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Nursing and You

Vol. 1, No. 1, Jan. 1999 - Women's Health Issues

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Welcome to Nursing and You

Welcome to the first issue of a new publishing venture for us at the College of Nurses of Ontario (CNO), the regulatory body for the nursing profession in this province.

There are several nursing publications in Ontario which have nurses as their main reading audience. Included among them is our own quarterly Communiqué, which keeps our more than 140,000 nurse members informed about self-regulation and the high standards needed to practise nursing in Ontario (see the article "What is the CNO?").

The College of Nurses exists primarily to serve and protect the public, the users of nursing services. Our job is to ensure that whenever you seek health care, you will receive the highest standard of care possible from the Registered Nurse (RN) or Registered Practical Nurse (RPN) who helps to deliver that care.

An important part of the College's mandate is to ensure public awareness of what we do and how we do it. The purpose of Nursing and You, therefore, is to introduce you to nurses working in various sectors of health care, and through their stories, to illustrate how self-regulation works, and why it means better health care for you.

Surveys have shown that nursing is one of the most honoured and respected professions in Canada and throughout the world. Ontarians can indeed be proud of their nurses, and we are proud of the part the College plays in helping nurses maintain their high standards.

We hope you enjoy reading Nursing and You, and that it helps you gain a little more insight into the exciting and demanding profession of nursing in Ontario. We welcome your comments and ideas, so please write or e-mail to us at the addresses on the website.

Petra Cooke, RN
Council President
College of Nurses of Ontario

Margaret Risk, RN
Executive Director
College of Nurses of Ontario

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Who's Who in the Emergency Room

Frequently, when we enter a health care setting, our state of mind is not at its best. We may for a variety of reasons be only vaguely aware that there are a number of health care providers in the vicinity, all very busy, and (we hope) in some mysterious way coordinated in their activity to ensure that our needs are met.

In this occasional "Who's Who" series in Nursing and You, we're going to visit some of these health care settings, to demystify their busyness, and sort out each individual's role. This month, we're in the emergency room at Markham-Stouffville Hospital, a mid-sized community hospital.

As with most emergency rooms, there are two ways to arrive at the ER at Markham-Stouffville:

  • the ambulatory entrance, which brings you into the waiting room;
  • or via the ambulance bay, which usually means you're being wheeled in on a gurney.

In the waiting room, we see a sign that says: "Triage Desk: Emergency. Check-in here first." "Triage" means "assessment"; what the sign means is that, unlike in some other ERs, the first person you're going to see here is a nurse, and not just any nurse, but the head nurse for the whole department. Because the triage nurse is probably the only provider to see each and every patient that comes into the ER, she or he is the traffic cop, deciding which patients need immediate treatment, the kind of treatment that each patient will need, and keeping track of it all on a master flow chart just out of sight of the patient (for confidentiality reasons).

When you are directed to the registration desk, however, the person you'll talk to is not a nurse, but a medical secretary, or someone with similar training. There are usually two registration clerks on the busy afternoon shift, as well as another secretary inside at the nursing station.

To the right of the triage desk are a pair of swinging doors; beyond them is where the ER action really is. The Markham-Stouffville ER is arranged in a circular layout, with the nursing station at the hub. For the most part, the farther a room from the station, the less of an "emergency" is involved. For instance, just inside the doors is the "urgent care" area, with six beds and two RNs assigned to it full-time. The RNs you meet in the ER have, in addition to their basic nursing education, a large amount of additional training in areas such as trauma response and critical care.

The room furthest away, about a five second walk, is the examination room, for those recovering from treatment or awaiting a room elsewhere in the hospital. One RN staffs this area (she is also the first nurse on call to the trauma or resuscitation room). There are also a number of specialty treatment areas, such as an orthopaedic room for bone fractures, a suture room, or an interview room for psychiatric patients. There is one RN responsible for the patients in this area; her role is to assist the physician with treatments and prepare the patient for procedures. Many of these rooms have just one bed; if you require one of these, your wait may be longer than average.

This will also be true if you require a specialized physician for assessment or treatment; there is only one doctor on any ER shift in this hospital, and specialists may be otherwise occupied elsewhere in the hospital or in the community.

A patient who arrives at the ER by ambulance enters by a different door, but otherwise the process is much the same. Unless wheeled immediately into the trauma room (with a great deal of resuscitation and stabilization equipment), just inside the ambulance bay doors, the patient will be assessed by the same triage nurse as the ambulatory patients, and put into the same flow, going to different areas according to need. The job of the ambulance paramedics ceases as soon as they've filled in the triage nurse on anything she or he needs to know.

In summary, then, the staff of this ER (on the busiest shift) is as follows: five nurses (one triage, one exam room, two urgent care, one specialty care), all of them RNs (although some ERs use registered practical nurses in areas like the examination room, where the patient's condition is less acute and more predictable); one physician; two registration clerks; one nursing station secretary; one porter, to transport patients and assist in restraint if necessary; and one volunteer, to change linens, assist with monitoring of waiting room patients, and other odd jobs. Only the five nurses and the physician are regulated health care providers; although the others may have considerable hospital experience, they are not expected, nor allowed, to play a significant role in the treatment of a patient.

In addition, a number of other members of the emergency team are on call should the need arise. These include a social worker, a chaplain (one in the hospital, others of different denominations throughout the community), and a number of specialist doctors, including a psychiatrist. It is a highly trained, dedicated team, intensely proud of what they do. "The ER," says Ru Taggar, RN, the coordinator of the department, "is an exciting and challenging place for nurses to work, one that calls on different components of your nursing education every minute of every day. We're really at the front lines of health care."

We'd like to thank Ru Taggar, Emergency Care Coordinator at Markham-Stouffville, and her obliging staff for their cooperation in the preparation of this article.

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How Nurses Regulate Themselves - Standards of Practice

There are many ways in which the nursing profession regulates itself through the College of Nurses of Ontario to protect the public. One of our most important obligations is to establish guidelines for how nurses do what they do, in an effective, safe and ethical manner.

There are two major components of the "standards of practice" for nursing, that in combination form CNO's expectations in relation to members' conduct and practice.

The first are the legislation and regulations, laws which apply directly to nursing practice. Particular examples here are the Regulated Health Professions Act, which identifies the "controlled acts" that nurses can perform (actions which, if performed by an unqualified person, could potentially harm a patient), and the Nursing Act, which defines the scope of practice of the profession. The regulations cover a variety of topics such as the requirements for registration, the quality assurance obligations of all nurses, and professional misconduct.

The standards of practice for nursing can also be found in a large number of documents that are variously called professional standards, policies and guidelines. The focus of these can be broad, applying to all nurses in all health care delivery settings, or they can address a particular aspect of practice. Examples of the former are standards on ethics, nurses' responsibility for ongoing learning, or professional behaviour, while the latter include standards on footcare, transporting patients, or giving telephone advice.

In the case of legislation and regulations, the provincial government makes the final decision, but the College provides comments and recommendations. In regard to all other standards of practice, the profession is entirely self-regulating. Members of the profession are consulted extensively in drafting the standards, which are ultimately adopted by the Council in an open meeting.

It is also important to note that standards of practice are never set in stone. Health care takes place in an environment of rapid change. College staff and Council members, as well as nurses and employers, constantly monitor the standards to ensure they fit with the reality of the workplace, and continue to adequately safeguard the public.

That is the key - the public. The over-riding concern of every activity the CNO undertakes is that whenever a health care client encounters a nurse, that client receives the highest quality of care possible.

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Ontario Nurses in the News: Mopping Up After Mitch

Captain Caroline Price is a Canadian Armed Forces RN with the new Disaster Assistance Response Team (DART). She arrived at the Honduran village of Sonaguera on November 12 of last year, in the aftermath of the destruction wrought by Hurricane Mitch, which destroyed many communities and took thousands of lives throughout Central America.

Capt. Price is one of four Ontario RNs on the 150-person DART team, the others being Yvonne Brierley, Tim Brown, and David King. Back home at CFB Petawawa, near Ottawa (she received her nursing degree at the University of Ottawa), she commands a field ambulance unit with 30 paramedics. At Sonaguera, the Canadian group is much more bare-bones. Actually, the medical group is only a part of the DART team. Equally important, even to Price, are the engineers. "The flooding contaminated a lot of the wells," she says, "and the engineers are working hard to get clean water again. Without that, much of what we do would be pretty pointless."

The day for DART, headquartered at La Ceiba on the Mosquito Coast ("very appropriately named," says Price) begins at six a.m. Breakfast, like the other meals, consists of hard rations ("you can't trust the fruit or veggies, and even with the rations, you're always looking for wee buggies"). Then it's into the helicopters to fly into one of the remote villages (the Canadians are responsible for an area of over 1,000 square kilometres) for an all-day clinic, where the team and its Honduran colleagues will see upwards of 500 people.

"The clinics operate much like a walk-in clinic back home. But thanks to Mitch, the conditions are pretty primitive, and the state of the children in particular is depressing sometimes. You know there are things wrong which could have been caught earlier, like untreated head injuries, and they've caused the effects of the flooding to be worse than they should have. But you end up doing quite a bit of teaching, and that's very satisfying," says Price.

Finally, after more than 12 hours, the helicopters return to take the team back to base, where they spend the night packing supplies for the next day, then crash into bed in tents set on pallets in the never-ending sea of mud. The nurses get only Sunday morning off.

On the day she spoke with us, Caroline Price and her colleagues had just been hit with another downpour. But she sounded upbeat nevertheless. "We were already in mud," she says, "now we're just in more mud."

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Around the Block, Around the World

From a regulatory point of view, Capt. Caroline Price and her colleagues in Honduras' Aguan Valley are no different from the nurses in the Markham-Stouffville ER or your community nursing home. No matter their practice setting, whether they're standing on gleaming linoleum or in ankle-deep mud, they are all Ontario nurses, and accountable to the College, and to you, for maintaining high standards of care.

For Capt. Price, the obstacles to maintaining those standards are definitely not typical of those she faced in Ontario. "You certainly have to modify your expectations. The biggest frustrations are in communication; there are never enough interpreters, it seems, and none of us spoke Spanish when we got here. But the toughest task is not in treating those we find; it's finding those we need to treat."

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What is the College of Nurses of Ontario?

The College of Nurses of Ontario (CNO) is the regulatory body for nursing in this province. Established by, but at arm's length from, the provincial government, CNO derives almost all of its revenues from annual membership fees; it receives no funding from the province. The College decides the criteria for becoming a nurse in Ontario, and the standards of practice which must be met to maintain that designation and privilege. No one can practise as a nurse in Ontario or use the titles "nurse", "registered nurse", or "registered practical nurse" without a valid certificate of registration from the College. There are similar Colleges for many other (though not all) categories of health care provider in the province. There are twenty-one regulatory Colleges in all.

The College of Nurses has over 140,000 practising members across Ontario (by comparison, there are about 25,000 physicians, 3,700 registered massage therapists, and 147 members in the College of Midwives). We have about 106,600 registered nurses (RNs) in the general class and 33,800 registered practical nurses. Over 200 registered nurses belong to the extended class, and are also known as nurse practitioners (see the "Diary" article on Wendy Pollard).

All of Ontario's health regulatory Colleges are structured similarly, as set out in the Regulated Health Professions Act (1994). We are charged with:

  • deciding what education and other qualifications are necessary to become a member;
  • establishing the standards of practice with which all our members must comply;
  • administering quality assurance programs that members are required to participate in to help maintain their competence; and
  • providing a complaint and investigative process for people who feel the standards have not been met.

CNO is governed by a 39-member Council, 21 of whom are nurses elected by their peers from across Ontario (14 RNs and 7 RPNs). The other 18 members of Council are appointed by the provincial government, and are members of the public. The Council President, chosen by the whole Council, may be either an elected or appointed member, but the two Vice-Presidents must be an elected RN and elected RPN.

Supporting the Council in its work are a number of statutory (i.e. established by law) committees. They are:

  • Executive Committee - makes decisions between the quarterly Council meetings, and has an important role in the complaints process.
  • Client Relations Committee - responsible for enhancing the relationship between the public and nurses, and administering the College's abuse prevention program.
  • Complaints and Discipline - these two committees deal with alleged infractions of the standards of practice and professional misconduct, which arise from complaints.
  • Registration Committee - assesses applicants' qualifications to practise nursing in Ontario.
  • Quality Assurance Committee - administers a program to assure the quality of practice, and ongoing competence.
  • Fitness to Practice Committee - holds hearings when a nurse is alleged to have a mental or physical condition affecting her or his ability to practise safely and competently.

You can reach us at the address or phone numbers elsewhere on the web site.

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Nursing Organizations in Ontario

Registration with the College of Nurses is compulsory in order to practise as a nurse in Ontario. But many of our members are also represented by organizations whose purposes are very different from those of the College.

The two largest professional associations, the Registered Nurses Association of Ontario (RNAO) and the Registered Practical Nurses Association of Ontario (RPNAO), represent the professional needs of their members and promote their interests in the public forum. Membership in these associations is voluntary. There are a number of smaller associations representing nurses in specific health care sectors, e.g. rehabilitation nurses or cancer nurses.

Many nurses are also members of a trade union. Of these, the Ontario Nurses' Association (ONA) and the Practical Nurses Federation of Ontario (PNFO) represent nurses only. There are also unions which, although not specific to nursing, include nurses in their membership, such as the Service Employees International Union, the Canadian Union of Public Employees, and the Ontario Public Service Employees' Union.

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Nurse as Teacher on the Maternity Ward

A lot of things have changed in the maternity ward since RN Ivy Drakes first came to Canada from Guyana 14 years ago, even since she came to obstetrics at North York General just seven years back. Some changes have been fundamental, some very simple.

"For instance," she says, "it's always been accepted that you had to clean the baby's navel with alcohol. But they did tests just a couple of years ago, and surprise, soap and water works just as well. There are all these traditions that we're challenging now."

Another example: when babyboomers were in their teens and beyond, it was not uncommon for new mothers to spend several days in the hospital after birth. Now, the norm is for mother and baby to be on their way home within 24 hours of birth. This means that there is very little time to prepare mothers for some of the fine arts of mothering, such as breastfeeding. Which makes Ivy Drakes and other maternity nurses teachers as much as care providers.

"I trained at Georgetown Hospital, the capital city on the coast, but part of our training was to go to the inland villages for several weeks, and work with the people there, teaching them how to take care of themselves. It was a very valuable experience."

Equally important to Ivy is keeping current through classes, which is a vital part of maintaining high standards of practice. She finds her employer to be very supportive in this regard. "Our head nurse sent several of us to a breast-feeding conference in Chicago recently," she says, "and a month-long class I took at Ryerson University last year on ante-partem (pre-operative) care was fully paid for by the hospital."

Recently, Ivy was invited to become an operating room nurse, helping with the deliveries. She declined, choosing to stay where she always had, working with mothers before and after birth. "I just love mothers and babies," she says.

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Assessing a Foreign-Trained Nurse

One of the important roles of the College of Nurses is to assess the education and experience of those who apply for registration, to ensure they are qualified to undertake the high standards of practice for nurses in Ontario. This is a greater challenge when the applicant is not from North America, for although the College has comprehensive files on nursing programs all over the world, it requires considerable ongoing research to keep those files complete and current.

Ivy Drakes recalls that when she first came with four colleagues to Canada from Guyana, some 14 years ago, they had to demonstrate to the College that their credentials met the basic education requirements for entry to practice in Ontario. "We knew we were qualified, that we were good enough," she says. "When we wrote the national nursing exam (required for every nurse applying for registration in Ontario), we all passed."

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Caring for the Female Elderly

Christina Newton has worked with the elderly for most of her life; for the past few years, she has been a Registered Practical Nurse (RPN) at Cedarvale Lodge, a nursing home in Keswick, about an hour north of Toronto. The people she cares for, people well into the autumn of their lives, cherish her smile and her laughter. "I was always the class clown", says Christina. "I like making people happy."

Gladys Spearn is a good example. Ms. Spearn is 85, and like many of the residents of Cedarvale, has lost her spouse and most of her friends. Christina says she doesn't get a lot of visitors anymore. And, of course, like most at Cedarvale, she is female. Only 12 of the Lodge's 60 beds are occupied by men. Whatever the reasons that women live longer than men, or that men are reluctant to move to nursing homes, the fact remains that Cedarvale's demographics are typical. Many more women than men live their last days in a nursing home.

Christina Newton has worked in nursing homes since she was a teenager, for many years as a Health Care Aide (an unregulated provider who has a minimal role in actual treatment of patients). But after watching her aunt work as an RPN, five years ago Christina decided to return to school. "I wanted to become more involved in the care of these people," she says, "more hands-on."

At Cedarvale, the RPNs administer most of the medications and treatments, while the RNs have a largely supervisory role. But Christina says all the nurses work very well together. "We discuss the residents and their problems as equals. We all chip in and help each other. It's a very good team atmosphere."

And a very good atmosphere for continuing learning as well. Cedarvale recently sent Christina on an intensive workshop about Alzheimer's Disease, a common affliction among the residents of Cedarvale. The residents range in age from 65 to 98, and Alzheimer's is the reason most of the younger ones are there.

For a lot of reasons, Christina enjoys her work at Cedarvale. But the clients are the major reason, clients like Gladys Spearn. "She needs a lot of TLC, lots of love." And Christina, along with her considerable skills as a nurse, is very happy to supply that particular need.

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What Is a Nurse?

In Ontario, nursing is one profession with two categories of care providers: Registered Nurses (RNs) and Registered Practical Nurses (RPNs). RPNs are known by various titles in different jurisdictions across North America. Christina Newton's Cedarvale Lodge (see the article "Caring for the Female Elderly") is an excellent example of a practice setting where the two categories (Cedarvale has four staff RNs and six RPNs) work closely together as a well-balanced team.

In most ways, the two categories are subject to the same regulatory requirements; the general standards of practice are the same, the complaints and discipline process, the registration process, all are the same. The two main areas of difference are educational requirements and scope of practice. Although all nursing students learn from the same body of nursing knowledge, RNs study it in greater depth and breadth over a longer period of time, and accordingly are able to provide care in more complex situations.

There are RNs who have received specific education in the primary care area, and are able to perform some of the diagnostic and treatment functions which were previously the exclusive domain of physicians. Although nurse practitioners (NPs) have existed for quite some time, their status has only recently been recognized and clarified in provincial legislation. The Expanded Nursing Services for Patients Act was passed in February of 1998, and soon after, the College of Nurses of Ontario began registering RNs in a new class - the Extended Class - to acknowledge their advanced knowledge and decision-making skills. Wendy Pollard (see our "Diary" article) was one of the first group of Ontario nurses to be registered in the Extended Class (EC).

RN(EC)s practise with extended scope in the areas of assessment, diagnosis, prescription of tests and treatments, and health promotion. Accordingly, they are often seen in community health centres, remote nursing stations and similar practice settings. As Wendy notes, however, "we are not mini-doctors, our focus is still on nursing." Her diary shows how different her practice is from that of a family physician.

RNs and RPNs are the only categories of nurse we regulate; indeed, they are the only categories of health care provider entitled to call themselves "nurses". Many of the health workers now becoming common in budget-cutting hospitals and other health care settings are not regulated in any way. And they are not nurses. Patients should never be afraid to enquire about the credentials of the person who is providing them with care.

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Diary: A Day in the Life of a Community Health Nurse Practitioner

Wendy Pollard is a nurse practitioner with the Tweed and District Community Health Centre in Tweed, Ontario, about 25 miles north of Belleville. She was one of the first to be registered in the College's new Extended Class. For Nursing and You, Wendy recounted a recent day in her working life, focusing on women's health issues, and highlighting the unique skills and practice of the nurse practitioner.

It's Wednesday, and I'm working the late shift today, seeing patients from 1 to 8 p.m. Because I have four teenagers, there's lots to do around the house, so it's well into the noon hour before I arrive at the Centre. Just time enough to look over my schedule before my first patient arrives.

1:00 p.m.

A woman in her eighties, suffering for three decades with diabetes. She's not been feeling very well lately, mostly increased leg pain from arthritis. An examination also reveals increased swelling in her left ankle, though it's not too serious yet. But there's an irregular heartbeat, never recorded before; I order an electro-cardiogram (ECG) and discuss it with the physician; we decide to send it on to a cardiologist to check for danger signs. I also order a blood sample to monitor the blood sugar levels for her diabetes. I ask her to come back in a month, sooner if the swelling in the ankle gets worse, and show her some things to do to ease the stress on her legs. No major danger signs yet, but she is 82 - we have to be careful.

1:45 p.m.

A 30-year-old woman with her two children. One is 18 months old, with a persistent cold and potential toilet training problems.We spend some time on the toilet training and other behavioural issues. Her four-year-old son is complaining of sore feet; I observe him and he rolls over on his ankles as he walks. Mom reveals she has very flat feet, so it's probably familial. I recommend good shoes with strong arch and ankle support, and after consulting with Mom, refer her to an orthopedic specialist for assessment. The physician concurs.

2:30 p.m.

I allow an hour for a thorough physical exam with woman in her early twenties. She's a single working mom with a three-year old daughter, and hasn't had a physical in almost three years. I start by talking about how she's coping with the stresses in her life. Physically, she complains of greater problems with allergies, and renewed acne. I go over her smoking and drinking, her sleep habits, her diet, her physical activity. After the complete physical, we come up with a plan together. I prescribe an acne medication and review good skin care, we go over the Canada Food Guide and suggest some diet changes. I recommend increased physical activity, and suggest she consider quitting smoking, giving her information on a self-help program offered through the health unit. This would be the single most important thing she could do to improve her health. I ask her to see me again in a couple of months if the acne persists, and to get physicals on at least a yearly basis.

3:30 p.m.

A 67-year-old man complaining of persistent cough, congestion, chills, and recurring sore throat. After examination, I rule out pneumonia and diagnose bronchitis. I prescribe an antibiotic for 10 days, and counsel him to quit smoking. I ask him to return in three or four days to follow up.

3:45 p.m.

A woman in her late teens, with one child (six months old), and about eight weeks pregnant. I ask her how she's feeling physically and emotionally. Her live-in boyfriend is good with the baby, and supportive and excited about the pregnancy. But she's having some nausea and vomiting already. She's still smoking, though she's planning to quit. We go through a thorough pre-natal counselling, almost as if it was the first time. Then, during the physical, I discover a tenderness in the lower right abdomen. After questioning, she says she's been having trouble sleeping on that side, and had a day of bleeding a couple of weeks back. I order a number of tests, including ultrasound, and try to reassure her as much as possible. But I'm worried.

4:45 p.m.

A 42-year-old man, here for injections of medication for his rheumatoid arthritis. Fairly routine, everything looks OK, I remind him to keep up his weekly visits.

5:00 p.m.

Supper hour. Lots of us will spend part of this vital time doing paperwork, but I need the stress relief and invigoration of a four-kilometre run instead.

6:00 p.m.

A 10-month-old boy with his mom, who also has two other pre-schoolers at home. She's here for the baby, but I begin by asking how she's doing; she's been having troubles with the middle child's behaviour. She's concerned about the baby's weight gain and his yellow colouring. After measurements, I allay her concerns about growth - he's normal - and by asking questions, discover that he's mostly eating carrots and sweet potatoes as veggies. I consult with the MD, and we agree that too much carotene is the reason for the skin colour.

6:30 p.m.

A woman in her mid-forties with a mole on her breast that's changed and is growing. I and the MD both examine it; it's probably harmless, but I book an appointment with him to remove it. We'll send it to pathology, and follow up with her when the report comes back. I find no other moles and reassure her, but go over the ABCs of skin cancer with her in any event.

7:00 p.m.

A two-year-old boy in with his mom for a well-child exam. Again I begin by asking her how she's coping with the terrible twos, and go over a lot of parenting issues. I begin the exam, but he won't let me do much, so I let him play with the stethoscope. I don't push it, because he appears healthy, and I want him to go away with a positive feeling about the visit. I do get his height and weight, and am a little concerned about his slow growth. It's probably genetic, but mom and I agree to have him seen by a paediatrician; the MD agrees, and we book an appointment.

7:45 p.m.

A five-year-old boy, here to follow up on an ear infection, for which I prescribed an antibiotic a few days ago. He's feeling much better, and this infection will go away, but I ask his mom to follow up with their specialist directly if there's any recurrence.

8:00 p.m.

Phew! Another full but fascinating day, with lots of twists and turns and issues. Time now for the paperwork and follow-up; maybe I'll be home by 9:30. A typical day in Tweed!

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Contact Us

For further information about any aspect of nursing regulation in Ontario, including how to express a concern about a nurse's conduct or practice, please contact:

College of Nurses of Ontario
101 Davenport Road
Toronto, Ontario, M5R 3P1
cno@cnomail.org

Telephone: 416 928-0900 or Toll Free 1 800 387-5526
Fax: 416 928-9841

 

 

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