Critical Care Nutrition Practice Management Guidelines: Fill & Download for Free

Yes. The circadian Rhythm. Your circadian rhythm is your body's internal clock and natural cycle of recovery. Don't mess with it. It affects everything in your body and lifestyle.Losing weight/becoming fit and healthy and sleeping disorder don't mix.One of the most critical aspects of fat loss is the most overlooked and neglected element of the formula for success. The Stress factor*. Stress reduction is the key and equally crucial as nutritional guidelines and the exercise volume/frequency.To begin your journey of fitness and rehabilitation, first, reduce the stressful events you can practically manage. I don't care what you may have to do, do it and get it over with, whatever it takes. Until then chances of mastering - a new lifestyle of healthy nutrition and exercises - are a mere pipe dream, an unattainable fanciful hope. It is counter-productive.If you are stressed out for whatever reason, chances of conquering your fitness will become harder, and it will become increasingly more tedious to stick to a program of fitness.One of the most effective things to do is to start sleeping based on the natural cycle. A good shuteye is the game changer. It affects your hormones leading to cascades of positive effects. Sleep plenty and sleep on time.After a vigorous exercises session and a healthy diet, a generous dose of sleep and recovery can do the magic, and if everything else is already in place (exercise and food), you exponentially increase your chance of success with any fitness planning.Although physical exercise reduces the overall stress, the initial mandatory reduction of everyday-stress is a big punch to begin the journey of fitness. Sleep a bit more and a bit longer.Irregular sleeping hours goes against the circadian rhythm of nature leading to a state of sleep disorder, and with that, a whole hosts of illnesses, weight gain, obesity may overwhelm you very quickly.*Stress Factor: Stress is a feeling of great strain/pressure. It is PAIN. Controlled and Small amounts of “stress” may be desired, factual, beneficial, and even healthy and considered positive element to get things of life done. . With weightlifting, Positive Stress helps improve athletic performance. Sleep on time!.

Q. As an inmate in a prison of any country, would you be allowed to (safely) wear your doctor-prescribed insulin pump?Diabetes Care in Prison: How to Manage Your Diabetes in PrisonBy Elisabeth Almekinder RN, BA, CDE 1 CommentThe United States has experienced mass incarceration, and now 2 million people are held in federal prisons and correctional institutions across the country. 80,000 of those, or 4.8%, are diabetics1. Statistics from 1998 show that 11 million people were set free from correctional institutions. Many more pass through the system, such as diabetics experiencing hypoglycemic episodes on the roadways who are often mistaken for being intoxicated or on illegal drugs2ADA Standards for Care in PrisonThe American Diabetes Association has written policies to guide correctional institutions in meeting national standards for diabetes care. They include provisions where a diabetic who is incarcerated would be allowed to perform their own self-care, including finger stick blood sugars and insulin or other diabetes injections, as well as keep extra carbohydrates in their jail cell for the possibility of a low blood sugar. The ADA stand generally sets forth standards where all prisons should continue Medical Nutrition Therapy, a regular activity regimen, and special dietary considerations for those with diabetes.It is true that a prison is a controlled environment. If everything were to be in place in prison for the diabetic as ADA envisions, then diabetes management in the prison would likely be better than diabetes management for the person prior to incarceration. This has been shown to be true in some prisons who do have strict guidelines for providing care to their diabetic prisoners and are following them. Some diabetics A1C prior to incarceration has been shown to drop several points once incarcerated due to stricter monitoring in the institution.The ADA recognizes a need for screening upon entrance to a correctional facility. A person with diabetes who is being incarcerated, particularly one who takes insulin injections, should be recognized immediately. This is to make sure that all those of particularly high risk for high or low blood sugars, and subsequent DKA or insulin shock are brought to the attention of facility guards and medical personnel. All of these patients should have their blood sugars checked within 1-2 hours of arrival at a correctional institution.Anyone brought to a facility displaying symptoms of confusion, sweating, irritability, or uncooperativeness that is thought to be under the influence of alcohol or drugs should also have their blood sugars checked to make sure that they are not experiencing hypoglycemia. An inmate’s prescriptions or Medical Nutrition Therapy should not be stopped. They should continue without pause. All diabetics, Type 1 and Type 2, should have a physical examination by a licensed medical professional “within a timely manner,” according to the ADA guidelines.For females, if a woman inmate is pregnant, the same guidelines for Gestational Diabetes apply as are in the Standards for Medical Care. They are to receive an initial screening and another at 24 to 28 weeks gestation. The ADA also thinks that inmates should get “diet education, multidisciplinary communication, and monitoring of food intake” in prison.They should have access to a Registered Dietician to provide diet instruction. They should be taught how to count carbohydrates and other components of diet in a group setting (in other words, they should receive the full provision of DSME or Diabetes Self-Management Education). Guidelines also get in to how medical emergencies should be handled, including hyperglycemia, and teaching guards how to recognize symptoms that require emergency treatment.I would recommend also reading the following articles:How To Manage Diabetes While On OxycodoneCan An Exercise Physiologist Help With Your Diabetes?Pramlintide (SymlinPen) Comprehensive Guide for Type 2 DiabetesWhat are Blood Sugar Target Ranges? What is Normal Blood Sugar Level?Cost of Diabetes vs Other Diseases – In the US and GloballyAre you allowed to self-manage your diabetes in prison?It seems to depend on where you are incarcerated as to whether or not you receive good diabetes care in prison, and are allowed to self-manage your condition. There are many cases in the news of those who did not receive appropriate care, and were allowed to slip into a diabetic coma from ketoacidosis or whose blood sugars dipped so dangerously low that they had a seizure and died. In reading around forums on this subject, some people report fairly good treatment, and improved diabetes control from the structured environment. Others report inadequate care that results in frequent issues.One woman reports going blind while in prison due to lack of insulin and hyperglycemia over a long incarceration period. It’s true that to control a diabetics blood sugars and provide appropriate care for those imprisoned long-term, would save the prison system and tax payers in medical costs for treating diabetes complications. Better care requires less transportation of the prisoner out of the facility to a hospital, thus improving security.Lack of trained staff to provide appropriate diabetes care in our over-crowded prisons is one problem. Some prisons only employ LPN’s, who are not allowed to assess. Medical nutritional therapy from registered dieticians also has gone lacking in prisons, and the diet is loaded in carbohydrates and added sugars. Prisoners are routinely given Kool-Aid. Vegetables and fruits are scarce.Exercise is often withheld. Most prisons won’t allow a prisoner to keep insulin needles or blood glucose monitors in the cell with them. Therefore, they must leave the cell, and go see the nurse- who checks their blood sugar and administers their insulin, often at a maximum of twice daily. This is a big problem for Type 1 diabetics, as they often need 4 or more injections of insulin per day to get descent control. Type 1s who use a pump will have to say goodbye to it in prison. They won’t be allowed to have the pump with a needle inserted into their skin for prison safety purposes.The County Jail perspectiveI interviewed a Registered Nurse at a local county jail. It seems that when you come into this particular county jail, you had better be aware of your own symptoms of low blood sugar. It is also apparent from speaking with the nurse, that you should speak up when the guards make their 15 minute rounds, because a diabetic is on “diabetic restrictions” and will only be allowed to buy sugar free snacks to take back to the cell. They are allowed nothing in their cell with quick acting carbohydrates to bring up a low blood sugar. If they feel low blood sugar symptoms coming on, they are to inform an officer on duty.Those with hypoglycemia unawareness are at significant risk at this particular county jail with the current practice that is in place. They are not allowed insulin injections, nor self-monitoring of blood sugar. They are not allowed to have any type of needle that could be considered a weapon in their jail cell. Upon intake, if they say they are diabetic, they get processed through the nurse’s office right away, unless the inmate tells them they have had their medicine for the day.If they don’t speak up and say they are diabetic, the deadline for medical processing is 24 hours. It really depends on the situation, according to the jail nurse interviewed. They are only allowed to exercise in their jail cells with no equipment provided, but they do get a “diabetic diet.” The nurse interviewed for this anonymous report was unable to think of any “earth shattering” incidents while she has been working at the county jail where a patient got into serious medical trouble leading to an incident. So far, they have had none that she is aware of.Federal Prison Guidelines – Are they more in line with ADA Recommendations?In some federal prison facilities, Type 1 and Type 2 diabetics who take insulin are all kept on the same cell block. This may be helpful, as other diabetic prisoners may pick up on the needs of other diabetic inmates in adjacent cells. It’s a fact that federal programs have the most guidelines. So goes it with the federal prison system. Still, internet searches yield a host of complaints related to diabetes care in the federal prison system. Again, care varies from institution to institution, and depends heavily on administration and their take on what kind and quality of care a diabetic patient may receive.It may also depend on the administration’s understanding of diabetes as a chronic disease, and even their knowledge of the different types and treatments for diabetes. It will depend on their policies and procedures in place, and their communication of the importance of following these policies and procedures from the top down.If they see that 4.8% of their population is getting foot ulcers that end up in amputation and a large financial expenditure for the institution, they may be more apt to put in place foot care for all diabetics in their facility.Solitary confinement or lockdown – what then?23 hours in the hole, as they say, can really stress a diabetic out. Blood sugars are going to soar, and from all accounts found by this author, you are not going to get the medical attention nor respect that you are looking for in solitary confinement. You will likely be thrown in there, with nothing but the floor underneath your body.Lockdowns could be similar, with no prisoners getting any of their extra needs met, and guards ignoring requests in an effort t to make the lockdown an effective punitive action. If you experience negligence that results in harm to you during solitary confinement or on lockdown, see the advocacy information listed below under the section, “How can prisoners obtain legal advocacy?”Diabetic prisoners in the newsThe headlines read, “Diabetic Dies in Jail after Police Refuse to give him Insulin.” This story made national news when a man in custody was allowed to go into DKA. He became “too weak to hold up his own head.” He was arrested for not paying his child support, and reportedly told officers that he needed his insulin, but they ignored his repeated requests. On autopsy, his blood sugar was up to 2,500 mg/dl.In New York, a drug dealer was arrested and thrown in Rikers Island Federal Prison. He was denied access to his insulin, and went into DKA, dying after 14 hours. In Virginia, a woman held at a facility there claims to have gone blind and has started a lawsuit. These and other headline stories exist all over the United States, where conditions in over-crowded mass-incarcerated prisons are resulting in sub-standard medical care for all prisoners, not just diabetics.Legal Rights of Prisoners with DiabetesThe ADA wrote a 59-page document outlining the “Legal Rights of Prisoners and Detainees with Diabetes.” In this document, constitutional rights of prisoners are outlined, and deliberate indifference to serious medical needs are considered to be cruel and unusual punishment.In other words, you should do your time, but you have the right to receive appropriate medical care for your condition while you are incarcerated. You are protected under the 8th Amendment of the US Constitution, as are those that are in pre-conviction detention who are protected under the Fourteenth Amendment. Some court cases also site the American with Disabilities act as outlining rights for diabetics in prison3.If a prisoner feels that his constitutional rights have been violated, the ADA document gives steps to take when filing a claim where the defendant is a state, municipality or government official. The majority of claims relate to healthcare that is sub-par. You must prove this, and in one case, a nurse missed one injection for a type 2 diabetic, but it resulted in no immediate problems for the diabetic.Therefore, the plaintiff was not able to show that it was “cruel and unusual punishment,” or “deliberate indifference” that violated his rights. It was simply a medicine error, so the courts will look at the severity to determine if your rights have been violated.How can prisoners obtain legal advocacy?The ADA is the place to look for online resources in the area of advocacy for those who feel that their rights have been violated in prison due to lack of medical treatment, or inadequate medical attention. They also offer advocacy, and you can click here, to go to their advocacy page, where you can ask questions and get help with finding legal assistance.Another good page to read about your rights related to correctional facilities also provides a link to the Prisoner Diabetes Handbook, and other resources. It is also on the ADA website. Click here to go to the resource page.I also recommend reading the following articles:47 Podiatrists Share Tips On Good Foot Care For Those With DiabetesAre People With Diabetes More Prone to Aggression?Ultimate Guide to the A1C Test: Everything You Need To KnowByetta for Type 2 Treatment: Comprehensive ReviewPre-existing Diabetes And PregnancyQuestions and AnswersIf I am in the county jail, will I get the same attention to my diabetes as I would get at a federal penitentiary?In the county jail, they tend to not stick by ADA recommendations as much as in the federal institutions. The federal prisons have more guidelines, more services and more funding to care for those with chronic diseases than do county jail facilities.How often are type 2 diabetics who don’t use insulin allowed to check their blood sugars in prison?From the research that I have done on county and federal prisons, a type 2 diabetic would not be allowed to check his own blood sugars in his cell in most cases. In some federal prisons, inmates report they are allowed to have a glucometer in their cell. In others federal penitentiaries, they are not allowed. This usually depends on the level of security of the federal prison. However, prisoners with type 2 diabetes in prison who do not take insulin generally visit the nurse for blood sugar checks and medication 1 to 2 times per day, depending on their doctor’s orders.Are all diabetics treated the same across all prisons and jail systems in the United States?No, varying financial situations, budgets, availability of trained staff, and even warden opinions on care for diabetic patients in prison, can affect the level of care. Those prisons in urban areas may have access to better care and services, as well as trained staff. Rural areas may lack in medical personnel to promptly deal with situations diabetics encounter, and lack in funding for needed services.Do you get to keep a blood sugar machine in your cell in prison or jail?In the county jail perspective section above, one county jail nurse interviewed stated that the county inmates are not allowed to keep any kind of sharp or needle in their cells. In several blogs online, I was able to find where some federal prisons do allow diabetics to keep their glucometer in their cell and monitor their own blood sugars. This is not the case in all federal prisons. However, the ADA does recommend that patients in prison with diabetes should be allowed to self-monitor their blood glucose.Are prisoners allowed to have food in their cells to combat low blood sugar symptoms?The nurse interviewed in the county jail perspective above states that patients are under “diabetes restrictions,” and are therefore not allowed to have any carbohydrate containing food in their cells. All snacks purchased at the commissary are to be sugar (carbohydrate) free. They must notify the guard on their 15 minute rounds if they have signs of high or low blood sugars, and rely on the guard to report to the nurse. Those with hypoglycemia unawareness would be at risk. In the federal and possibly some county prisons, carbohydrates are allowed in the inmate’s cell, but this may vary from facility to facility, based on many factors.If prison or jail meals are vary starchy, are they allowed substitutions? In some larger facilities where there are dieticians, the diabetic may be given healthier substitutions, but for the most part, the internet is filled with inmates with diabetes complaining about poor dietary choices in prisons and jails nationwide.Do diabetics who are incarcerated get a different diet?Yes, in most institutions, they get what is generically referred to as a “diabetic diet”If they are not allowed to keep a fast acting carbohydrate in their cell, are they able to get juice or something to bring up their blood sugar?In some cases, yes. Other high profile cases in the news criticize prison officials when inmates are allowed to have seizures and die in their cells due to no quick carbohydrates available and lack of timeliness of response by guards and prison medical personnel.If a diabetic prisoner experiences high blood sugar and diabetic ketoacidosis (extremely high blood sugar over 500 mg/dl) do they take inmates to the hospital or keep them in their cells?This has a lot to do with the prison officials and the guards on duty at the time of the medical emergency. You can refer to the section above, “Diabetic Prisoners in the News,” above, for stories that made national headlines related to this subject where a prisoner died due to DKA (Diabetic Ketoacidosis).Has anyone ever died in prison from diabetes acute complications?Yes, there are several high profile cases that were in the national news outlines in the section above entitled, “Diabetic Prisoners in the News.”Can you wear an insulin pump in prison?No, it is considered a weapon. Insulin is given by the medical staff in prison.Will I be able to get diabetes education in prison?The ADA thinks you should, but whether or not this is the case, varies from facility to facility, and may be based on availability of qualified providers, administration support of the program, and funding, among other things.How can I manage my diabetes during periods of solitary confinement or lockdown?See the section on solitary confinement and lockdowns above.What are my rights and what if I’m unhappy with the care I receive for diabetes in prison?See the section above on legal rights and how to obtain advocacy.Are women with diabetes in prison getting different treatment than men?Research revealed poor treatment for diabetics for both men and women in correctional institutions in certain situations. However, I have seen no research to back up that care for one gender is better or worse than for another gender.What if I need specialized care in prison because of diabetes? Will I get it?Maybe, and maybe not. It depends on the facility. Some people complain that they only have plastic flip-flop style shoes in prison, and no appropriate footwear. Some complain that they are not allowed specialized treatments such as to go to a hyperbaric wound healing clinic.How will I be able to make an appointment with medical staff when I’m an inmate?In some instances, you may be able to send a message through a guard, or send a request through the prison warden.

An emergency medical technician (EMT), also known as an ambulance technician, is a health professional that provides emergency medical services.EMTs are most commonly found working in ambulances. In English-speaking countries, paramedics are a separate profession that has additional educational requirements, qualifications, and scope of practice.EMTs are often employed by private ambulance services, municipal EMS agencies, government, and fire departments. Some EMTs are paid employees, while others (particularly those in rural areas) are volunteers.EMTs provide medical care under a set of protocols, which are typically written by a physician.EMTs are exposed to a variety of hazards such as lifting patients and equipment, treating those with infectious disease, handling hazardous substances, and transportation via ground or air vehicles. Employers can prevent occupational illness or injury by providing safe patient handling equipment, implementing a training program to educate EMTs on job hazards, and supplying PPE such as respirators, gloves, and isolation gowns when dealing with biological hazards.Infectious disease has become a major concern, in light of the COVID-19 pandemic. In response, the U.S. Centers for Disease Control and Prevention and other agencies and organizations have issued guidance regarding workplace hazard controls for COVID-19. Some specific recommendations include modified call queries, symptom screening, universal PPE use, hand hygiene, physical distancing, and stringent disinfection protocols.Research on ambulance ventilation systems found that aerosols often recirculate throughout the compartment, creating a health hazard for EMTs when transporting sick patients capable of airborne transmission.Entry-level EMS healthcare professional, with 120 hours of classroom training followed by 40 hours clinical placement.A state-level exam needs to be completed before you are invited to register as an EMT.EMT's are trained in basic life support, anatomy/physiology, pathophysiology, pharmacology, ECG monitoring, advanced airway management (supraglottic airways), spinal immobilization and the administration of medication typically oral, intramuscular, inhaled, nebulised or sublingual.In the United States, EMTs are certified according to their level of training. Individual states set their own standards of certification (or licensure, in some cases) and all EMT training must meet the minimum requirements as set by the National Highway Traffic Safety Administration's (NHTSA) standards for curriculum.The National Registry of Emergency Medical Technicians (NREMT) is a private organization that offers certification exams based on NHTSA education guidelines and has been around since the 1970s.Currently, NREMT exams are used by 46 states as the sole basis for certification at one or more EMT certification levels.A NREMT exam consists of skills and patient assessments as well as a written portion.On June 12, 2019, the NREMT changed the rules regarding age limits for EMTs, AEMTs, and Paramedics. There is no longer an age limit for registered personnel. However, applicants must successfully complete a state-approved EMT course that meets or exceeds the NREMT Standards within the past 2 years of applying. Those applying for the NREMT Certification must also complete a state-approved EMT psychomotor exam. It is possible for the candidate to be refused access to a state-approved course due to their age within the state.LevelsNHTSA recognizes four levels of Emergency Medical Technician:EMR (Emergency Medical Responder)EMT (Emergency Medical Technician)AEMT (Advanced Emergency Medical Technician)ParamedicSome states also recognize the Advanced Practice Paramedic or Critical Care Paramedic level as a state-specific licensure above that of the Paramedic. These Critical Care Paramedics generally perform high acuity transports that require skills outside the scope of a standard paramedic (such as mechanical ventilation and management of cardiac assist devices).In addition, EMTs can seek out specialty certifications such as Wilderness EMT, Wilderness Paramedic, Tactical EMT, and Flight Paramedic.In 2009, the NREMT posted information about a transition to a new system of levels for emergency care providers developed by NHTSA with the National EMS Scope of Practice project.By 2014, these "new" levels will replace the fragmented system found around the United States. The new classification will include Emergency Medical Responder (replacing first responder), Emergency Medical Technician (replacing EMT-Basic), Advanced Emergency Medical Technician (replacing EMT-Intermediate/85), and Paramedic (replacing EMT-Intermediate/99 and EMT-Paramedic). Education requirements in transitioning to the new levels are substantially similar.The procedures and skills allowed at this level include bleeding control, management of burns, splinting of suspected fractures and spinal injuries, childbirth, cardiopulmonary resuscitation, semi-automatic defibrillation, oral suctioning, insertion of oropharyngeal and nasopharyngeal airways, pulse oximetry, blood glucose monitoring, auscultation of lung sounds, and administration of a limited set of medications (including oxygen, epinephrine, dextrose, nalaxone, albuterol, ipratropium bromide, glucagon, nitroglycerin, nitrous oxide, and acetylsalicylic acid). Some areas may add to the scope of practice, including intravenous access, insertion of supraglottic airway devices and CPAP. Training requirements and treatment protocols vary from area to area.An ambulance with only EMTs is considered a Basic Life Support (BLS) unit, an ambulance utilizing AEMTs is dubbed an Intermediate Life Support (ILS), or limited Advanced Life Support (LALS) unit, and an ambulance with Paramedics is dubbed an Advanced Life Support (ALS) unit. Many states allow ambulance crews to contain a mix of crews levels (e.g. an EMT and a Paramedic or an AEMT and a Paramedic) to staff ambulances and operate at the level of the highest trained provider. There is nothing stopping supplemental crew members to be of a certain certification, though (e.g. if an ALS ambulance is required to have two Paramedics, then it is acceptable to have two Paramedics and an EMT). An emergency vehicle with only EMRs or a combination of both EMRs and EMTs is still dubbed a Basic Life Support (BLS) unit. An EMR must usually be overseen by an EMT-level provider or higher to work on a transporting ambulance.Education and trainingEMT training programs for certification vary greatly from course to course, provided that each course at least meets local and national requirements. In the United States, EMRs receive at least 40–80 hours of classroom training and EMTs receive at least 120–300 hours of classroom training. AEMTs generally have 200–500 hours of classroom training, and Paramedics are trained for 1,500–2,500 hours or more.In addition to each level's didactic education, clinical rotations are typically also be required. Similar in a sense to medical school clinical rotations, EMT students are required to spend a required amount of time in an ambulance and on a variety of hospital services (e.g. obstetrics, emergency medicine, surgery, intensive care unit, psychiatry) in order to complete a course and become eligible for the certification and licensure exams.The number of clinical hours for both time in an ambulance and time in the hospital vary depending on local requirements, the level the student is obtaining, and the amount of time it takes the student to show competency.In addition, a minimum of continuing education (CE) hours is required to maintain certification. For example, to maintain NREMT certification, EMTs must obtain at least 48 hours of additional education and either complete a 24-hour refresher course or complete an additional 24 hours of CEs that would cover, on an hour by hour basis, the same topics as the refresher course would.Recertification for other levels follows a similar pattern.EMT training programs vary greatly in calendar length (number of days or months). For example, fast track programs are available for EMTs that are completed in two weeks by holding class for 8 to 12 hours a day for at least two weeks. Other training programs are months long, or up to 2 years for Paramedics in an associate degree program. EMT training programs take place at numerous locations, such as universities, community colleges, technical schools, hospitals or EMS academies. Every state in the United States has an EMS lead agency or state office of emergency medical services that regulates and accredits EMT training programs. Most of these offices have web sites to provide information to the public and individuals who are interested in becoming an EMT.Medical directionIn the United States, an EMT's actions in the field are governed by state regulations, local regulations, and by the policies of their EMS organization. The development of these policies are guided by a physician medical director, often with the advice of a medical advisory committee.In California, for example, each county's Local Emergency Medical Service Agency (LEMSA) issues a list of standard operating procedures or protocols, under the supervision of the California Emergency Medical Services Authority. These procedures often vary from county to county based on local needs, levels of training and clinical experiences.New York State has similar procedures, whereas a regional medical-advisory council ("REMAC") determines protocols for one or more counties in a geographical section of the state.Treatments and procedures administered by Paramedics fall under one of two categories, off-line medical orders (standing orders) or on-line medical orders. On-line medical orders refers to procedures that must be explicitly approved by a base hospital physician or registered nurse through voice communication (generally by phone or radio) and are generally rare or high risk procedures (e.g. vasopressor initiation).In addition, when multiple levels can perform the same procedure (e.g. AEMT-Critical Care and Paramedics in New York), a procedure can be both an on-line and a standing order depending on the level of the provider.Since no set of protocols can cover every patient situation, many systems work with protocols as guidelines and not "cook book" treatment plans.Finally, systems also have policies in place to handle medical direction when communication failures happen or in disaster situations.The NHTSA curriculum is the foundation Standard of Care for EMS providers in the US.EmploymentEMTs and Paramedics are employed in varied settings, mainly the prehospital environment such as in EMS, fire, and police agencies. They can also be found in positions ranging from hospital and health care settings, industrial and entertainment positions.The prehospital environment is loosely divided into non-emergency (e.g. patient transport) and emergency (9-1-1 calls) services, but many ambulance services and EMS agencies operate both non-emergency and emergency care.In many places across the United States, it is not uncommon for the primary employer of EMRs, EMTs, and Paramedics to be the fire department, with the fire department providing the primary emergency medical system response including "first responder" fire apparatus, as well as ambulances.In many other locations, emergency medical services are provided by a separate, or “third-party”, municipal government emergency agency (e.g. Boston EMS, Austin-Travis County EMS).In still other locations, emergency medical services are provided by volunteer agencies. College and university campuses may provide emergency medical responses on their own campus using students.In some states of the US, many EMS agencies are run by Independent Non-Profit Volunteer First Aid Squads that are their own corporations set up as separate entities from fire departments. In this environment, volunteers are hired to fill certain blocks of time to cover emergency calls. These volunteers have the same state certification as their paid counterparts.NURSEThe authority for the practice of nursing is based upon a social contract that delineates professional rights and responsibilities as well as mechanisms for public accountability. In almost all countries, nursing practice is defined and governed by law, and entrance to the profession is regulated at the national or state level.The aim of the nursing community worldwide is for its professionals to ensure quality care for all, while maintaining their credentials, code of ethics, standards, and competencies, and continuing their education.There are a number of educational paths to becoming a professional nurse, which vary greatly worldwide; all involve extensive study of nursing theory and practice as well as training in clinical skills.Nurses care for individuals of all ages and cultural backgrounds who are healthy and ill in a holistic manner based on the individual's physical, emotional, psychological, intellectual, social, and spiritual needs. The profession combines physical science, social science, nursing theory, and technology in caring for those individuals.To work in the nursing profession, all nurses hold one or more credentials depending on their scope of practice and education. In the United States, a Licensed Practical Nurse (LPN) works independently or with a Registered Nurse (RN). The most significant difference between an LPN and RN is found in the requirements for entry to practice, which determines entitlement for their scope of practice. RNs provide scientific, psychological, and technological knowledge in the care of patients and families in many health care settings. RNs may earn additional credentials or degrees.In the United States, multiple educational paths will qualify a candidate to sit for the licensure examination as an RN. The Associate Degree in Nursing (ADN) is awarded to the nurse who has completed a two-year undergraduate academic degree awarded by community colleges, junior colleges, technical colleges, and bachelor's degree-granting colleges and universities upon completion of a course of study usually lasting two years. It is also referred to as Associate in Nursing (AN), Associate of Applied Science in Nursing (AAS), or Associate of Science in Nursing (ASN).The Bachelor of Science in Nursing (BSN) is awarded to the nurse who has earned an American four-year academic degree in the science and principles of nursing, granted by a tertiary education university or similarly accredited school. After completing either the LPN or either RN education programs in the United States, graduates are eligible to sit for a licensing examination to become a nurse, the passing of which is required for the nursing license. The National Licensure Examination (NCLEX) test is a standardized exam (including multiple choice, select all that apply, fill in the blank and "hot spot" questions) that nurses take to become licensed. It costs two-hundred dollars to take the NCLEX. It examines a nurses ability to properly care for a client. Study books and practice tests are available for purchase.Some nurses follow the traditional role of working in a hospital setting. Other options include: pediatrics, neonatal, maternity, OBGYN, geriatrics, ambulatory, and nurse anesthetists and informatics (eHealth). There are many other options nurses can explore depending on the type of degree and education acquired. RNs may also pursue different roles as advanced practice nurses.Nurses are not doctors' assistants. This is possible in certain situations, but nurses more often are independently caring for their patients or assisting other nurses.RNs treat patients, record their medical history, provide emotional support, and provide follow-up care. Nurses also help doctors perform diagnostic tests. Nurses are almost always working on their own or with other nurses. Nurses will assist doctors in the emergency room or in trauma care when help is needed.Medication management and administration are part of most hospital nursing roles, however, prescribing authority varies between jurisdictions. In many areas, registered nurses administer and manage medications prescribed by a professional with full prescribing authority such as a nurse practitioner or physician. As nurses are responsible for evaluating patients throughout their care - including before and after medication administration - adjustments to medications are often made through a collaborative effort between the prescriber and the nurse. Regardless of the prescriber, nurses are legally responsible for the drugs they administer. There may be legal implications when there is an error in a prescription, and the nurse could be expected to have noted and reported the error. In the United States, nurses have the right to refuse any medication administration that they deem to be potentially harmful to the patient.Nursing is the most diverse of all health care professions. Nurses practice in a wide range of settings but generally nursing is divided depending on the needs of the person being nursed.The major populations are:communities/publicfamily/individual across the lifespanadult-gerontologypediatricsneonatalwomen's health/gender-relatedmental healthinformatics (eHealth)acute care hospitalsambulatory settings (physician offices, urgent care settings, camps, etc)school/college infirmariesThere are also specialist areas such as cardiac nursing, orthopedic nursing, palliative care, perioperative nursing, obstetrical nursing, oncology nursing, nursing informatics, telenursing, radiology, and emergency nursing.Nurses practice in a wide range of settings, including hospitals, private homes, schools, and pharmaceutical companies. Nurses work in occupational health settings (also called industrial health settings), free-standing clinics and physician offices, nurse-led clinics, long-term care facilities and camps. They also work on cruise ships and in military service. Nurses act as advisers and consultants to the health care and insurance industries. Many nurses also work in the health advocacy and patient advocacy fields at companies such as Health Advocate, Inc. helping in a variety of clinical and administrative issues.Some are attorneys and others work with attorneys as legal nurse consultants, reviewing patient records to assure that adequate care was provided and testifying in court. Nurses can work on a temporary basis, which involves doing shifts without a contract in a variety of settings, sometimes known as per diem nursing, agency nursing or travel nursing. Nurses work as researchers in laboratories, universities, and research institutions. Nurses have also been delving into the world of informatics, acting as consultants to the creation of computerized charting programs and other software. Nurse authors publish articles and books to provide essential reference materials.The fast-paced and unpredictable nature of health care places nurses at risk for injuries and illnesses, including high occupational stress. Nursing is a particularly stressful profession, and nurses consistently identify stress as a major work-related concern and have among the highest levels of occupational stress when compared to other professions. This stress is caused by the environment, psychosocial stressors, and the demands of nursing, including new technology that must be mastered, the emotional labor involved in nursing, physical labor, shift work, and high workload. This stress puts nurses at risk for short-term and long-term health problems, including sleep disorders, depression, mortality, psychiatric disorders, stress-related illnesses, and illness in general. Nurses are at risk of developing compassion fatigue and moral distress, which can worsen mental health. They also have very high rates of occupational burnout (40%) and emotional exhaustion (43.2%). Burnout and exhaustion increase the risk for illness, medical error, and suboptimal care provision.Nurses are also at risk for violence and abuse in the workplace.Violence is typically perpetrated by non-staff (e.g. patients or family), whereas abuse is typically perpetrated by other hospital personnel. Of American nurses, 57% reported in 2011 that they had been threatened at work; 17% were physically assaulted.In the US, scope of practice is determined by the state or territory in which a nurse is licensed. Each state has its own laws, rules, and regulations governing nursing care. Usually the making of such rules and regulations is delegated to a state board of nursing, which performs day-to-day administration of these rules, licenses for nurses and nursing assistants, and makes decisions on nursing issues. In some states, the terms "nurse" or "nursing" may only be used in conjunction with the practice of a registered nurse (RN) or licensed practical or vocational nurse (LPN/LVN).In the hospital setting, registered nurses often delegate tasks to LPNs and unlicensed assistive personnel.RNs are not limited to employment as bedside nurses. They are employed by physicians, attorneys, insurance companies, governmental agencies, community/public health agencies, private industry, school districts, ambulatory surgery centers, among others. Some registered nurses are independent consultants who work for themselves, while others work for large manufacturers or chemical companies. Research nurses conduct or assist in the conduct of research or evaluation (outcome and process) in many areas such as biology, psychology, human development, and health care systems.Many employers offer flexible work schedules, child care, educational benefits, and bonuses. About 21 percent of registered nurses are union members or covered by union contract.Nursing is the nation's largest health care profession. In 2017, there were more than 4,015,250 registered nurses and 922,196 licensed practical nurses nationwide.Of all licensed RNs, 2.6 million or 84.8% are employed in nursing. Nurses comprise the largest single component of hospital staff, are the primary providers of hospital patient care, and deliver most of the nation's long-term care. The primary pathway to professional nursing, as compared to technical-level practice, is the four-year Bachelor of Science in Nursing (BSN) degree. Registered nurses are prepared either through a BSN program; a three-year associate degree in nursing; or a three-year hospital training program, receiving a hospital diploma. All take the same state licensing exam. (The number of diploma programs has declined steadily—to less than 10 percent of all basic RN education programs—as nursing education has shifted from hospital-operated instruction into the college and university system.)Educational and licensure requirementsDiploma in NursingThe oldest method of nursing education is the hospital-based diploma program, which lasts approximately three years. Students take between 30 and 60 credit hours in anatomy, physiology, microbiology, nutrition, chemistry, and other subjects at a college or university, then move on to intensive nursing classes. Until 1996, most RNs in the US were initially educated in nursing by diploma programs.[62]According to the Health Services Resources Administration's 2000 Survey of Nurses only six percent of nurses who graduated from nursing programs in the United States received their education at a Diploma School of Nursing.Associate Degree in NursingThe most common initial nursing education is a two-year Associate Degree in Nursing (Associate of Applied Science in Nursing, Associate of Science in Nursing, Associate Degree in Nursing), a two-year college degree referred to as an ADN. Some four-year colleges and universities also offer the ADN. Associate degree nursing programs have prerequisite and corequisite courses (which may include English, Math and Human Anatomy and Physiology) and ultimately stretch out the degree-acquiring process to about three years or greater.Bachelor of Science in NursingThe third method is to obtain a Bachelor of Science in Nursing (BSN), a four-year degree that also prepares nurses for graduate-level education. For the first two years in a BSN program, students usually obtain general education requirements and spend the remaining time in nursing courses. In some new programs the first two years can be substituted for an active LPN license along with the required general studies. Advocates for the ADN and diploma programs state that such programs have an on the job training approach to educating students, while the BSN is an academic degree that emphasizes research and nursing theory. Some states require a specific amount of clinical experience that is the same for both BSN and ADN students. A BSN degree qualifies its holder for administrative, research, consulting and teaching positions that would not usually be available to those with an ADN, but is not necessary for most patient care functions. Nursing schools may be accredited by either the Accreditation Commission for Education in Nursing (ACEN) or the Commission on Collegiate Nursing Education (CCNE).Graduate educationAdvanced education in nursing is done at the master's and doctoral levels. It prepares the graduate for specialization as an advanced practice registered nurse (APRN) or for advanced roles in leadership, management, or education. The clinical nurse leader (CNL) is an advanced generalist who focuses on the improvement of quality and safety outcomes for patients or patient populations from an administrative and staff management focus. Doctoral programs in nursing prepare the student for work in nursing education, health care administration, clinical research, public policy, or advanced clinical practice. Most programs confer the PhD in nursing or Doctor of Nursing Practice (DNP).Advanced practice registered nurse (APRN)Areas of advanced nursing practice include that of a nurse practitioner (NP), a certified nurse midwife (CNM), a certified registered nurse anesthetist (CRNA), or a clinical nurse specialist (CNS). Nurse practitioners and CNSs work assessing, diagnosing and treating patients in fields as diverse as family practice, women's health care, emergency nursing, acute/critical care, psychiatry, geriatrics, or pediatrics, additionally, a CNS usually works for a facility to improve patient care, do research, or as a staff educator.Licensure examinationCompletion of any one of these three educational routes allows a graduate nurse to take the NCLEX-RN, the test for licensure as a registered nurse, and is accepted by every state as an adequate indicator of minimum competency for a new graduate. However, controversy exists over the appropriate entry-level preparation of RNs. Some professional organizations believe the BSN should be the sole method of RN preparation and ADN graduates should be licensed as "technical nurses" to work under the supervision of BSN graduates. Others feel the on-the-job experiences of diploma and ADN graduates makes up for any deficiency in theoretical preparation.RNs are the largest group of health care workers in the United States, with about 2.7 million employed in 2011.It has been reported that the number of new graduates and foreign-trained nurses is insufficient to meet the demand for registered nurses; this is often referred to as the nursing shortage and is expected to increase for the foreseeable future. There are data to support the idea that the nursing shortage is a voluntary shortage.In other words, nurses are leaving nursing of their own volition. In 2006 it was estimated that approximately 1.8 million nurses chose not to work as a nurse. The Bureau of Labor Statistics (BLS) reported that 296,900 healthcare jobs were created in 2011. RNs make up the majority of the healthcare workforce, therefore these positions will be filled primarily by nurses. The BLS also states that by 2020, there will be 1.2 million nursing job openings due to an increase in the workforce, and replacements.With health care knowledge growing steadily, nurses can stay ahead of the curve through continuing education. Continuing education classes and programs enable nurses to provide the best possible care to patients, advance nursing careers, and keep up with the Board of Nursing requirements. The American Nurses Association and the American Nursing Credentialing Center are devoted to ensuring nurses have access to quality continuing education offerings. Continuing education classes are calibrated to provide enhanced learning for all levels of nurses. Many States also regulate Continuing Nursing Education. Nursing licensing boards requiring Continuing Nursing Education (CNE) as a condition for licensure, either initial or renewal, accept courses provided by organizations that are accredited by other state licensing boards, by the American Nursing Credentialing Center (ANCC), or by organizations that have been designated as an approver of continuing nursing education by ANCC.There are some exceptions to this rule including the state of California, Florida, and Kentucky. National Healthcare Institute has created a list to assist nurses in determining their CNE credit hours requirements. While this list is not all-inclusive, it offers details on how to contact nursing licensing boards directly.Board certificationProfessional nursing organizations, through their certification boards, have voluntary certification exams to demonstrate clinical competency in their particular specialty. Completion of the prerequisite work experience allows an RN to register for an examination, and passage gives an RN permission to use a professional designation after their name. For example, the passage of the American Association of Critical-care Nurses specialty exam allows a nurse to use the initials 'CCRN' after his or her name. Other organizations and societies have similar procedures.The American Nurses Credentialing Center, the credentialing arm of the American Nurses Association, is the largest nursing credentialing organization and administers more than 30 specialty examinations.