urban settings.

    Self-Assessment Quiz Question 4

    Although there are many factors that can lead to the reemergence of an ID thought to be eradicated, overall, which of the following situations was most likely to contribute to the measles outbreak described in the case study?

    1. Antimicrobial resistance.
    2. Decreases in population density.
    3. Reduced mobility.
    4. A growing population of people who refuse to vaccinate themselves and/or their children.

    Pertussis (Japan)

    Beginning in the early 1900s, the microorganism Bordetella pertussis, which caused the disease pertussis (whooping cough), was studied in rodents. As a result of this early work, a number of toxins and so-called protective antigens were discovered. Unfortunately, while providing some protection from the disease, significant adverse events were implicated with the use of these early vaccine products. Research continued, resulting in the development of safer products (Cherry, 2019).

    By 1974, Japan had assembled a successful vaccination effort to protect children from pertussis. In that year, it is estimated that almost 80% of children were vaccinated, and only 393 cases with no deaths were reported (CDC, 2018). As far back as the 1940s, though, reports have been published suggesting that some vaccines may lead to severe neurological disease. Critical to the pertussis vaccine was a 1974 article by Kulenkampff et al. (1974). This publication described observations of 36 children over the course of 11 years that were thought to suffer neurological complications after immunization for pertussis. They rationalized their findings by noting that the complications were all clustered around the 24-hour interval after inoculation. In summary, they suggested that the pertussis vaccine should be avoided in patients with a history of fits (sudden appearance of a symptom; Farlex Partner Medical Dictionary, n.d.), a family history of fits, or those with previous reactions to vaccinations, recent infection, or with presumed neurological deficit (Kulenkampff et al., 1974). Additional studies conducted in Sweden, Wales, and England found high incidences of encephalopathy thought to be linked to vaccines. In addition to rumors regarding the safety of the pertussis vaccine, it was believed in Japan that the pertussis vaccine was no longer needed. By 1976, only 10% of newborns were vaccinated for pertussis (CDC, 2018).

    In 1979, a pertussis epidemic took hold in Japan, resulting in more than 13,000 cases. Mortality attributed to this outbreak was estimated to be 41 deaths. In the meantime, efforts were in play to develop a novel, safer vaccine. In 1981, the Japanese government reinitiated an immunization program using the new product. As a result of this campaign, the number of pertussis cases began dropping to pre-1974 levels (CDC, 2018).

    Vaccine Hesitancy – Anti-Vaxxers

    WHO defines vaccine hesitancy as a “delay in acceptance or refusal of vaccines despite availability of vaccination services.” Vaccine hesitancy is a global phenomenon, reported in more than 90% of countries. As an example, immunization for measles has dropped to less than 95% in multiple regions. This is critical, because this is the immunization threshold set by WHO to maintain herd immunity (The Lancet, 2019).

    Nursing Consideration

    Unfortunately, the fear of autism’s linkage to vaccination is still prevalent in our communities. Effective nurses and APN should familiarize themselves with this controversy, allowing them to help allay the fears of their patient’s caregiver or parents.

    In an effort to support healthcare professionals’ efforts to increase vaccine uptake, WHO has developed a series of training modules designed to aid in facilitating difficult conversations with those that are vaccine hesitant. It may be useful to consider the statement by Dr. Michael Gannon, president of the Australian Medical Association, who noted that pediatric patients are 10,000 time more likely to suffer neurological injury as a result of measles than by vaccination (The Lancet, 2019).

    The threat of vaccine hesitancy is real, and is threatening to reverse many of the great accomplishments to date in the battle against ID. In an effort to reverse the current anti-vaxing trend, all health professionals, public health officials, governments, and the industry must collaborate to dispel the myths and misinformation regarding vaccinations (The Lancet, 2019).

    Case Study 3

    Jennifer appears to be a happy, well-developed girl, aged 2 years. Her family recently relocated and is taking her for her initial visit to a Pediatric Nurse Practitioner (PNP), Mike, for her 2-year-old well-child examination. After visiting a bit with Jennifer’s mother, Mike learns that Jennifer has had a few ear infections and her mother believes that she may be developing another. Jennifer was born at 36 weeks gestation, the product of an in vitro procedure. She was breastfed for 1 year and appears to have met all of her development milestones. Jennifer’s mom feeds her a balanced diet of organic fruits and vegetables and provides plenty of oat milk in a sippy cup. The entire family is vegetarian. She has no siblings and her parents, both aged 43 years, exercise regularly and are healthy. Everything went pretty much according to Mike’s plans, until he reached the topic of immunizations. Jennifer’s mom stated that she had received no immunizations. When Mike politely asked the reason for the decision to forego the usual brace of vaccinations, her mother shared her maternal concerns. She explained that her sister’s baby was diagnosed with autism at age 2. She went on to say that he was a perfectly healthy baby until he received his 1-year vaccines. She got emotional at that point and said that it has been very difficult for the family, and she is certainly not going to make the mistake that her sister made. Furthermore, she believed that it would be better for Jennifer to develop natural antibodies the way they did in the old days, like with measles and chicken pox.

    Self-Assessment Quiz Question 5

    What is the most likely reason that Jennifer’s mom is unwilling to vaccinate her daughter?

    1. She is not very interested in the well-being of Jennifer.
    2. She is convinced that ID are a product of conspiracy theories.
    3. She believes that immunizations can do more harm than good.
    4. She believes that vaccine-preventable diseases no longer exist.

    Human Response to EID

    Certainly, many EID are serious, some with potentially fatal consequences. Despite these obvious outcomes, the total impact on humankind is likely more complex.

    Psychosocial impact of EID

    The evolving COVID-19 pandemic, seemingly changing on a daily basis, lends itself to the dissemination of misinformation and confusion, resulting in a dazed population, unclear on what to fear, who to trust, and how to best live their lives. These feelings are not new; a long history of major ID outbreaks has provided examples of societal response. In 1990, Philip Strong, against the backdrop of HIV/AIDS, authored Epidemic Psychology: A Model. In this critical book, Strong explained how epidemics are able to create threats to the human race by pitting all of society against one another (Strong, 1990). Large outbreaks of novel ID often result in enormous threats to public health and global economies, planting fear, stigma, and a variety of calls to counteract the disease (Loveday, 2020).

    Pandemic-associated distress encompasses closely related ideas. For example, fear of the emerging infection may lead to suspicions that those around us may infect us. Early on in an epidemic, if there is an uncertainty of how exactly the disease is transmitted, additional anxieties can develop as individuals consider the possibilities: is it through human contact, the environment, food, breathing, coughing, or sneezing? These ambiguities can breed fear, which may lead to irrational behavior. Typically, the next step is the stigmatization of those infected with the disease, resulting in stereotyping of the main carrier groups. While these phenomena plant the seeds of fear, in many cases, incessant media commentary typically provides the conditions for fear to grow. Media headlines often discuss superspreader events and describe the so-called patient zero, both of which help to characterize scapegoats. While much of this is sensational and raises the visibility of those reporting it, the media often lacks useful information that individuals might use to protect themselves from infection (Loveday, 2020).

    The public is often faced with unrelenting amounts of information, with much of it intended to place blame on how an EID could have been allowed to occur. The opinions offered often conflict with one another. In some cases, explanations offered result in unsubstantiated moral judgements, which again, are not usually productive (Loveday, 2020).

    To counter a pandemic, there must be a call to action, ranging from local to international responses. To be effective, many of the countermeasures taken will infringe on rights and freedoms, while disrupting normal trade, travel, and personal activities. While such reactions may result in tamping down the EID in the short term, long-term social unrest and distrust often results. In the initial phases of the coronavirus outbreak in China, seemingly draconian measures appeared to be effective at curbing the spread of infection. Nonetheless, the sometimes forceful removal and quarantine of citizens suspected of harboring the virus created harsh optics that could be difficult to see and accept in return for a hope of eradicating the disease. WHO and similar public health organizations have, in some cases, been able to develop balanced public health messages designed to counter the panic-causing misinformation often associated with EID (Loveday, 2020).

    Despite these efforts, it appears that the model suggested 30 years ago by Strong still describes the human response to novel EID: initial overreaction, followed by the emergence of news and images confirming society’s worst fears. It is incumbent on health professionals to best understand all available information and help their patients to best normalize the threat so that they can make proper decisions. A sense of proportion is required that allows individuals to take infection threats seriously while toning down fear, stigma, and scapegoating.

    Effect on Routine Healthcare

    In the case of the COVID-19 pandemic, while hospitals were often flooded with patients seeking care, general practitioners often reported a lack of patients, with a number of elective procedures postponed indefinitely. In addition to the fear factor, millions of people lost health insurance and the ability to pay for critical preventive care. Many experts predict that the COVID-19 pandemic will be followed by a second, less obvious pandemic, fueled by poor diet, diminished exercise, avoidance of maintenance medications, and mental health flare ups. Potentially more serious are reported anecdotes of decreased incidence of heart attack and stroke, with some suggesting that this is a sign of people avoiding hospitals even in the most extreme situations. As a corollary observation, reduction in healthcare access is a well-acknowledged cause of morbidity and mortality subsequent to natural disasters. The reduction in healthcare usage has been associated with layoffs and, potentially, facility closures. At such time that society begins to return to normal, these deficiencies may result in healthcare shortages (Barnett, 2020).

    The incidence of measles infections has risen on a global basis of 556% between 2016 and 2019. The fundamental cause of this increase is a failure to immunize. While a hesitancy to vaccinate is likely driving some of the acceleration, access barriers are also contributing to inadequate levels of immunization. Some experts share a concern that the COVID-19 pandemic is likely to make matters worse. Evidence showed a significant decline in routine childhood vaccinations in the first 8 months of the pandemic. It appears that under-resourced public health departments, overwhelmed with a response to COVID-19, have largely not identified locations where immunization coverage is lacking. This lack of oversight allows the development of pockets of potentially susceptible individuals. Meanwhile, the practice of social distancing reduces travel and social interaction, all while wearing facial coverings and taking other precautions that give the measles virus fewer opportunities to spread. This results in the creation of “artificial scenarios,” suggesting safer than actual conditions. As a result, when the COVID-19 pandemic eases and restrictions are removed, it seems reasonable to expect an acceleration in the incidence of measles (Belluz, 2020).

    Nursing Consideration

    Nurses should be especially diligent in their efforts to ensure that their patients remain up to date with their vaccinations. In the case where patients have fallen behind on their scheduled immunizations, nurses can suggest adherence to CDC endorsed catch-up vaccine schedules. The CDC pediatric catch-up vaccination schedule can be found online at https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html

    Mental Health Issues

    It has been reported that an escalation of mental health and substance abuse problems has been occurring during the COVID-19 pandemic. What may not have been expected is the scale of these issues. It appears possible, if not likely, that mental health and substance abuse may reach their own epidemic proportions. The combination of high unemployment, housing instability, and social isolation work in unison to result in a reported one-third of Americans experiencing new or worsened mental health symptoms. Alcohol sales since the beginning of the pandemic have risen by 250%. Likely most alarming is the number of individuals needing treatment that are delaying, avoiding, or are unable to access proper care. While telehealth may help some, it has been suggested that those most needing assistance have the fewest resources and are thus unable to take advantage of these technologies. Staffing shortages caused by pandemic health conditions may also hinder mental health professional efforts. The reality of the situation is that if mental health needs are not adequately addressed in times of a pandemic, the result will be an increased number of drug overdoses, suicides, homelessness, and untreated mental illness. Sadly, it is anticipated that these consequences are most likely to impact the same populations of people most at risk of contracting an EID: people of color, older people, and those of lower socioeconomic classes (Kozak, 2020).

    Nursing Consideration

    Nurses can certainly make a difference by checking in with their patients to proactively screen for medical concerns. Nurses can communicate to their patients that they are never too busy to help and, despite changes to practice during a pandemic, they remain present to serve as a main conduit to healthcare.

    Pandemic Fatigue

    While individuals may be more willing to take the precautions required early in a pandemic to prevent the spread of infection, it is evident that, at some point, many will become tired of following these guidelines. This phenomenon can be called pandemic fatigue. Pandemic fatigue occurs at the point that people get frustrated with their situation and want to return to the life they enjoyed before the pandemic. As a result, some may give up on protective measures. Unfortunately, if the pathogen is still present in the community, these lax practices provide an opening for it to infect more people. It can be hypothesized then, that pandemic fatigue can be a contributor to the spread of an EID (Akins, 2020).

    Human Attribution for EID

    Many individuals may decide that the optimum approach is to seek and follow the best scientifically-supported approaches to avoiding, managing, and treating an EID. Pragmatically, this logic-based method may be a good way for some to cope with the out-of-control feelings associated with pandemic disease. Others may employ different tactics, such as denial of the problem or focusing more on assigning blame to the perceived cause of the pandemic.


    According to the Stanford Encyclopedia of Philosophy, blame is a negative response pointed at someone, or their behavior. As an example, in the case where one party wrongs another, the victim reacts with a verbal rebuke. Of course, blame could also be focused on someone for their attitudes or characteristics. Since blame can be directed at a plethora of offenses, the act of blaming can also vary greatly, including a broad range of inward and outward responses to beliefs, desires, emotions, and expectations. Blame is a very common part of the human moral experience. While praise may be the counterweight to blame, the latter response remains a more significant component of moral philosophy (Tognazzini & Coates, 2018).

    Uniacke (2020) takes a more contemporary approach to blame, acknowledging that accidents happen and, on some occasions, life does not proceed according to plan, noting that in some cases, the default reaction is to find someone else to blame for their problems. In truth, most of the things that happen in life result from manifold contributing factors and can be caused by a mixture of actions – some of our own making and some contributed by others. As a real-world example, consider a cyclist hitting a rough patch in the road and falling. If the incident was deconstructed, it may become evident that while the poorly maintained road contributed to the accident, perhaps if the cyclist was not going so fast and was looking where they were going, they could have avoided the hazard. Many mistakes will be made, some with minimal penalties, with others resulting in catastrophic consequences. It is critical that when things do go wrong, individuals acknowledge their errors and learn to do better going forward. In the absence of this process, humanity is doomed to never being able to improve itself (Uniacke, 2020).

    Blame, As It Relates to Pandemics

    So, blame is a destructive emotion, yet often a go-to part of the human toolkit. It seems likely that when it comes to pandemics, such as the coronavirus, it is critical for many to be able to assign blame. Specifically, they are likely to attribute blame in line with the classic definition provided by Tognazzini & Coates (2018), which states blame is a negative response pointed at someone or at their behavior. Unfortunately, there are ample examples to prove that hypothesis.

    A recent article in Breitbart News stated that the coronavirus originated in Wuhan, China, and that the Chinese government was not forthcoming in describing the seriousness of the outbreak. Furthermore, they claim that WHO was well aware of the virus but withheld the information, while simultaneously praising China for their transparency on the matter. According to this account, then Vice President Pence stated that “China is to blame for the coronavirus,” and then went on to state that China prohibited US personnel from entering China to investigate until mid-February, even though the initial cases of COVID-19 occurred in November 2019 (Bleau, 2020).

    It appears evident that some are listening, with a few responders becoming self-styled vigilantes. Early in the pandemic, a Singaporean law student was attacked by a group of strangers. When walking in London one night, the victim passed a group of people. As he heard the word “coronavirus,” he turned and one of the men in the group shouted at him, and then punched him in the face, leaving him with a black eye. One of the men shouted, “I don't want your coronavirus in my country," before striking him a second time in the face, resulting in facial fractures. The group then fled before the police arrived. The Metropolitan Police investigated the beating as a racially aggravated assault. In response to his ordeal, the victim posted to Facebook: "Racism is not stupidity – racism is hate. Racists constantly find excuses to expound their hatred – and in this current backdrop of the coronavirus, they've found yet another excuse" (Iau, 2020).

    Evidence-Based Practice

    Cho et al. (2020) conducted a nationwide (US) sample of 842 adults in an effort to characterize factors associated with a stigmatization of Asians during the COVID-19 pandemic as well as to discover factors that can prevent or mitigate stigmatization. Data obtained from this effort were able to assign racial prejudice, biased media, and maladaptive coping techniques as causes of stigmatization. Of these features, racial prejudices, stereotypes, and emotions toward Asian Americans were the strongest predictor of stigmatization. People who felt relatively powerless to deal with COVID-19, while estimating its high perceived harm, were more likely to stigmatize Asian Americans. Investigators concluded that in order to reduce stigmatization, racial stereotypes, emotions, maladaptive coping, and biased media need to be countered through the provision of education and enhanced public resources to better understand the causes of COVID-19 (Cho et al., 2020).

    Oddly enough, all of the blame is not just directed at the Asians, as explained in a publication by Jean (2020). She states that a number of reports are appearing that blame Jews for the recent COVID-19 pandemic. According to these accounts, Jews intentionally invented the coronavirus to spread it globally, and then used it as a way to profit or achieve global control, adding that historically, economic downturns have always led to increases in antisemitic acts. The imagery and language employed in this tactic are similar to the medieval “blood libels,” where Jewish people were blamed for spreading disease through the poisoning of wells in order to control economies. The current conspiracy theories were most frequently reported in the US, France, and Germany (Jean, 2020).

    Many individuals blame the government for the ravages of COVID-19. Harvey suggests that partial re-openings of the US economy may be a direct cause of the COVID-19 resurgence, with most of the blame being assigned to state and local governments for their decisions to reopen. While acknowledging that much of the rhetoric presented by governors and mayors has not been helpful, he asks, what choice did they have in the matter? Since the federal government failed to address their local problems, reopening was the only approach that could possibly repair budgets that were decimated by shutdowns. He argued that the federal government should have aggressively attacked the economic problems early in the pandemic. Perhaps if individuals were not so concerned for the survival of their businesses, they might not have been so eager to reopen (Harvey, 2020).

    There seems to be plenty of blame available for consideration relating to the root causes of the current COVID-19 pandemic. One not so obvious assessment was offered by Kessel, who bluntly stated in a September 2020 article that “the pandemic is your fault.” Most people who are doing what they are told, wearing a mask, social distancing, and washing their hands frequently may scoff at this thesis. Our ability to easily assign blame may help us to shrug off this notion with contempt. A large majority of Americans place blame for the global spread of the coronavirus squarely on the Chinese government for not rapidly containing the contagion. Others blame politicians for prioritizing their political future over the health of those that they govern. Alternatively, it is easy enough to blame people holding large unmasked parties or bar goers. There is ample blame to go around. Pinning the blame for the virus on one’s self, though, can be difficult. Nonetheless, some experts say that everyone plays a role in creating conditions favorable for explosive EID. The causative factors are not always evident, though. These ID experts posit that food choices, the clothes that are worn, the decision to own electronic devices, bearing children, and the amount of travel, for example, are all choices that apply pressure to the natural world. According to this view, it is nearly impossible to make choices that do not stress the natural world. In short, the more that humans interrupt native ecosystems, the better the odds that mankind will contract the diverse and potentially deadly viruses that wild animals carry (Kessel, 2020).

    It is understood that the pathogens causing EID have been present for millennia. Humans have colonized every corner of the earth, bringing populations into contact with the last remaining wildlife-borne viruses that have not yet infected people. According to this thinking, no person caused COVID-19, rather, it was a group effort, involving everyone in the developing world. Human appetite for consumption has changed the planet to such an extent that people now subjugate every ecosystem on earth. Nonetheless, humans typically fault one country or another for their problems, blaming people who choose to eat one species of animals over another. Others cite acts of God, blaming nature for their dilemma. In Kessel’s view, people need to collectively accept the blame for COVID-19 and many other global problems, understand what is happening, and then take decisive action to change it (Kessel, 2020).

    Case Study 4 – Phase 1

    Henry, an APN for a large family practice group in a Midwest college town, has noted an uptick in the number of COVID-19 cases in his community. He has studied current CDC practice guidelines and feels that he is doing a good job of protecting his patients and himself from infection. Unfortunately, none of his careful planning prepared him to manage a verbal outburst from his patient Julia. Julia had been experiencing symptoms of fever, cough, general fatigue, and an inability to smell or taste. Based on the presence of the novel coronavirus in the community and her symptoms, Henry suggested that she be tested for COVID-19. At first Julia resisted, stating, “I take good care of myself; only dirty people get the corona.” Nonetheless, Henry persisted and, eventually, she agreed to be tested. Henry was not surprised when the test came back positive. This afternoon, he had to call her on the telephone to discuss the results and provide directions for her care.

    Henry began the call by asking how Julia was feeling that day. She noted that she remained tired and was coughing a bit more and was still unable to taste or smell. Henry then told her that he had received her test results, and that, unfortunately, she had tested positive for COVID-19. Before he could even begin to describe what she needed to do for self-care and to protect those around her, Julia interrupted and started into a rant, making random comments about the China virus and how it was not her fault that the Chinese were unable to control the spread of the virus. Henry continued listening, thinking that she would wear herself out and he could continue. Eventually, she did slow down a bit and Henry was able to explain the need to isolate herself, treat her fever with ibuprofen, and call if her symptoms should worsen. Nonetheless, Henry was not happy with the interaction and felt that he was unable to provide proper care.

    Self-Assessment Quiz Question 6

    It is well acknowledged that humans often need to assign fault for predicaments. Which of the following statements about blame is true?

    1. Blame is uncommon, its philosophical counter, “praise,” is used much more often in American society.
    2. In many cases, blame cannot be affixed to a single element; usually actions occur as a result of a combination of events.
    3. Stereotyping usually plays no role in developing stigmatism in the COVID-19 pandemic.
    4. Causative factors for the COVID-19 pandemic are evident and fully established.

    Self-Assessment Quiz Question 7

    Think about the way that Henry managed his conversation with Julia. Could he have done anything differently?

    1. Henry approached the situation poorly. He should have immediately interrupted Julia and provided a factual representation of how the virus spread to and within the US.
    2. Henry approached the situation poorly. He should have chastised Julia for not taking proper precautions to protect herself from the virus.
    3. Henry approached the situation adequately but should have reassured her that the government had done everything possible to protect her and her infection was an unfortunate case of bad luck.
    4. Henry did the best he could when dealing with a difficult patient. He listened and did not interrupt her, waiting until he was able to communicate what he had to say.

    Politicization of Pandemics

    In addition to the risk of stigma arising from the occurrence of pandemics, the occurrence of such global disasters also leaves the door open to ambitious politicians who can use it to their partisan advantage. Again, the case in point is COVID-19. The Director General of WHO, Dr. Tedros Adhanom Ghebreyesus, recently stated that, indeed, the coronavirus is being politicized to the extent that there is no overall global leadership, creating a greater threat to humanity than the virus itself. In his words, global solidarity to counter a pandemic is vacant, and COVID-19 has made it worse. Although Dr. Ghebreyesus did not name who he thought was politicizing the pandemic, the US Government has criticized WHO and threatened to stop funding the global health organization. These  global fractures demonstrates that, although the whole world is suffering from COVID-19, there is great disparity in the impact of and response to the pandemic among regions and countries (Voice of America [VOA], 2020).

    As politicians continue their discussions over public bailouts, the prioritization of employer liabilities, and the correct way to conduct death counts, COVID-19 marches on with more infections, more death, increased unemployment claims, and general dread. As politicians remain engaged in tribal battle, action to obtain meaningful change often bears the brunt of it. The individual skirmishes have resulted in a piecemeal approach to managing COVID-19 across the US, to include reviving its economy. The easing of lockdowns in some regions has not resulted in the promised large-scale reductions in unemployment. Instead, such changes are often associated with increased incidence of viral infection (Marcellus, 2020). According to a Brookings Institute report, a coherent reopening strategy is much more important than individual state reopening timelines. This report goes on to state that, in order to keep people safe, it is necessary that Americans come to trust their government leaders, and that they receive a consistent message. These discrepancies and associated behaviors can be measured by examining surveys. A recent survey instrument found that 52% of people identifying as Democrats compared to 37% of Republicans practice social distancing and avoid even small gatherings. Further to this, differences can be observed by reviewing state policies governing lockdowns, which also reflect a political divide (Graham & Pinto, 2020).

    Anthony Fauci, MD, Director of the U.S. National Institute of Allergy and Infectious Diseases, described the politicization of the coronavirus pandemic as unfortunate. As background, he stated that over the past 40 years or so, he has experienced a variety of infectious outbreaks, but never one with such divisiveness as that associated with COVID-19. Rather than politicize the situation, he claimed that it is critical that the government functions only in the context of good public health. Instead, in the US, the government’s response to the pandemic has been widely criticized, downplaying the impact on the country and presenting dubious claims (Lavers, 2020).

    While the US is not the only country guilty of politicizing COVID-19, some countries are taking steps to avoid it. In March 2020, it was reported that Otumbo Osei Tutu (the Asantehene [ruler] of Ghana) requested a 1-month moratorium on political activities so that Ghana could focus all of its attention on countering the coronavirus. It was his expectation that the media cool its political discourse and dedicate its coverage to methods designed to contain the viral spread. To this end, he suspended all major traditional activities at the Manhyia palace. The Information Minister was impressed with Tutu’s efforts and encouraged other traditional rulers and institutions to follow the example set at the palace. Tutu’s Deputy Chief of Staff of International Relations then advised all Ghanaians to adhere to directives discouraging social gatherings. The Ghanaian Representative to the United Nations, Nana Apenteng, stated that it is critical that the government projects a unified front against the coronavirus to avoid the collapse of Ghana’s healthcare system (GhanaWeb, 2020).

    Real Solutions to Managing EID

    After better understanding the realities associated with an actual pandemic, the urgency to prevent, mitigate, and respond to emerging ID seems evident. While human nature may gravitate toward the assignment of blame for emerging ID and politicians are often quick to seize the occurrence of pandemics as a tool, it is generally more useful to focus on what can be done to avoid it--failing that, to blunt its impact.

    In 2017, the CDC issued a document, National Pandemic Influenza Plans. Predating the COVID-19 pandemic by at least 2 years, it describes, in general terms, a coordinated national approach to managing a pandemic. In summary, it states that the US government has long been aware of the hazards of an influenza pandemic (CDC, 2017c). Ignoring high-level government platitudes, there are a few things that can be done to help better understand EID, preventing, and managing pandemics.

    How to Best Control/Manage EID

    Better Hygiene

    For any infection to become problematic, the pathogen needs to enter the body, multiply in numbers, and then interfere with typical body function. Developing a good understanding of how infections are transmitted can go a long way toward avoiding sickness. The way that organisms move from host to host is not fully worked out and new knowledge is continually emerging. In broad strokes, what is known is that the majority of pathogenic microorganisms enter the body through orifices, such as the mouth, nose, eyes, ears, anus, or genital passage. In some cases, they are able to transit the skin through animal or insect bites. No matter the access point, infections can be stopped by preventing the entry of pathogens to the body. Although these guidance statements were written with generalized infections in mind, these approaches are also applicable to mitigating the spread of emerging diseases that have established a toehold in a community. One of the best and primary defense strategies is based on solid personal hygiene. In many cases, the spreading of infection can be stopped by adhering to a few critical habits and guidelines described below (Harvard Health Publishing, 2016):

    • Hands should be thoroughly washed with soap and water for at least 20 seconds, rinsed, and then dried after using the bathroom, before preparing or eating food, and after completion of dirty tasks. Handwashing should also follow nose blowing, coughing, sneezing, and caring for a pet or sick person. So far as technique, it is important that hands are thoroughly wetted and lathered with soap, rubbed into the palms, back of hands, and wrists. The fingertips, between the fingers, and under fingernails must also not be neglected. Lastly, it is important to rinse under running water and dry hands and wrists completely (Harvard Health Publishing, 2016). In the absence of soap and water, hand sanitizer (containing at least 60% alcohol) is an acceptable substitute.

    Evidence-Based Practice

    It is well accepted and supported by data that proper handwashing is critical to curbing the spread of ID in a clinical setting. Zivich and colleagues (2018) noted that the impact of handwashing on reducing the incidence of ID in nonclinical workplaces was not well established. In order to resolve this lack of information, they led a systematic review of the scientific literature to characterize the impact of handwashing on ID prevention in office-based workspaces. To this end, they evaluated a total of 11 studies published between 1960 and 2016. These publications were able to demonstrate that hand hygiene, at various levels of rigor, was able to reduce self-reported symptoms of illness. More specifically, these analyses suggested that proper hand hygiene is more effective against gastrointestinal illness than respiratory disorders. Nonetheless, they note that complete consensus on this observation was not present. Overall, investigators concluded that even minimal hand hygiene efforts were effective at reducing the incidence of employee illness through reduced infections (Zivich et al., 2018).

    Nursing Consideration

    It is well established that we live our lives surrounded by germs. While some are harmless and even helpful, our world is also sprinkled with dangerous species. Fortunately, rudimentary sanitary practices are able to combat many of these organisms. Nurses must ensure that their patients are aware of these facts and are well educated about the necessity of proper handwashing and sanitation. These practices are essential companions to all forms of healthcare.

    • In order to stop the spread of airborne microorganisms, it is important to properly cover the mouth when coughing or sneezing. Ideally, the mouth and nose should be covered with a tissue, which is then disposed of. If a tissue is not available, the next best approach is to cough or sneeze into the elbow rather than into the hand.
    • All skin injuries (cuts) should be promptly washed and bandaged. In the case of serious lacerations, prompt medical assessment and treatment are often warranted.
    • Healing wounds, blemishes, and pimples should be left alone: picking at them may open the skin, providing a microbial access point.
    • Sharing of glasses, dishes, or other eating utensils should be avoided.
    • Napkins, tissues, or handkerchiefs used by other people should be avoided.

    (Harvard Health Publishing, 2016)

    In most cases, foodborne infections are not especially serious. Nonetheless, on occasion, ID breakouts have been linked to issues with contaminated food – some resulting in serious medical conditions. In the majority of cases, these types of infections can be avoided by proper preparation and storage of foods (Harvard Health Publishing, 2016). A few guiding principles include the following (Harvard Health Publishing, 2016):

    • Carefully rinse all foods under running water before cooking or serving.
    • Thoroughly wash hands with soap and water both before and after handling raw meats or fish.
    • Retain separation between raw and cooked foods, avoiding the sharing of utensils used for raw and cooked meats without properly washing between uses.
    • Cook and reheat hot foods to an appropriate temperature using an internal thermometer.
    • Thaw frozen foods only in the refrigerator or microwave oven.

    Nursing Consideration

    The incidence of foodborne bacteria, both susceptible and resistant to treatment with antibiotics, is widespread. Fortunately, these pathogens can generally be killed using proper cooking methods. Nurses should educate their patients on these potential risks and encourage them to handle and cook their foods properly to avoid illness from foodborne pathogens.

    Public Health Measures

    In 1920, Charles-Edward Amory Winslow, an American bacteriologist and public health expert, wrote that “[public health is] the science and art of preventing disease, prolonging life, and promoting health through organized efforts and informed choices of society, organizations, public and private, communities, and individuals” (Winslow, 1920). Specifically, public health is directed to the study of population analyses designed to improve well-being and quality of life by preventing and treating disease and other health conditions. Public health can be broken into fields of study that include epidemiology, psychology, environmental health, behavioral health, as well as occupational health and safety. Since the study of public health requires the analyses of large datasets (based on populations of interest), the proper use of statistics is critical. Multiple datapoints (samples from a larger population) are collected and, when analyzed, can be used to make inferences about the greater population. In general, as the science of data and statistical analyses has matured, advances in the field of public health have been appreciated. Scientists interested in promoting public health learned as early as the 1820s that they could best help large populations of people by using data and statistics to structure information in a way that readers could easily absorb and understand (Oregon Health & Science University [OHSU], n.d.).

    Further to the proper sharing of information, significant medical discoveries in the 1850s contributed to public health. In 1854, statistics, maps, and mortality data were employed to determine the source of a cholera outbreak in London. Using these findings, the public water supply was repaired to control the outbreak. On the basis of this experience was born the modern field of epidemiology. In addition, shortly after this time, the science of bacteriology emerged. By the 1880s, a number of highly pathogenic bacteria were identified. These discoveries formed the foundations required to determine how these diseases spread and facilitated the development of vaccines to prevent epidemics. By the 1890s, bacteriology laboratories began to appear in many cities. These facilities were purpose-built to allow the identification of a variety of diseases such as diphtheria, tuberculosis, typhoid, and cholera. They were able to examine a variety of media, to include foodstuffs, to best maintain the health of their communities. Whenever a potential communicable disease was identified, samples were collected and sent to the city’s bacteriology laboratory for evaluation. If a culture was positive, the source of infection could be isolated by quarantine in order to protect the community. In addition, bacteriologists detailed causes of death in the community, to include the presence of communicable disease (OHSU, n.d.).

    While historically public health was focused on the practice of collecting outbreak data to control the spread of ID, current infection control approaches rely on surveillance for early detection of infections in an effort to prevent disease. WHO supports an infection prevention campaign called “Clean Care is Safer Care.” The objective of this program is to ensure that infection control is fully appreciated as a critical contributor to patient safety and well-being (Decision Support in Medicine, 2017).

    A number of factors and tools are required to support public health; examples include the following (Decision Support in Medicine, 2017):

    • Data analysis.
    • Public reporting of communicable disease data.
    • Investigation of ID outbreaks.
    • Education to both healthcare professionals and the public.
    • Development of effective guidelines.

    Increased Vaccination Rates

    Vaccine products are able to protect the body from ID by eliciting immune responses resulting in the formation of antibodies to counter the pathogen. In many cases, vaccines are able to offer a cost-effective, safe, and efficacious tool intended to prevent illness, accompanying disability, and potential death resulting from ID. Over many years, vaccines have saved millions of lives and significantly decreased the incidence of a variety of sometimes deadly diseases. Nonetheless, there remains a need for novel vaccines to counter existing and emerging pathogens. As a result, abundant research is being conducted by government and commercial organizations (National Institute of Allergies and Infectious Diseases [NIAID], 2020).

    In an effort to partially solve the problems of EID, global efforts are underway to develop efficacious vaccine products. In the US, the Advisory Committee on Immunization Practices (ACIP) was formed to generate recommendations for the optimum use of vaccines to the director of CDC and the Secretary of HHS. ACIP is classified as a federal advisory committee that makes their decision making and documents available to the public. They use an evidence-to-recommendation approach, based on burden of disease; safety and efficacy of the vaccine product; acceptability to patients, clinicians, and immunization programs; as well as issues related to implementation of immunization programs (Lee et al., 2020).

    Despite significant efforts by ACIP to provide recommendations designed to guide the use of vaccines, such policy making for rapidly emerging ID present unique challenges. For example, the burden of disease may be unevenly distributed, inflicting greater impact on older individuals and those of color. Furthermore, the risk of exposure and morbidity/mortality can vary greatly across populations. Differences in vaccine characteristics among candidates may dictate that certain products are preferable in some populations compared to other products. Lastly, the timing of availability and supply chain limitations relative to demand often result in even greater complexities (Lee et al., 2020).

    Typically, ACIP begins developing policy after many years of research. As a result, the target disease is often well characterized, to include transmission patterns, risk factors, and its immunologic properties. In the case of novel, rapidly emerging ID much of this critical information is unknown. Nonetheless, a need to make consistent, evidence-based recommendations is required. There is precedent for such policy making, though. ACIP played a critical role in developing guidance for use of a vaccine to counter the 2009 Swine Flu pandemic. In anticipation of the need for such guidance, ACIP convened an emergency meeting in July of that year to finalize their recommendations. These adoptions were widely implemented, facilitating the equitable distribution of a vaccine product and ensuring consistent communication (Lee et al., 2020).

    In April 2020, ACIP formed a COVID-19 working group to begin the development of evidence-based approaches to a COVID-19 vaccination policy. The overarching goals were to evaluate all available evidence and provide recommendations for the safe and effective use of COVID-19 vaccine products, the chances of reducing disease transmission, morbidity, and mortality of COVID-19 disease. Furthermore, they examined the potential of vaccines to minimize societal disruption and to maintain proper healthcare capacity. Lastly, ACIP endeavored to adopt approaches designed to ensure equity in the allocations and distribution of any vaccine products. In July 2020, ACIP reconvened to discuss emerging information describing known epidemiology and pathology of disease as well as immunologic responses to disease, vaccine candidates, and considerations for their recommendations. Despite the many unknowns, rapidly emerging bases of evidence, and the need to work under conditions of high uncertainty, ACIP developed multiple principles designed to guide decision making. Safety was deemed to be of paramount importance, understanding that safety profiles may vary greatly across populations. It was determined that, in order to allow for the evolution of recommendations, real time monitoring of safety and efficacy would be required. ACIP also realized that it would be critical that their guidance would support an efficient and equitable distribution of any vaccine products (Lee et al., 2020).

    Also, in June 2020, the U.S. Food & Drug Administration published their guidance on the development and ultimate regulatory licensure of COVID-19 vaccines. Recognizing the challenges of developing such a product in a limited time frame, FDA guidance recommended that a product should provide a minimum of 50% efficacy compared to placebo in the prevention of COVID-19 infection and disease (Lee et al., 2020).

    Nursing Consideration

    Nurses and nurse practitioners, through comprehensive educational efforts, are in an ideal position to help break down some of the psychological barriers that may prevent proper vaccination practices. Nurses should make an effort to insert practical immunization information into their patient education repertoire.

    Strategic Testing

    Definitive testing of people suspected of being infected with an ID provides critical data aiding in understanding the contours of a pandemic. It is important because it is impossible to know with certainty the true number of afflicted individuals, only the infection status of those that have been tested using an accurate instrument. As a result, in most pandemics, the true number of infected patients is typically higher than official counts. Test data can be misleading because jurisdictions may use differing approaches for reporting information. For example, some countries report the total number of tests performed, while others report the number of people tested (some people may be tested more than once). Test coverage by region is also inconsistent. In Iceland, a relatively extensive tester, more than 10% of the population has been tested for COVID-19. On the other side of the spectrum, Indonesia has tested far fewer of its residents: 0.01%. Typically, increased rates of testing provide more robust and reliable data. Statistical theory states that the larger the sample, the closer the resultant estimate will be to reality (that is to say the only way to know the true infection rate would be to test everyone). The other reason that increased testing is generally more accurate is that a high capacity for testing indicates that there is no need for rationing (testing only the highest risk individuals; Hassel, 2020).

    The required testing capacity to provide an accurate assessment of disease spread varies over the course of an outbreak. At the beginning, when the number of infected is low, a much smaller number of tests are required to accurately assess disease spread. As the frequency of disease expands, test capacity must rapidly grow to meet the demand. As a result, the metric “number of tests/confirmed cases” is a reasonable tool that indicates if adequate testing is occurring. If the ratio is decreasing, that indicates that the amount of testing is becoming less adequate. As an example, as of April 2020, Vietnam conducted 400 tests for each confirmed case of coronavirus infection, while in the US approximately five tests were conducted for each case (Hassel, 2020).

    It is evident that both testing coverage and the number of tests conducted for every confirmed case provide useful information to understand the spread of an ID. A jurisdiction that is conducting a small number of tests relative to the number of confirmed cases is not testing enough. While this approach may capture the most severe cases, it is likely overlooking asymptomatic people or those with mild symptoms. Unfortunately, these unidentified individuals may be contagious and able to propagate the ID (Hassel, 2020).

    By late October 2020, the US had documented its 5 highest days of positive COVID-19 test results, with signs that these figures would continue to rise. CDC stated the need to develop a strategy to better identify individuals who are asymptomatic, yet contagious. These patients are not rare; according to recent CDC estimates, they comprise 40% of coronavirus positive cases. Dr. Thomas Tsai of the Harvard Global Health Institute noted that the time to develop a comprehensive national test strategy passed months previous. At this point, he stressed that the emphasis should be on developing an approach to identify asymptomatic COVID-19 patients (Vera & Maxouris, 2020).

    Contact Tracing

    Contact tracing and case investigation are key tools in pandemic management. These activities involve close work with patients diagnosed with an ID. The main thrust of the work is to identify and provide support to the patient’s contacts who may have been infected through exposure to the diagnosed patient. The objective is to separate those that are potentially infected before they can spread the disease to susceptible people. This process is a core disease control measure that has been used effectively for a number of decades. It is important to note that a proper response to an outbreak is multipronged: contact tracing is just one of the required tools (CDC, 2020b).

    Case investigation is the process of determining who has received confirmed test results and probable cases of an ID. Contact tracing is the next step, where individuals who have come into contact with that person are identified, monitored, and offered support. If all infected and potentially exposed individuals can be identified and self-isolated, experience has shown that the chain of transmission can be broken, preventing further spread of the disease in a community. These methods are not novel, rather they have been effectively employed to curb the spread of a variety of ID, including tuberculosis, sexually transmitted infections, and HIV/AIDS. These approaches are well known by public health agencies and are designed to be easily adapted to a variety of ID (CDC, 2020b).

    Aspects of the ID must be taken into consideration when designing effective case investigation and contact tracing operations (CDC, 2020b). Points for consideration include the following:

    • If the ID can spread asymptomatically, contact tracing efforts must be more rapid than in cases where symptoms precede contagiousness.
    • Procedural recommendations must be flexible to allow modifications as additional data emerges.
    • Remote communications, i.e., by telephone, should be the primary contact approach.
    • Prioritization, when needed, should be based on vulnerability.
    • If capacity exists, patients with probable, as well as confirmed cases should be investigated.
    • Extensive community engagement is critical to support acceptance of contact tracing efforts.
    • In addition to identifying at-risk individuals, significant social support is also required to best facilitate safe self-isolation and testing.
    • Jurisdictions must develop plans to rapidly organize contact tracing workforces at time of need.
    • While digital contact tracing tools may supplement conventional efforts, they cannot replace the need for a large human contact tracing work force.

    (CDC, 2020b)

    Evidence-Based Practice

    In the case of COVID-19, combinations of public health directives such as stay-at-home orders, public mask wearing, case investigations, contact tracing, and quarantine have been employed in an effort to blunt the spread of disease. Kanu (2020) closely examined data obtained in Delaware to characterize the impact of these interventions. Delaware reported its first case in March 2020. They began case investigations immediately and issued a stay-at-home order on March 24. A mask mandate took effect on April 28 and contact tracing efforts began on May 12. In Kanu’s assessment, disease incidence, hospitalization, and mortality were examined over the period spanning March to June. Results demonstrated that the incidence of COVID-19, hospitalizations, and mortality decreased by 82%, 88%, and 100%, respectively from late April to June, aligned with the mask mandate and contact tracing. The investigator concluded that when combined, available mitigation strategies can reduce the incidence of COVID-19 and associated mortality. Furthermore, he stated that it is doubtful that, if employed alone, any one single approach was likely to be effective (Kanu, 2020).

    Self-Assessment Quiz Question 8

    Since Julia had tested positive for COVID-19, Henry needed to report the case to the County Health Department. Which of the following are core public health objectives designed to curb the spread of ID?

    1. Identify people that infected individuals have come into contact with.
    2. Isolate all known contacts that have been potentially infected.
    3. Provide support for suspected contacts.
    4. All of the above.

    Self-Assessment Quiz Question 9

    Ideally, the County Health Department would employ a comprehensive contact tracing program to investigate each identified case of COVID-19 within their jurisdiction. Regarding an effective contact tracing program, which of the following elements is false?

    1. Time is of the essence; effective tracing should be rapid in cases of diseases that can spread asymptomatically.
    2. Procedures must be rigid to ensure consistent data collection.
    3. Community engagement can facilitate effective contact tracing efforts.
    4. If capacity permits, possible contacts as well as certain contacts should be investigated.

    Herd Immunity

    If the point can be reached where a high percentage of a population is immune to an ID (either through vaccination or the development of immunity via previous exposure to the pathogen), it becomes difficult for the ID to spread. This obstacle is a result of there being a limited number of susceptible individuals. As an example, if a person with measles is surrounded by others who are immune to the virus, the disease cannot be easily transmitted, and then dissipates as the infected person recovers. This is called herd or community immunity. This mode of protection is beneficial since it provides a defense for vulnerable people, such as newborns, the elderly, or individuals too ill to be vaccinated. It is critical to note that herd immunity is not a panacea for all vaccine-preventable diseases. An example is tetanus; while tetanus is classified as an ID, it is not contagious, rather it enters the body as environmental bacterial. Regardless of the level of tetanus vaccination in a community, nonimmunized people remain fully susceptible to the disease. The extent of protection in a community required for herd immunity varies by pathogen. While it may ultimately be effective, herd immunity does not provide absolute safety from infection (Immunisation Coalition, n.d.).

    If COVID-19 is ever stopped, it will likely be as a result of the attainment of herd immunity. As with any infection, there are three ways to achieve that endpoint: a large percentage of the population gets infected; most people receive an effective vaccine for the coronavirus; or a combination of both. There are at least three scenarios that may lead to herd immunity for COVID-19 (D’Souza & Dowdy, 2020):

    1. Worst case. This could occur if no mitigation strategies were employed, such as social distancing, wearing of face masks, or proper sanitation to slow the spread of disease. The virus is adequately virulent to impact millions of people in just a few months, conferring extensive immunity. As a result, this situation would likely overwhelm health systems and result in substantial mortality.
    2. Perhaps ideally, mitigation strategies are employed to maintain or reduce current levels of infection until an efficacious vaccine is widely available.
    3. Most likely, realities will dictate that a compromise posture is employed where the rates of infections rise and fall and mitigation approaches are loosened as infection rates decrease and tightened as needed to counter increases in disease until an efficacious vaccine is widely available (D’Souza & Dowdy, 2020).

    Preparing for EID

    The avian influenza (H5N1) virus made its first known transmission from poultry to humans in 1997, resulting in the death of six of 18 infected Hong Kong citizens. This experience spurred the US government and WHO to increase their preparedness for a pandemic. Since that time, the world has experienced instances of novel influenza A viruses, including avian and swine flu. While not nearly at the level of the COVID-19 pandemic, these experiences made it evident that a pandemic could place enormous demands on public health systems and essential community service industries (CDC, 2017d). Although major planning efforts are focused on influenza pandemics, the key concepts are applicable to most any EID.

    HHS: 2005 Pandemic Influenza Plan

    As described previously, pandemics caused by EID are not novel. Governments have had time to prepare and, to their credit, efforts have been made to prepare for pandemic emergencies.

    While on vacation in the summer of 2005, President George W. Bush began reading a book chronicling the 1918 flu pandemic “The Great Influenza.” When he returned to Washington, he gave the book to his National Security Advisor, stating, “This happens every 100 years. We need a national strategy.” From this was born a plan to best manage a pandemic. This guide described global warning systems, funding for rapid vaccine development technology, and a national stockpile containing therapeutic drug products, masks, and ventilators. In order to design the strategy, the government conducted cabinet-level exercises (Mosk, 2020).

    A total of $7 billion was allocated for setting up the plan. Cabinet secretaries urged their staff to participate and a website (www.pandemicflu.gov) was launched, which is still in use. Unfortunately, this high level of engagement was not sustained and, as a result, large parts of the plan were not completed and, in some cases, elements were abandoned in favor of new, emerging crises. With the passing of time, it became difficult to justify the necessary funding and staffing levels. Nonetheless, comments made by President Bush 15 years ago still hold true, and elements of this original work remain and form the basis for the US pandemic response (Mosk, 2020).

    In 2005, HHS published its Pandemic Influenza Plan, a 396-page guidebook designed to prevent, control, and mitigate the impacts of high-risk influenza viruses. It was noted that certain strains of influenza had pandemic potential and would require the extensive use of vaccines, diagnostics, and antiviral therapeutics, as well as a variety of preparedness and response efforts (CDC, 2017e).

    Progress has been made since this initial publication, necessitating the need for an update. In a 2017 update, progress was reviewed, illustrating both successes as well as gaps in preparedness. Significant achievements include expanded surveillance, increased laboratory capacity, new vaccines, and antiviral resistance monitoring capabilities. Furthermore, extensive coverage is dedicated to mitigation measures that communities and individuals can take to slow the spread of a novel virus starting at the earliest stages of a pandemic (CDC, 2017e).

    The intention with the 2017 update was to reflect a comprehensive, system approach to enhancing preparedness and response across various sectors and disciplines. The challenge of creating and maintaining such an extensive plan is to cover most eventualities, while retaining the flexibility to adjust as conditions warrant. The objective of the plan was to allow HHS to quickly respond to a pandemic, while at the same time strengthening their response to seasonal influenza (CDC, 2017e).

    WHO: Global Influenza Strategy 2019–2030

    WHO published the Global Influenza Strategy for 2019–2030 in order to build and enhance global and national preparedness for a pandemic. It was specifically designed to counter the threat of zoonotic influenza while improving the prevention and control of seasonal influenza worldwide. The strategy was intended to unify the global goals and priorities of all member countries (WHO, 2019).

    In spite of all of the progress that has been made, WHO acknowledged that critical gaps and challenges remain. They identified the two most urgent needs, which formed the foundation of this long-range planning document (WHO, 2019):

    • Current prevention and control tool limitations – there is an urgent need for better mechanisms to prevent, control, and treat influenza.
    • Robust national capacities for influenza preparedness and response are essential. It was recognized that influenza programs are able to enhance the core capacities across all areas of public health (WHO, 2019).

    Dr. Tedros Adhanom Ghebreyesus, Director General of WHO, summarized the threat by stating (WHO, 2019):

    “The threat of pandemic influenza is ever-present. The on-going risk of a new influenza virus transmitting from animals to humans and potentially causing a pandemic is real. The question is not if we will have another pandemic, but when. We must be vigilant and prepared – the cost of a major influenza outbreak will far outweigh the price of prevention.”

    Role of Nurses in Combating Emerging ID

    Nurses practicing in settings related to public health have clear roles and responsibilities intended to eliminate the health inequalities present in our society. These responsibilities focus on the critical importance of awareness of self and others, forming the foundation of human relationships. There is a requirement that these health professionals acknowledge that all cultures and populations are not known or understood. Many of the same roles and responsibilities assigned to public health nurses apply to most other nurses practicing in a variety of specialties and settings. All nurses must recognize and understand the impact on health and outcomes of social determinants, to include environment, socioeconomic status, access to care, and availability of transportation and food, as well as many other factors. Poverty, general inequity, and other social determinants clearly contribute to global health issues and their contribution to morbidity and mortality (Edmonson et al., 2017).

    Nurses are in an ideal position to carefully evaluate individuals, communities, and the greater population for susceptibilities, advocate for equality and justice, and involve themselves in their communities in order to best address local, national, and even worldwide health problems (Edmonson et al., 2017).

    Evidence-Based Practice

    Lam and colleagues (2018) conducted a systematic review of the scientific nursing literature in order to explore nurse preparedness to function in an epidemic event. It is appreciated that nurses are often tasked with providing a frontline response to an outbreak of an ID. With this critical role, it is important that their preparedness for epidemic events is well characterized. In order to conduct this evaluation, Lam and colleagues identified eligible, qualitative published studies, then extracted and synthesized the findings. A total of seven studies describing nurses’ experiences and perceptions of epidemic events were selected for evaluation. Upon examination of the resultant data, a total of three interlocking themes were identified: personal resources (individual nurses), workplace resources (healthcare institutions), and situational influences. It was determined that, in order to provide an effective response, additional efforts are needed to enhance and reinforce interplay between these themes. Investigators concluded that these interactions are critical, and that additional research is needed to fully understand and appreciate the dynamic (Lam et al., 2018).

    Nursing Consideration

    It is critical that, in order to enhance nurse preparedness and response to an epidemic event, appropriate training and education is provided for nurses focused on the topic of ID. Furthermore, nursing management needs to ensure that institutional assistance is available to provide support for nurses in the event that an epidemic event occurs (Lam et al., 2018).

    Situational Management: Reactions and Overreactions to Emerging Infections.

    An EID that reaches the state of pandemic may contribute to a secondary epidemic – one of fear. At the onset, when most people do not know anyone afflicted, they may view the disease in the abstract, minimizing the risk, easily feeling immune. Nonetheless, as the disease spreads and increases in prevalence, anxieties often surge, overwhelming a person’s ability to think rationally. This state may result in an overreaction to the situation. So, depending on the phase of an epidemic, outbreaks can present two dueling challenges: both underreaction and overreaction (Klitzman, 2020).

    Past epidemics, such as Ebola, HIV/AIDS, and SARS, have provided insights into how humans typically process and manage such situations. Often, individuals will experience both forms of reaction, initially adopting an under-reactive posture and then, based on limited information and accompanying fear, overcompensating, moving them into an over-reactive state. In order to slow down this rapidly swinging pendulum, responses should ideally be rational and evidence-based, not panic-based (Klitzman, 2020).

    According to an April 2020 survey conducted by the Pew Research Center (PRC), President Trump’s initial management of the coronavirus outbreak was widely criticized, with 65% of Americans stating that he was too slow to take major steps to address threats to the US despite the reporting of disease in other countries (PRC, 2020). Although it is impossible to know President Trump’s logic behind his actions, based on the perception of a majority of Americans, this can be classified as an underreaction.

    Although not an EID-related event, the Three Mile Island nuclear event, which has never been positively associated with any chronic negative health outcomes, terrified many Americans. The result was often a generalized fear of nuclear power. In this case, people were intently focused on that one incident, not aware of the large number of other nuclear plants that were operating safely. This oversight kept people from realizing that the probability of an accident at any given nuclear facility was very small. Nonetheless, the resultant overreaction was great, with some experts suggesting that this fear kept nuclear power from reaching its potential in the US, instead relying on the dirty and unhealthy combustion of fossil fuels (Oster, 2020).

    While some responses to EID will certainly promote safety and save lives, others will impact livelihoods to an extent exceeding their benefit. It is impossible to rationally assess this tradeoff using partial information. What is needed is full-picture data, not anecdotal stories that often fill media reports (Oster, 2020).

    Optimistically, the coronavirus pandemic and the wreckage that it leaves behind might motivate societies to learn how to better calibrate between overreactions and underreactions. Proper preparation and evidence-based responses could save valuable time in the case of future epidemics, resulting in better outcomes (Klitzman, 2020).

    Nurses Can Manage Human Response to EID

    According to a 2019 Gallup poll, for the 18th consecutive year, Americans rate nurses as the most ethical and honest among professions. More specifically, 85% of Americans surveyed stated that nurses’ ethical standards and honesty are high or very high. To put this in perspective, automobile salespersons, the profession held in lowest esteem, received the same rating from 9% of people surveyed. According to Gallup, nurses have consistently outrated all other professions by a wide margin. For perspective, medical doctors were similarly rated by 65% of individuals (Reinhart, 2020).

    Nurses can leverage the high levels of trust that they have earned to act as the voice of reason in unsettled times. Through calm and rational acts, they can help patients sift through the layers of misinformation and provide evidence-based approaches to safely managing a pandemic emergency. In many cases, nurses are the front line in healthcare. Prevention is key, and nurses are ideally situated to convey these critical messages.

    At a foundational level, nurses can provide their patients with information describing clear basic hygienic practices. It is critical that such educational topics are evidence-based and not highly controversial. Points for consideration include the following:

    • The novel coronavirus, as well as many other pathogenic viruses, is largely thought to spread from person-to-person to those who are in close contact with one another; ideally individuals should try to maintain separation of at least 6 feet to avoid respiratory droplets generated by coughs and sneezes. Virus may also spread by airborne particles generated from talking or screaming. Whichever the source, particles can land in the mouth or nose of people, or in some cases be inhaled into the lungs. As a result, it is critical to wear face coverings and to cover the mouth and nose with a tissue or the interior portion of the arm when coughing or sneezing. Used tissues should be immediately discarded and hands should be thoroughly washed with soap and water or alcohol-based hand sanitizer (containing at least 60% alcohol; HHS, 2020).
    • In addition to social distancing and facial covering, handwashing and effective personal hygiene practices are critical to maintaining good health. Individuals should get in the habit of frequently washing their hands. Lastly, it is important to avoid touching eyes, nose, and mouth to avoid self-infection from contaminated hands (HHS, 2020).

    Nurses are well positioned to lead the charge against EID by teaching their patients how to not just survive, but to thrive in a far from sterile world, through a collection of low-cost, high-impact practices. If properly executed, nurses can maintain balance in an often-misinformed world, promote proper immunizations, demonstrate sanitation techniques, and contribute to the generation of timely public health guidance.

    Case Study 4 – Phase 2

    Three days later, Henry was disturbed to see Julia’s telephone number appear on the caller ID. He was not looking forward to spending more time listening to her unproductive ramblings. Nonetheless, he took a deep breath and answered the telephone. While she was still worked up and speaking at a rapid rate, he quickly realized that she had changed her approach to dealing with her diagnosis. She was calling to inform him that she had come to terms with her diagnosis and wanted advice on good practices that she could share with her niece to better protect her from contracting the infection.

    Self-Assessment Quiz Question 10

    Which of the following suggestions should Henry share with Julia?

    1. All people should maintain a distance of at least 6 feet from other individuals.
    2. Everyone should wear face coverings, especially when proper distance between people cannot be maintained.
    3. People should wash their hands frequently with soap and water.
    4. All of the above.


    The COVID-19 global pandemic has forced all people, especially nurses, to learn about, manage, and prepare for EID. While many of these ideas are novel for most people, the scourges of ID and resultant pandemics have occurred for millennia. Despite epic advances in science and medicine, many aspects of EID remain unchanged over time. Despite its long existence, in the past 50 years or so, increased interest in EID has taken hold. In an effort to best understand and manage the risks inherent to EID, large research investments have been made and a number of government organizations have been formed. Many of the drivers of EID, such as climate change and antimicrobial resistance, seem linked to the progress of mankind, as people broaden their geographic footprint and become bigger users of available technology. Although major efforts have eradicated a number of once lethal diseases, for a variety of reasons, some of these maladies continue to recur, significantly contributing to human morbidity and mortality. In addition to the physical detriments attributed to EID, their sheer scale and associated unknowns also greatly impact the social fabric of society, creating a number of secondary problems. The good news is that there are solutions to EID that can be at least partially effective. To enhance efficacy, science must continue to advance, with resultant information effectively and consistently communicated. The keys to making it all work, though, are held by the people. All citizens must work together and follow best practices to help curb the spread of EID. Nurses hold a critical role in the process. In addition to their solid understanding of the science, they are well respected in society. As a result of this special trust, nurses are in an ideal position to communicate to their patients the information needed to best manage an EID. With a bit of effort, nurses are in a position to not only keep their patients healthy, but to help them flourish in the scary, unknown environment associated with a dangerous infectious disease outbreak.


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    Watkins, K. (2018). Emerging infectious diseases: A review. Current Emergency and Hospital Medicine Reports, 6, 86-93. https://doi.org/10.1007/s40138-018-0162-9

    Watts, E. (2020). What Rome learned from the deadly Antonine plague of 165 A.D. https://www.smithsonianmag.com/history/what-rome-learned-deadly-antonine-plague-165-d-180974758/

    Winslow, C. E. A. (1920). The untilled fields of public health. Science, 51, 23. http://dx.doi.org/10.1126/science.51.1306.23

    World Health Organization. (2019). Global influenza strategy 2019-2030. https://apps.who.int/iris/bitstream/handle/10665/311184/9789241515320-eng.pdf?ua=1

    World Health Organization. (2020a). Antimicrobial resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance#:~:text=Antimicrobial%20resistance %20happens%20when%20microorganisms%20%28such%20as%20bacteria%2C,antimicrobial%20resistance%20are%20sometimes%20referred%20to%20as%20%E2%80%9Csuperbugs%E2%80%9D

    World Health Organization. (2020b). Emergencies – Pandemic, epidemic diseases. https://www.who.int/emergencies/diseases/en/

    World Health Organization. (2020c). Emergencies preparedness, response. https://www.who.int/csr/en/

    Yang, W. (2020). Transmission dynamics of and insights from the 2018-2019 measles outbreak in New York City: A modeling study. Science Advances, 6(22), eaaz4037. https://advances.sciencemag.org/content/advances/6/22/eaaz4037.full.pdf

    Zivich, P. N., Gancz, A. S., & Aiello, A. E. (2018). Effect of hand hygiene on infectious diseases in the office workplace: A systematic review. American Journal of Infection Control, 46, 448-455. https://www.ajicjournal.org/article/S0196-6553(17)31148-3/fulltext

    Self-Assessment Answers and Rationale

    1. The correct answer is B.

    Rationale: Antimicrobial Resistance (AMR) is a growing problem that may make previously susceptible bacteria immune to treatment with formerly effective antibiotic therapy regimens.

    1. The correct answer is B.

    Rationale: Regardless of the level of immunization in a community, the presence of even a small number of unvaccinated individuals creates a level of susceptibility, even to diseases considered eliminated, such as measles in the US. Nonetheless, in order to infect a susceptible person, the virus needs a way to enter the community. In many cases, it is through an unprotected person traveling to a region where that ID is endemic.

    1. The correct answer is C.

    Rationale: The US expended significant effort and resources to achieve the coveted measles elimination status, as defined by WHO. According to WHO criteria, in order to maintain this status, no measles outbreaks can be sustained for a period greater than 1 year in duration.

    1. The correct answer is D.

    Rationale: A major driver to the reemergence of some preventable ID is a reduction in the use of immunizations. One reason for this is a growing population of people who refuse to vaccinate themselves and/or their children. In many cases, this is driven by controversial studies linking measles vaccinations and autism.

    1. The correct answer is C.

    Rationale: Jennifer’s mom appears to prescribe to the circulating belief that vaccines can result in the affliction of autism.

    1. The correct answer is B.

    Rationale: Blame is often a simplification where a person suffering an insult attributes blame to one specific causative element. In reality, actions typically occur when a number of elements combine to create a situation that allows the insult to occur.

    1. The correct answer is D.

    Rationale: While the interaction was far from ideal, in some cases, clinicians need to work with whatever personalities their patients have. In this case, while he was unable to provide the full level of care that he wanted to, he practiced patience and was thus able to at least deliver the minimum amount of information indicated by the situation.

    1. The correct answer is D.

    Rationale: Although public health professionals have many responsibilities, in the case of managing an outbreak of ID, their key roles are to identify and provide support to all individuals who may have been infected through exposure to the diagnosed patient. Another objective is to separate those that are potentially infected before they can spread the disease to susceptible people.

    1. The correct answer is B.

    Rationale: Contact tracing procedures should be flexible to allow modifications as new information emerges. For example, it may become apparent over time that whatever approach initially worked may become unwieldy as case numbers increase.

    1. The correct answer is D.

    Rationale: In addition to social distancing and facial covering, handwashing and good person hygiene practices are critical to maintaining good health in the face of an epidemic ID. Henry should be pleased that, possibly through his attention to Julia, despite her difficult demeanor, she came to trust him, relying on his advice to counter the spread of COVID-19.

    Final Examination Questions

    1. Which of the following are mechanisms by which ID are known to be transmitted between individuals?
      1. Droplets associated with sneezes and coughs.
      2. Via the placenta or through breast milk.
      3. Insect vectors.
      4. All of the above.
    1. What distinguishes an endemic from an epidemic ID?
      1. Only epidemics are caused by the occurrence of an ID.
      2. Endemic diseases are usually described as constant, while epidemics are associated with

         an unexpected increase in the incidence of an ID.

    1. Endemic diseases often result from a pathogen’s spread through a previously naïve


    1. Epidemic ID often exist at a moderate background level for many years.
    1. Regarding the Black Death of 1350 CE, which of the following statements is false?
      1. It is thought that it began in Asia and then migrated to Europe.
      2. Current thinking is that it was transmitted to people by rats.
      3. It persisted for some time, recurring six times after the initial wave of infection.
      4. It was deadly; killing at least 60% of the people living in London in the first year.
    1. Which of the following statements describing R0 is true?
      1. It describes the lethality of an ID.
      2. This number is derived on the assumption that the population of interest is only partly susceptible to the ID of interest.
      3. If R0 is greater than one, the incidence of the disease will eventually dissipate.
      4. When R0 = 12, on average, each infectious person is expected to infect an additional 12 individuals.
    1. Unfortunately, many so-called “old” diseases reemerge from time to time. Although there could be many reasons for this phenomenon, in the majority of cases it is linked to which of the following?
      1. Decreased pathogenic virulence.
      2. Reduction in the availability of susceptible individuals.
      3. Changes in human behavior.
      4. Advances in antimicrobial technologies.
    1. Which of the following statements regarding vaccine hesitancy is true?
      1. WHO attributes the problem to a lack of vaccination services.
      2. It is a problem only in developing countries.
      3. It is thought to have caused the immunization rate for measles to fall under 95% in some parts of the world.
      4. It may be a result of conclusive evidence linking some vaccinations with autism.
    1. Which of the following phenomena are not likely to occur secondary to a global pandemic?
      1. A growing level of trust between members of society.
      2. An overall decrease in health status.
      3. Decreases in substance abuse.
      4. Fear of infection, leading to increased rates of vaccination for ID.
    1. Which of the following practices are effective tools to prevent or manage ID?
      1. Enhanced personal hygiene.
      2. Strong public health measures.
      3. Comprehensive vaccination strategies.
      4. All of the above.
    1. Regarding the use of testing for the presence of ID in the time of an epidemic, which of the following statements is false?
      1. It is not helpful unless the entire population can be assessed.
      2. Because of differing approaches used across jurisdictions, resultant data can be misleading.
      3. The higher the level of testing, generally the more useful the resultant data.
      4. When the ratio of tests/confirmed cases is decreasing, that suggests that an inadequate number of tests are being conducted.
    1. What determines the role that nurses may take in the management of a global pandemic?
      1. Nurses are considered trustworthy; thus, people are usually willing to listen as they communicate information regarding how to best manage a pandemic.
      2. Nurses almost always lack the information needed to explain the pathology of disease.
      3. The key to prevention is education, historically not a nurse’s strong suit.
      4. Nurses are especially vulnerable to misinformation, often resulting in them taking biased positions on critical situations.

    Final Examination Questions


    Answer A

    Answer B

    Answer C

    Answer D



    Which of the following are mechanisms by which ID are known to be transmitted between individuals?

    Droplets associated with sneezes and coughs.

    Via the placenta or through breast milk.

    Insect vectors.

    All of the above.



    What distinguishes an endemic from an epidemic ID?

    Only epidemics are caused by the occurrence of an ID.

    Endemic diseases are usually described as constant, while epidemics are associated with an unexpected increase in the incidence of an ID.

    Endemic diseases often result from a pathogen’s spread through a previously naïve region.

    Epidemic ID often exist at a moderate background level for many years.



    Regarding the Black Death of 1350 CE, which of the following statements is false?

    It is thought that it began in Asia and then migrated to Europe.

    Current thinking is that it was transmitted to people by rats.

    It persisted for some time, recurring six times after the initial wave of infection.

    It was deadly, killing at least 60% of the people living in London in the first year.



    Which of the following statements describing R0 is true?

    It describes the lethality of an ID.

    This number is derived on the assumption that the population of interest is only partly susceptible to the ID of interest.

    If R0 is greater than one, the incidence of the disease will eventually dissipate.

    When R0 = 12, on average, each infectious person is expected to infect an additional 12 individuals.



    Unfortunately, many so-called “old” diseases reemerge from time to time. Although there could be many reasons for this phenomenon, in the majority of cases it is linked to which of the following?

    Decreased pathogenic virulence.

    Reduction in the availability of susceptible individuals.

    Changes in human behavior.

    Advances in antimicrobial technologies.



    Which of the following statements regarding vaccine hesitancy is true?

    WHO attributes the problem to a lack of vaccination services.

    It is a problem only in developing countries.

    It is thought to have caused the immunization rate for measles to fall under 95% in some parts of the world.

    It may be a result of conclusive evidence linking some vaccinations with autism.



    Which of the following phenomena are not likely to occur secondary to a global pandemic?

    A growing level of trust between members of society.

    An overall decrease in health status.

    Decreases in substance abuse.

    Fear of infection, leading to increased rates of vaccination for ID.



    Which of the following practices are effective tools to prevent or manage ID?

    Enhanced personal hygiene.

    Strong public health measures.

    Compre-hensive vaccination strategies.

    All of the above.



    Regarding the use of testing for the presence of ID in the time of an epidemic, which of the following statements is false?

    It is not helpful unless the entire population can be assessed.

    Because of differing approaches used across jurisdictions, resultant data can be misleading.

    The higher the level of testing, generally the more useful the resultant data.

    When the ration number of tests/con-firmed cases is decreasing, that suggests that an inadequate number of tests are being conducted.



    What determines the role that nurses may take in the management of a global pandemic?

    Nurses are considered trustworthy; thus, people are usually willing to listen as they communicate information regarding how to best manage a pandemic.

    Nurses almost always lack the information needed to explain the pathology of disease.

    The key to prevention is education, historically not a nurse’s strong suit.

    Nurses are especially vulnerable to misinforma-tion, often resulting in them taking biased positions on critical situation.


  • Facing Legal and Ethical Issues in Nursing


    7 Contact Hours

    Released: April 10, 2019

    Expire:  April 10, 2022

    Author: Adrianne Avillion, DEd, RN

    Adrianne E. Avillion, DEd, RN, is an accomplished nursing professional development specialist and health care author. She earned her doctoral degree in adult education and her MS in nursing from Penn State University and a BSN from Bloomsburg University. Dr. Avillion has held a variety of nursing positions as a staff nurse in critical care and physical medicine and rehabilitation settings with emphasis on neurological and mental health nursing as well as a number of leadership roles in nursing professional development. She has published extensively and is a frequent presenter at conferences and conventions devoted to the specialty of continuing education and nursing professional development. Dr. Avillion owns and is the CEO of Strategic Nursing Professional Development, a business that specializes in continuing education for health care professionals and consulting services in nursing professional development. Her most recent publications include The Path to Stress-Free Nursing Professional Development: 50 No-Nonsense Solutions to Everyday Challenges and Nursing Professional Development: A Practical Guide for Evidence-Based Education.

    Reviewer: Irene Owens, APRN, FNC, BC

    Irene is an accomplished nurse practitioner and nurse educator. She earned her post-master's certificate in family practice at Florida State University and her master’s degree in nursing education and BSN at Florida Southern College in Lakeland. Irene has held a variety of nursing positions as a staff nurse in pediatrics, a school nurse working with physically impaired children. She has spent over 20 years teaching in the field as an instructor and professor for LPNs and registered nurses. She has served as the vice president and president of the Lake County Oncology Nursing Society, a chapter of the Oncology Nursing Society (ONS). She has devoted time to medical mission work and has worked in a free clinic practicing as a provider of care for adult patients without insurance. Irene has also worked in private practice specializing in family health with emphasis on chronic illness.


    Legal issues in nursing are based on legislation, practice standards, and licensure. Ethical issues, on the other hand, are often based on subjective values of “right” and “wrong. ” The purpose of this course is to help nurses deal with many of the ethical issues they face in their professional practice, as well as legal considerations that may impact on ethical issues of patient care.


    Upon completion of this course, the learner should be able to:

    • Describe how nursing scope of practice and standards of professional nursing practice govern nursing.
    • Explain how state nurse practice acts define and describe nursing practice.
    • Describe how the act of delegation is encompassed in the nurse practice act.
    • Correlate nursing professional boundaries with appropriate nursing practice.
    • Discuss legal and ethical implications of nursing practice.
    • Describe professional guidelines for use of social media.
    • Discuss how ethics and moral distress impact nursing.

     Author’s Note: This education program is not a substitute for, nor is it intended to be, legal/ethical counseling or legal/ethical advice. For specific legal/ethical advice pertaining to you and your practice, consult appropriate legal authorities or ethical experts.

    How to receive credit

    • Read the entire course online or in print which requires a 7-hour commitment of time.
    • Depending on your state requirements you will be asked to complete either:
      • An affirmation that you have completed the educational activity
      • A mandatory test (a passing score of 70 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention.
    • Provide required personal information and payment information.
    • Complete the mandatory Self-Assessment and Course Evaluation
    • Print your Certificate of Completion.

    Accreditations and Approvals:

    Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center’s Commission on Accreditation. 

    Individual State Nursing Approvals

    In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by:  Alabama, Provider #ABNP1418 (valid through March 1, 2021); California Board of Registered Nursing, Provider #CEP15022; District of Columbia Board of Nursing, Provider # 50-4007; Florida Board of Nursing, Provider #50-4007; Georgia Board of Nursing, Provider #50-4007; and Kentucky Board of Nursing, Provider #7-0076 (valid through December 31, 2019).  This CE program satisfies the Massachusetts Board’s regulatory requirements as defined in 244 CMR5.00: Continuing Education.

    Activity Director

    June D. Thompson, DrPH, MSN, RN, FAEN

    Lead Nurse Planner


    Resolution of Conflict of Interest

    In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.

    Sponsorship/Commercial Support and Non-Endorsement

    It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.


    The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition  ©2019:  All Rights Reserved.  Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC.  The materials presented in this course are meant to provide the consumer with general information on the topics covered.  The information provided was prepared by professionals with practical knowledge of the areas covered.  It is not meant to provide medical, legal, or professional advice.  Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state.  Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials.  Quotes are collected from customer feedback surveys.  The models are intended to be representative and not actual customers.


    December 21, 1953: Last week American smokers pricked up their ears at a piece of medical news that caused a rash of frightening statements from eminent doctors attending the Greater New York Dental meeting. Cigarettes, smokers heard, had for the first time been shown to be capable of causing cancer. … New Orleans’ famed lung surgeon, Alton Ochsner, said, "Based on the number of people who are smoking now, I predict that in 1970 cancer of the lung will represent 18% of all cancer… one out of every 10 or 12 men." … The American Tobacco Company hastened to point out that tests on mice do not prove that tobacco can cause lung cancer in man. The figures on human deaths show that heavy smokers are likelier to get lung cancer in later life than nonsmokers. They do not necessarily mean that everyone should promptly stop smoking, for this might create nervous ailments in smokers who would feel that they had lost a comforting relaxation. (Life Magazine, 1953)

    The preceding excerpt is from a 1953 issue of the now out-of-print weekly Life Magazine.


    • What ethical questions can be triggered by realizing that as early as 1953, the dangers of cigarette smoking were becoming apparent, yet it was not until the mid- to late-1960s that the United States federal government mandated warnings in an attempt to inform the American public of health dangers associated with smoking?
    • What ethical obligations did health care professionals have regarding recognition of these dangers?
    • What are the legal implications for nurses provided with information that may cause patient harm but are legally acceptable?
    • Do health care professionals have an obligation to act on research findings regardless of legislative mandates?
    • What legal/ethical dilemmas do nurses and other health care professionals face when they are made aware of a practice that can compromise wellness?
    • How do patient rights and confidentiality factor into legal and ethical nursing practice?

    Critical Thinking Scenario 1

      Mrs. Davidson is a 60-year-old investment banker who has recently received a diagnosis of Stage II breast cancer. Her mother and grandmother were breast cancer survivors. Mrs. Davidson has a 35-year-old daughter from whom she is estranged. After undergoing genetic testing, Mrs. Davidson was found to have a genetic mutation that significantly increases the risk of breast cancer. Mrs. Davison has made it clear to her physician and the nursing staff that she will not be sharing the results of the genetic testing with her daughter, Victoria. One of Mrs. Davidson’s nurses knows Victoria; they attend the same church. The nurse believes that Victoria has a right to know about results of the genetic testing.

      Can the nurse legally disclose information about Mrs. Davidson?

      Legally, disclosure is not needed to provide nursing care in this circumstance. The nurse has neither the legal obligation nor the legal right to disclose patient information. Disclosure without Mrs. Davidson’s permission is not allowed even though the nurse’s concerns about Victoria are reasonable (Mathes & Reifsnyder, 2014). However, the nurse can educate Mrs. Davidson about the implications of the test results for both Mrs. Davidson and her family members. This must be done in an objective, supportive manner and may provide opportunities for continued discussion and, hopefully, for ways to help Mrs. Davidson relay important information to her daughter. Ethically, the nurse feels a strong compulsion to disclose patient information that legally she cannot.

    Legal and ethical components of nursing practice are complex and can generate vigorous debate and moral quandaries. This education program is designed to help practicing nurses deliver nursing care that meets both legal and ethical standards.


    The International Council of Nurses (ICN) (2019) defines nursing as encompassing “autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well, and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.”

    Nursing as a profession requires rules and regulations, standards of practice, laws, and codes of ethics to establish levels of professional behavior that are safe, appropriate, ethical, and legal.

    In the United States, there are three levels of nursing practice:

    1. Registered nurse (RN).
    2. Advanced practice registered nurse (APRN).
    3. Licensed practical nurse (LPN).

    The ANA describes RNs as forming the backbone of health care provision in the United States (American Nurses Association, 2019). The association identifies the following key responsibilities of the RN (American Nurses Association):

    • Performs physical exams and obtains health histories before making critical decisions.
    • Provides health promotion, counseling, and education.
    • Administers medications, provides wound care, and carries out a multitude of personalized interventions.
    • Coordinates care in collaboration with a large array of health care professionals.

    APRN refers to a nurse who has at least a master’s degree in addition to the initial nursing education and licensing required for all RNs. Responsibilities of the APRN include the following (American Nurses Association, 2019):

    • Providing primary and preventive health care to the public.
    • Treating and diagnosing illnesses.
    • Advising the public on health issues.
    • Managing chronic disease.
    • Engaging in continuing education to remain at the forefront of any developments in the APRN field.

    Examples of APRNs include the following specialists (American Nurses Association, 2019; Devine, 2019):

    • Nurse practitioner (NP): The NP prescribes medication and diagnoses and treats minor illnesses and injuries.
    • Certified nurse midwife (CNM): The CNM provides gynecological and low-risk obstetrical care.
    • Clinical nurse specialist (CNS): The CNS provides an advanced level of care in hospitals and other clinical settings.
    • Certified registered nurse anesthetist (CRNA): These nurses administer more than 65% of anesthetics given to patients every year.

    The licensed practical nurse, known as licensed vocational nurse (LVN) in California and Texas, complements the health care team by providing basic and routine care consistent with her education and under the supervision of an RN, APRN, or MD (American Nurses Association, 2019).

    Key responsibilities of the licensed practical nurse include the following (American Nurses Association, 2019):

    • Checks vital signs and looks for signs that health is deteriorating or improving.
    • Performs basic nursing functions such as changing bandages and wound dressings.
    • Ensures patients are comfortable, well fed, and hydrated.
    • Administers medications in some settings.

    Scope of Practice

    Shannon is a newly licensed registered nurse. During orientation to her new role as an RN on an oncology unit, Shannon is told that she must become familiar with (and stay familiar with) the scope and standards of nursing practice in the state in which she practices. Shannon has studied, in general terms, scope and standards of nursing practice during her years in a BSN program. However, as she is now a licensed professional, Shannon wants to understand, in more depth, the scope of practice that defines nursing actions.

    What is scope of practice? The ANA describes nursing scope of practice as an explanation of the who, what, where, when, why, and how of nursing practice. Furthermore, scope of practice delineates what the law allows based on specific education, training, experience, and licensure (American Nurses Association, n.d.a).

    Nursing Consideration

     Nurses must know not only their own scope of practice but also the scope of practice of others such as LPNs and nursing assistants to whom they delegate tasks. RNs who delegate tasks are still accountable for that delegation in terms of its safety and appropriateness (Mathes & Reifsnyder, 2014).

    Determining the Scope of Practice

    How can nurses determine if an action is within their scope of practice? First, they must review appropriate standards, laws, and rules of nursing practice. They must know the contents of their nurse practice acts in their states, and what their licenses allow them to do. Then they should consider the following three steps to help determine if an action is within the legal scope of practice. These steps have been compiled from various resources (American Nurses Association, n.d.a; Empowered Nurses.org, 2015; Mathes & Reifsnyder, 2014; Russel, 2017).

    Step 1: Clarify what skills, education, and training are needed to perform an action. Nurses should ask themselves the following questions:

    • Is this action allowable by law according to legal standards and the nurse practice act in my state?
    • If so, does the employing health care facility have policies and procedures that provide guidance for its performance?
    • Do I have the necessary skills, experience, and training to perform this action?
    • Am I competent to perform this action? If in doubt, nurses must seek help from a supervisor or peers who are competent in this action. Nurses must remember that once a patient assignment is accepted, they are responsible for fulfilling it safely and competently.

    Step 2: Realize that what may be common practice (e.g., “We’ve always done it this way”) may not necessarily be legal or in the best interests of the patient. For example: Suppose a highly experienced LPN has been allowed to perform physical assessments independent of, and without collaboration with, an RN. This has been going on for years. However, in some states, this is beyond the legal scope of practice for LPNs. An RN who continues to delegate this action to LPNs is accountable for this illegal practice. Delegating tasks outside the scope of practice can be potential grounds for disciplinary action against both the LPN who performed the assessment and the RN who inappropriately delegated the task. It may also be the basis for a malpractice lawsuit if a patient is harmed as a result of such an action.

    Step 3: Determine if the action taken is one that a reasonably prudent nurse with similar education, training, and experience would do; if a valid order for the task has been written by a physician, physician assistant, or APRN; and if the nurse in question has demonstrated competency in the skill and behavior required and has documentation of such competency. For example: Suppose a nurse is asked to counsel a patient regarding pregnancy prevention. This patient has received a diagnosis of schizophrenia and is not currently controlled with antipsychotic medication. The nurse has not worked with patients with schizophrenia and is unsure how to assess comprehension or how to adequately communicate with this patient. Nurse colleagues say, “Just do the best you can.”

    What should the nurse do? In this situation, the nurse must seek help from a supervisor or other appropriate source of assistance such as a mental health specialist. Lack of competency in working with mental health patients is as much a concern as if asked to perform a specific motor skill procedure with which the nurse is unfamiliar.

    Nursing Consideration

    All nurses must be sure to act within their scope of practice and within their experience and training. If nurses are asked to do something that is within the legal scope of their nursing practice, but their training and experience have not prepared them to safely and competently perform this action, they should not do it (Mathes & Reifsnyder, 2014). They should seek help from a nurse who can safely and competently perform the action. They also need to seek training opportunities so that they can achieve competency in performing new procedures.

    Standards of Professional Nursing Practice

    Carol is one of several nurses named in a malpractice lawsuit. A patient had been receiving antibiotic therapy for an infection. The infection grew steadily worse, and the patient had to have his leg surgically amputated as a result of the infectious process. When questioned by the plaintiff’s (patient’s) attorney, Carol is asked about the nursing process as it relates to professional nursing practice standards. The attorney focuses on the fifth step of the nursing process, evaluation: “By closely analyzing the effectiveness of the care plan and studying patient response, the nurse hones the plan to achieve the very best patient outcomes” (American Nurses Association, 2019). There is no documentation that Carol evaluated the effectiveness of the antibiotic therapy, as evidenced by documenting and monitoring the appearance of the wound when she and her colleagues changed the dressing. The plaintiff’s attorney is charging that Carol failed to adhere to standards of professional nursing practice.

    The standards of professional nursing practice focus on facilitating the delivery of safe and effective nursing care. Most, if not all, state boards of nursing describe standards and scope of practice related to their nurse practice acts.

    But what exactly are standards of professional nursing practice? Standards of professional nursing practice consist of the critical thinking model referred to as the nursing process and the ANA’s Standards of Professional Performance. The standards for professional nursing practice describe those duties and responsibilities that all RNs must be able to fulfill safely and competently regardless of the setting of their practice or their specialty (Mathes & Reifsnyder, 2014).

    Nursing Consideration

    Professional nursing associations such as the American Association of Critical Care Nurses have developed scope and standards of practice pertaining to their respective specialties. Such standards generally build upon the ANA’s Nursing Scope and Standards of Practice. Nurses must be aware of such scope and standards and practice within their respective specialties.


    The nursing process consists of five steps (American Nurses Association, n.d.b):

    1. Assessment.
    2. Diagnosis.
    3. Outcomes/planning.
    4. Implementation.
    5. Evaluation.


    The RN uses a systematic, dynamic way to collect and analyze patient data. Assessment is the first step in delivering nursing care. Assessment includes physiological, psychological, sociocultural, spiritual, economic, and life-style data. Such data include both objective and subjective data (The American Nurses Association, n.d.b).

    Subjective data signify the perception or reality experienced by the patient or family member relaying the information. It refers to what patients or family members say (Capriotti, 2018).

    Objective data are data that come from assessment. They are sources of information pertaining to what the nurse can see, hear, smell, and feel.


    The nursing diagnosis is the nurse’s clinical judgment about the patient’s response to actual or potential health conditions or needs. Nursing diagnosis is the basis of the nurse’s plan of care (American Nurses Association, n.d.b).   

    The RN does not make medical diagnoses. APRNs, however, may diagnose and treat minor medical illnesses and injuries if that is within the scope of practice and licensure, and appropriate education and training has been received (American Nurses Association, 2019).


    Based on assessment and nursing diagnosis, the nurse establishes measurable and achievable short-term and long-term goals. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health care professionals caring for the patient have access to it (American Nurses Association, n.d.b). Patients, families, and other appropriate persons such as caregivers should be part of the planning process.


    Implementation occurs as the RN puts into practice the identified plan of care (Mathes & Reifsnyder, 2014). Nurses use the plan of care to ensure continuity of care across the continuum of care (American Nurses Association, n.d.b). Although RNs may delegate some interventions, they maintain the authority and responsibility for supervising those to whom they delegate tasks and for the implementation and evaluation of the plan of care (Mathes & Reifsnyder, 2014).


    Evaluation requires that the RN monitor and evaluate progress toward the achievement of desired patient outcomes (Mathes & Reifsnyder, 2014). RNs work with the patient/family and other members of the health care team to systematically monitor the effectiveness of nursing interventions and progress toward goal achievement. The patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the plan of care modified as needed (American Nurses Association, n.d.b; Mathes & Reifsnyder, 2014).

    Critical Thinking Scenario 2

      Diana is an RN enrolled in an advanced practice nursing program. She anticipates graduation from the program within six months. Her colleagues, including the physicians with whom she works, know that she will soon fulfill a role as an APRN.

      Diana works in a small rural hospital as a critical care nurse. Her nursing colleagues as well as some of the physicians are pressuring Diana to fulfill some of the responsibilities of an APRN, including prescribing certain medications. The pressure is becoming intense, and Diana begins to suspect that her job may depend on fulfilling the APRN role now.

      What should Diana do?

      Diana has not yet completed the requirements to practice as an APRN. She needs to explain, firmly, to her colleagues that her current licensure and education do not allow her to function as an APRN. She should confer with her immediate supervisor and, if that fails to generate the support she needs, to the director of nursing. Diana cannot legally or ethically fulfill a role for which she is not yet legally qualified.

    Critical Thinking Scenario 3

      David is a registered nurse named in a lawsuit as having failed to properly evaluate patient status and provide appropriate nursing care. A patient was admitted to the hospital for emergency surgery after experiencing a ruptured appendix and resulting peritonitis. During surgery, the patient experienced an unexpected severe loss of blood. After surgery, the nurses were focused on monitoring the patient for hypovolemic shock, administering blood transfusions, and assessing for signs of expanding infection. The patient was slightly confused and complained of aching legs and stomach. The nurses, including David, were so focused on the blood loss, infection, and surgical site that they more or less dismissed the patient’s complaints of leg pain. Within 24 hours, the patient was found to have thrombophlebitis that began in the aching legs. Ultimately, the thrombus caused a fatal stroke. The patient’s family sued citing that David and his colleagues had failed to adequately assess and evaluate the patient’s condition according to the nursing process. Sadly, David and his colleagues failed to adequately assess the patient and evaluate his condition. Although the nurses were justifiably concerned with other critical factors of patient care, they were obligated to investigate the patient’s complaint of aching legs by assessing the problem and evaluating patient outcomes. Failure to do so resulted in a fatal error.


    The Standards of Professional Nursing Practice are “authoritative statements of duties that all registered nurses, regardless of role, population, or specialty are expected to perform competently.” These standards are subject to formal, periodic review and revision. Competencies, which may be evidence of standard compliance, accompany each standard (American Nurses Association, 2015a).

    The following is a summary of the highlights of the ANA Standards of Practice. Note that this is only a brief summary (American Nurses Association, 2015a). Nurses should access the ANA website for further information on obtaining a copy of Nursing: Scope and Standards of Practice (3rd ed.) at http://www.nursingworld.org/Standard 1: Assessment

    “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” Competencies related to this standard focus on methods of data collection, including the incorporation of physical, psychosocial, environmental, emotional, cognitive, sexual, cultural, age-related, spiritual, and economic factors and engaging interprofessional team members in data collection collaboration.

    Additional competencies for the graduate-level prepared RN focus on assessment of interactions among the various components of health care and synthesizing the results.

    Standard 2: Diagnosis

    “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” The diagnosis standard competencies focus on using assessment data to identify and prioritize nursing diagnoses.

    Additional competencies for the graduate-level prepared RN focus on the inclusion of methods to analyze diagnostic practice patterns of nurses and the employment of data to articulate diagnoses, problems, and issues of health care consumers and organizational systems.

    Standard 3: Outcomes Identification

    “The registered nurse identifi