Central Venous Pressure Monitoring

Central venous pressure (CVP) describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system. It is a good approximation of right atrial pressure, which is a major determinant of right ventricular end diastolic volume (right ventricular preload).

CVP can be measured by connecting the patient's central venous catheter to a special infusion set which is connected to a small diameter water column. If the water column is calibrated properly the height of the column indicates the CVP.

Factors which increase CVP are:

• Hypervolemia
• forced exhalation
• Tension pneumothorax
• Heart failure
• Pleural effusion
• Decreased cardiac output

Factors which decrease CVP are:

• Hypovolemia
• Deep inhalation

Chest Tube Thoracostomy (CTT)

The free end of the tube is usually attached to an underwater seal, below the level of the chest to allow the fluid or air to move from the pleural space, preventing anything returning to the chest.

Sizes of Chest Tube:
Newborn = 12-14 Fr
Child = 18 Fr
Adult or Teen Male = 28-32 Fr
Pp Adult or Teen Female = 28 Fr

A chest tube is a flexible plastic tube that is inserted through the side of the chest into the pleural space.

Indications

Pneumothorax: accumulation of air in the pleural space
Pleural effusion: accumulation of fluid in the pleural space
Chylothorax: a collection of lymphatic fluid in the pleural space
Empyema: a pyogenic infection of the pleural space
Hemothorax: accumulation of blood in the pleural space
Hydrothorax: accumulation of serous fluid in the pleural space

Contraindications

Contraindications to chest tube placement include refractory coagulopathy, lack of cooperation by the patient, and diaphragmatic hernia. Additional contraindications include scarring in the pleural space (adhesions)

Insertion site
- 5th intercostal space slightly anterior to the mid axillary line, or
- in an area described as the "safe zone", a region bordered by: the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple

Procedure

A small incision is made over the "safe zone" after injection of a local anesthesia, and a passage is made through the skin and muscle into the chest. The tube is placed through this passage.

Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area.

A chest radiograph confirms the location of the drain.

The tube stays in for as long as there is air or fluid to be removed, or risk of air gathering.

Chest Drainage Canister

There are generally three chambers.
1. The first chamber is a collecting chamber.
2. The second is the "water seal" chamber which acts as a one way valve. Air bubbling through the water seal chamber is usual when the patient coughs or exhales but may indicate, if continual, a pleural or system leak that should be evaluated critically. It can also indicate a leak of air from the lung.
3. The third chamber is the suction control chamber. The height of the water in this chamber determines the negative pressure of the system. Bubbling should be kept a gentle bubble to limit evaporating the fluid. Increased wall suction does not increase the negative pressure of the system.

Complications

Major complications are hemorrhage, infection, and reexpansion pulmonary edema. Chest tube clogging can also be a major complication if it occurs in the setting of bleeding or the production of significant air or fluid. When chest tube clogging occurs in this setting, a patient can suffer from pericardial tamponade, tension pneumothorax, or in the setting of infection, an empyema. All of these can lead to prolonged hospitilization and even death. To minimize potential for clogging, surgeons often employ larger diameter tubes. These large diameter tubes however, contribute significantly to chest tube related pain. Even larger diameter chest tubes can clog.[4] In most cases, the chest tube related pain goes away after the chest tube is removed, however, chronic pain related to chest tube induced scarring of the intercostal space is not uncommon.

Injury to the liver, spleen or diaphragm is possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracic aorta and heart have also been described.

Minor complications include a subcutaneous hematoma or seroma, anxiety, shortness of breath (dyspnea), and cough (after removing large volume of fluid).

Subcutaneous emphysema indicates backpressure created by a clogged drain or insufficient negative pressure.

Glasgow Coma Scale

Best eye response (E)

There are 4 grades starting with the most severe:

1. No eye opening
2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)
3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)
4. Eyes opening spontaneously

Best verbal response (V)

There are 5 grades starting with the most severe:

1. No verbal response
2. Incomprehensible sounds. (Moaning but no words.)
3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)

Best motor response (M)

There are 6 grades starting with the most severe:

1. No motor response
2. Extension to pain (abduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response)
3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
6. Obeys commands. (The patient does simple things as asked.)

Interpretation

Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35".

Generally, brain injury is classified as:

• Severe, with GCS ≤ 8
• Moderate, GCS 9 - 12
• Minor, GCS ≥ 13.

Tracheal intubation and severe facial/eye swelling or damage make it impossible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached e.g. 'E1c' where 'c' = closed, or 'V1t' where t = tube. A composite might be 'GCS 5tc'. This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for 'abnormal flexion'. Often the 1 is left out, so the scale reads Ec or Vt.

The GCS has limited applicability to children, especially below the age of 36 months (where the verbal performance of even a healthy child would be expected to be poor). Consequently the Pediatric Glasgow Coma Scale, a separate yet closely related scale, was developed for assessing younger children.

Revisions

• Glasgow Coma Scale: While the 15 point scale is the predominant one in use, this is in fact a modification and is more correctly referred to as the Modified Glasgow Coma Scale. The original scale was a 14 point scale, omitting the category of 'abnormal flexion'. Some centres still use this older scale, but most (including the Glasgow unit where the original work was done) have adopted the modified one.

Tracheal intubation

Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction. The most widely used route is orotracheal, in which an endotracheal tube is passed through the mouth and vocal apparatus into the trachea. In a nasotracheal procedure, an endotracheal tube is passed through the nose and vocal apparatus into the trachea. Other methods of intubation involve surgery and include the cricothyrotomy (used almost exclusively in emergency circumstances) and the tracheotomy, used primarily in situations where a prolonged need for airway support is anticipated.

USE OF ANESTHESIA
Intubation is usually performed after administration of general anesthesia and a neuromuscular-blocking drug. It can however be performed in the awake patient with local or topical anesthesia, or in an emergency without any anesthesia at all.

PROCEDURE
1. An anesthesiologist opens the patient's mouth by separating the lips and pulling on the upper jaw with the index finger. Holding a laryngoscope in the left hand, he or she inserts it into the mouth of the patient with the blade directed to the right tonsil.
2. Once the right tonsil is reached, the laryngoscope is swept to the midline, keeping the tongue on the left to bring the epiglottis into view. The laryngoscope blade is then advanced until it reaches the angle between the base of the tongue and the epiglottis.
3. Next, the laryngoscope is lifted upwards towards the chest and away from the nose to bring the vocal cords into view. Often an assistant has to press on the trachea to provide a direct view of the larynx.
4. The anesthesiologist then takes the endotracheal tube, made of flexible plastic, in the right hand and starts inserting it through the mouth opening. The tube is inserted through the cords to the point that the cuff rests just below the cords.
5. Finally, a balloon cuff is typically inflated just above the far end of the tube to help secure it in place, to prevent leakage of respiratory gases, and to protect the tracheobronchial tree from receiving undesirable material such as stomach acid.
6. The tube is then secured to the face or neck and connected to a T-piece, anesthesia breathing circuit, bag valve mask device, or a mechanical ventilator.
6. Using a stethoscope , the anesthesiologist listens for breathing sounds to ensure correct placement of the tube.

COMPLICATIONS
Tracheal intubation can be associated with minor complications such as broken teeth or lacerations of the tissues of the upper airway. It can also be associated with potentially fatal complications such as pulmonary aspiration of stomach contents which can result in a severe and sometimes fatal chemical aspiration pneumonitis, or unrecognized intubation of the esophagus which can lead to potentially fatal anoxia.

INDICATIONS

Depressed level of consciousness - Damage to the brain (such as from a massive stroke, non-penetrating head injury, intoxication or poisoning) may result in a depressed level of consciousness. When this becomes severe to the point of stupor or coma (defined as a score on the Glasgow Coma Scale of less than 8),[3] dynamic collapse of the extrinsic muscles of the airway can obstruct the airway, impeding the free flow of air into the lungs. Furthermore, protective airway reflexes such as coughing and swallowing may be diminished or absent. Tracheal intubation is often required to restore patency (the relative absence of blockage) of the airway and protect the tracheobronchial tree from pulmonary aspiration of gastric contents.

Hypoxemia - Intubation may be necessary for a patient with decreased oxygen content and oxygen saturation of the blood caused when their breathing is inadequate (hypoventilation), suspended (apnea), or when the lungs are unable to sufficiently transfer gasses to the blood. Such patients, who may be awake and alert, are typically critically ill with a multisystem disease or multiple severe injuries.[1] Examples of such conditions include cervical spine injury, multiple rib fractures, severe pneumonia, acute respiratory distress syndrome (ARDS), or near-drowning. Specifically, intubation is considered if the arterial partial pressure of oxygen (PaO2) is less than 60 millimeters of mercury (mm Hg) while breathing an inspired O2 concentration (FIO2) of 50% or greater. In patients with elevated arterial carbon dioxide, an arterial partial pressure of CO2 (PaCO2) greater than 45 mm Hg in the setting of acidemia would prompt intubation, especially if a series of measurements demonstrate a worsening respiratory acidosis. Regardless of the laboratory values, these guidelines are always interpreted in the clinical context.[5]

Airway obstruction - Actual or impending airway obstruction is a common indication for intubation of the trachea. Life-threatening airway obstruction may occur when a foreign body becomes lodged in the airway; this is especially common in infants and toddlers. Severe blunt or penetrating injury to the face or neck may be accompanied by swelling and an expanding hematoma, or injury to the larynx, trachea or bronchi. Airway obstruction is also common in people who have suffered smoke inhalation or burns within close to the airway or epiglottitis caused by infection. Sustained generalized seizure activity and angioedema are other common causes of life-threatening airway obstruction which may require tracheal intubation to secure the airway.[1]

Manipulation of the airway - Diagnostic or therapeutic manipulation of the airway (such as bronchoscopy, laser therapy or stenting of the bronchi) may intermittently interfere with the ability to breathe; intubation may be necessary in such situations.[4]

EQUIPMENT

Laryngoscopes

Laryngoscope handles with an assortment of Miller blades (large adult, small adult, child, infant and newborn)










This device is designed to allow the laryngoscopist to directly view the larynx. It consists of a handle containing batteries that power a light and a set of interchangeable blades, which are either straight or curved.


Laryngoscope handle with an assortment of Macintosh blades (large adult, small adult, child, infant and newborn)











The Macintosh blade is the most widely used curved laryngoscope blade,[8] while the Miller blade[9] is the most popular style of straight blade.[10] Both Miller and Macintosh laryngoscope blades are available in sizes 0 (infant) through 4 (large adult).

Stylets

An intubating stylet is a malleable metal wire designed to be inserted into the endotracheal tube to make the tube conform better to the upper airway anatomy of the specific individual. This aid is commonly used with a difficult laryngoscopy.

Tracheal tube

The endotracheal tube has a fitting designed to be connected to a source of pressurized gas such as oxygen. At the other end is an orifice through which such gases are directed into the lungs and may also include a balloon (referred to as a cuff). The tip of the endotracheal tube is positioned above the carina (before the trachea divides to each lung) and sealed within the trachea so that the lungs can be ventilated equally.


Originally made from latex rubber,[28] most modern endotracheal tubes today are constructed of polyvinyl chloride. Tubes constructed of silicone rubber, wire-reinforced silicone rubber or stainless steel are also available for special applications. For human use, tubes range in size from 2 to 10.5 mm (0.1 to 0.4 in) in internal diameter. The size is chosen based on the patient's body size, with the smaller sizes being used for infants and children.

METHODS TO CONFIRM PLACEMENT

No single method for confirming tracheal tube placement has been shown to be 100% reliable. Accordingly, the use of multiple methods for confirmation of correct tube placement is now widely considered to be the standard of care.[32] Such methods include direct visualization as the tip of the tube passes through the glottis. With a properly positioned tracheal tube, equal bilateral breath sounds will be heard upon listening to the chest with a stethoscope, and no sound upon listening to the area over the stomach. Equal bilateral rise and fall of the chest wall will be evident with ventilatory excursions. A small amount of water vapor will also be evident within the lumen of the tube with each exhalation and there will be no gastric contents in the tracheal tube at any time.[31]

Ideally, at least one of the methods utilized for confirming tracheal tube placement will be a measuring instrument. Waveform capnography has emerged as the gold standard for the confirmation of tube placement within the trachea. Other methods relying on instruments include the use of a colorimetric end-tidal carbon dioxide detector, a self-inflating esophageal bulb, or an esophageal detection device.[33] The distal tip of a properly positioned tracheal tube will be located in the mid-trachea, roughly 2 cm (1 in) above the bifurcation of the carina; this can be confirmed by chest x-ray. If the tracheal tube is inserted too far into the trachea, the tip will often be located within the right main bronchus, because this bronchus has a less acute angle than the left.[34]

4 Ways to Strengthen Your Immune System

Hype about immune boosters can end up putting a real pinch your wallet. Here are tips you can bank on.

By Christopher Woolston

1. Go nuts for E. Immune cells can’t function without proper nutrition, says Simin Meydani, PhD, director of the USDA Human Nutrition Research Center at Tufts University. "In an outbreak, a deficiency of nutrients can be as dangerous as not washing your hands," she says. But many people don't get enough vitamin E, a proven immune enhancer, says Patricia Sheridan, PhD, at the University of North Carolina at Chapel Hill. You need at least 15 mg of E daily, she says, which you can get in a generous handful of almonds (7 mg of E per ounce). The elderly and people with weakened immune systems may need a supplement of 200 mg of E, Meydani believes.



Most people don't get enough vitamin E, a proven immune enhancer.


In her study of nursing home residents, supplementing with that amount cut the risk of colds and flu by about 20 percent. Don't take more, though: One highly publicized study suggested that high doses (400 mg per day or more) can increase the risk of death.

2. Don't stint on selenium. This trace mineral helps build immune system enzymes. Most people in the United States aren't deficient but could use a little extra to sharpen their immune systems, Sheridan says. She recommends about 55 micrograms, which you can get in a tuna sandwich.

3. Consider popping the "sunshine vitamin." Vitamin D is needed to produce certain germ-killing proteins (a recent study suggests that low levels raise the risk of respiratory infection by more than 35 percent). But many people fall short, says Michael Holick, MD, professor of medicine at Boston University. You can't get much vitamin D from food, so Holick recommends that adults supplement with 1,000 IU a day, plus a multivitamin containing another 400 IU.

4. Work out (but don’t burn out). Even a little exercise can wake up the immune system, says Thomas Lowder, PhD, at the University of Houston. (Exercise that wrecks you for days can actually make you more vulnerable, though.) In a 2006 study, women either exercised moderately five times a week or stretched once a week. By study's end, the exercisers were only one third as likely as the stretchers to be sniffling and sneezing. "Nobody can say for sure how much exercise it takes to improve the immune system," Lowder says. "But it's not much, and it happens very quickly."

Fiber: The New Superstar Nutrient

Find out why getting fiber from whole foods is important for a healthy diet.

By Janis Graham

Fiber has never been what you’d call a sexy nutrient. Suddenly, it’s a superstar: Manufacturers are adding it to yogurt, juice, even artificial sweetener. But as with many celebrities, there’s an unseemly backstory: Experts aren’t sure that these fiber-boosted foods are worth trying.



Beans are an excellent source of fiber.

Yes, you should eat lots of fiber. There’s no question that a diet rich in high-fiber foods is a powerful lifesaver—it’s known to lower the risk of heart disease and diabetes, and it helps prevent weight gain. Recent studies show a fiber-rich diet cuts the risk of breast cancer, too, and the chances you’ll develop cancer of the small intestine.

But the new foods might not count. That’s because many of them use “isolated” fiber—stuff that’s been stripped out of the foods that originally contained it, says nutrition expert Tara Gidus, RD. Isolated fibers like inulin, polydextrose, and maltodextrin are flavorless and don’t turn juice and yogurt into a gummy, grainy glop. The downside: There’s no evidence that they protect against chronic diseases.

So go ahead and try a glass of fiber-boosted grape juice, or stir some fiber into your coffee along with your artificial sweetener. Just don’t forget to also eat more whole grains, beans, and fruits and veggies—they’re proven lifesavers.

Tastier Than You Think
Not crazy about stewed prunes (4 g fiber per 1/2 cup)? Try these surprising high-fiber foods:
1 artichoke - 10 g
1 pear - 6g
1/2 cup raspberries - 4g
1/4 cup hummus - 4g

How To Stop Excessive Sweating In A Natural Way

Excessive sweating is often painful and causes of fear of a person. There are many challenges related to the condition that more than physical suffering.

There are many opportunities for common sense, the problem of feeding the sweating is an important factor regarding the problem. A person should avoid drinking too much caffeine in coffee and soft drinks.

Caffeine is the poor condition because they can foster fear and more importantly, the hyper activity of the nervous system. Drink plenty of water every day to clean your system. Rejects water and regulates your body of toxins.

Food is another important point. Eat more fruits and vegetables in the integrated power plan. Try to remove excess sugar to improve their ability to reduce sweating. Always wear clothes, skin to breathe.

Loose clothing is best for your skin. The cotton fiber is good in the wet and warm wool in winter. Do not wear clothes close, the problem worse by sweating.

Bath and shave every day under the arms is a good exercise for this problem. Avoid red meat and strong smell of fish, as we know, increased sweating. Stress causes sweat to find an exercise to be done in a newspaper, work to reduce stress.

Walking is a simple and economic form of exercise. Practice of meditation and breathing to calm these factors contribute to an effective reduction of sweating to. Stress is often a great thing, like not forget this. If you have the common sense of these councils, improving their chances to reduce or control sweating.

It is not only a treatment, worked for 95% of people who have their method. This workaround for your problem lean away for the rest of his life, and that is security. They have a duty to try himself. For more information, please click the link below. Try and if you do not get their money.

Lower Your Cholesterol

Find out how to eat and exercise for lower cholesterol, learn easy, effortless ways to lower your cholesterol and get the facts on cholesterol supplements, statins and other cholesterol medication.

Are You At Risk?

Heart disease is the No. 1 killer among both men and women. And about half of all adults in America have cholesterol levels that are too high. Take our quiz to test your knowledge about cholesterol, and get tips on how to improve your diet, exercise, and other factors that can affect your heart disease risk.

Ready, Set, Lower Cholesterol!

1. Quiz: Test your cholesterol IQ
2. Eat for better cholesterol: 12 Essential foods
3. Dinner ideas: 14 Cholesterol-friendly recipes
4. Risk factors you can change
5. Cholesterol: Myth vs. reality

Weight Loss Tips

Men and women are different. They have different needs, different structures of the body and different levels of the hormone. Therefore, it is clear that the weight loss for women is at least something different from the weight loss for men.

While the principles that I recommend to all persons of weight loss are the same, to the extent that it will have positive effects on the individual depends on many things, including sex. Women can, for example, have more success using hormonal balance than men because they are more likely to suffer more estrogen dominant.

However, here are some simple principles of weight loss for women:

1. Drink more water - the water helps eliminate toxins and hydration, refreshing and replenishing your body's cells. More water means a cleaner and more efficient.

2. Balance your hormones - hormone imbalance affects all women to some extent. In terms of weight loss, I firmly believe that all women are much more the results using a natural hormone balancing method to do nothing. It should be a part of your weight loss and efforts to benefit more ways to enumerate here.

3. Suppression of your system - the parasites remain a problem for many people. The contracts are in contact with animals or travel abroad through consumption of contaminated water among many other ways. You can remove all the pests naturally through security and effective remedies rather than drugs.

4. Intelligent exercise - Do strength training and make sure your cardio is as high as you can handle.

5. Get your right to food - Avoid AGT and highly processed foods, such as eating near the source of raw food as possible.

The RN Contract Trap

- Atty. Robert Reeves, Apr 27, 2009

For many foreign nurses

(RNs) the chance to immigrate to the U.S. is the opportunity of a life time.  For so many, immigrating to the U.S. is the reason they went to nursing school and took up the profession.  Many others, such as marketing majors, physicians, computer engineers, etc. have switched professions to become nurses in order to immigrate to the U.S. 

 

The shortage spurred the growth and creation of hybrid industries such as nurse registries and temporary nursing staff companies.  These types of companies assign nurses on a temporary basis with their client hospitals, medical facilities, and private homes. 

A nurse working for one of these companies for example, might find herself working at Hospital A for 2 days out of the week and Hospital B for 3 days.  Then, a few months later, working 4 days for Hospital C.  The RN goes wherever her employer has been contracted to provide services.  She is not an employee of the hospital, but rather the registry company.

Because of the shortage, various RN employers (hospitals, agencies, RN staffing companies) heavily recruit for RNs overseas. Foreign RNs who wish to immigrate are delighted at the opportunity the recruiters offer and are often all too eager to sign up.

While this path may be one of the easiest ways to immigrate, it is not without its pitfalls.  Employment-based sponsorship means the RN will be allowed to immigrate if the RN intends to work on a permanent basis for the petitioning employer.  This is a critical condition of immigrating that carries consequences if not fulfilled.  

During the typical recruitment process, the RNs are promised sponsorship in exchange for working for the employer.  Contracts are prepared and representations are made regarding the nature of work, type of work, place of work, working conditions and wages.  Many RNs are so eager to immigrate, they do not carefully read these contractual documents, ask serious questions regarding the terms and conditions, or have the contracts reviewed by their own attorney.   

In the excitement of the prospect of immigrating to the U.S. many RNs are seduced with the notion that the dream job

awaits them in the U.S.  For some this is true, but for many, it has drastic consequences.  The RNs gloss over the contracts and assume an attitude of, “I’ll deal with it later.”

The most common contractual clause that wreaks havoc on an immigrating RN’s life is the breach of contract damages clause.  Most contracts typically require the RN to work for a specific number of years and failure to do so triggers the damages clause.  The damages can range from $15,00 to $50,000 dollars! 

 

Many RNs signing these contracts are unfamiliar with the litigious culture in the U.S.  Some come to the U.S. and find the working conditions and salaries they were told they would receive are not the same as represented when first recruited.  Some conditions are so unbearable.

For example, being placed in graveyard shifts in hospitals far from home. Or, not being placed in any hospital and collecting no salary while the sponsor tries to obtain a new client for the RNs placement.  Many of these RNs then leave their employers and this is when additional tragedy strikes.

The employer begins a campaign of harassment and may sue for breach of contract and obtains a judgment against the RN for the penalty amount.  The judgment typically comes with a wage garnishment order.  This means the RN’s new employer is required to pay a portion of the RN’s wages to the sponsor to cover the judgment.  Because RNs are in a licensed occupation requiring a reporting of where they work, it is very simple for the sponsor to locate the RN and exact the judgment.

But, worse than a breach of contract is the possible immigration consequence.  The RN has obtained permanent residency because she stated she intends to work on a permanent basis for her sponsor.  By leaving or changing employers shortly after entering the U.S., she has now opened the door for the Immigration Service to revoke the green card!  Some employers immediately notify the Immigration Service when an RN leaves exposing the RN to possible green card revocation and deportation. 

For many others, the immigration consequence comes several years later when the RN is applying for U.S. citizenship.  The Immigration Service reviews the basis of the green card and determines how long the RN worked for her sponsor.  If it determines that the RN has only worked for a short period of time, it may begin revocation and deportation proceedings against both the RN and her family members who obtained green cards through her.

 These tragic consequences can be avoided by careful review in the beginning.  For many of those currently in the position, there is still immigration and contractual relief available.  The U.S. Constitution prohibits slavery and indentured servitude and because in many cases the sponsoring employer breaches the contract, the employee is not liable for any damages. This core constitutional value is the basis for providing relief to those forced to leave their sponsors.  This will be the subject of our second part of this article. 

 

Author's Note: The analysis and suggestions offered in this column do not create a lawyer-client relationship and are not a substitute for the individual legal research and personalized representation that is essential to every case.

 

Reeves & Associates, a PLC

Unit 507 Tower One Ayala Triangle

6767 Ayala Ave., Makati City, Philippines 1226

Phone: (632) 759-6777

Facsimile: (632) 759-7888

scasal@rreeves.com

Pasadena, CA Phone: (626) 795-6777

San Francisco, CA Phone: (415) 568-3777

Las Vegas, NV: (702) 227-9888