Dropping out of the Hospital Rat Race: Nurse Entrepreneurship

Dropping out of the Hospital Rat Race: Nurse Entrepreneurship

Dropping out of the Hospital Rat Race: Nurse EntrepreneurshipI’ve talked to a lot of nurses lately who feel pressure to go back to school and make more money with an MSN of some sort. Obviously, universities are all about the chance to get a few more years of tuition from them. There are other options besides heading back to the classroom, and one of the most flexible, lucrative, and terrifying is nurse entrepreneurship. Going at it alone is a common response to burnout or an unfulfilling career, but results may vary. If discouragement at work is why entrepreneurship sounds appealing, check out the FreshRN® posts on bullying and stress.

Dropping out of the Hospital Rat Race: Nurse Entrepreneurship

On one end are Multi-Level Marketing health drinks and essential oils that cause your former friends to flee in terror when they see you coming. I kid, they are a valid option and definitely have their place if you can find your niche and avoid becoming a social pariah.

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Close enough. We’ll start our discussion at the other end of entrepreneurship: new ideas and inventions incorporated into a stream of business income.

For example, you could invent a capcaicin-based lotion for children to decrease pain from injections and IVs or a travel pillow that diffuses lavender and magnesium—perfect for the next Greyhound bus trip so you won’t have to pack a pillow, Benadryl, and Febreze. In between are content providers and entrepreneurs like Kati and her insightful posts about blogging and not being a sucker. Nursing school doesn’t include entrepreneurial training, while chiropractors and dentists are more accustomed to starting their own businesses. Massage therapists and similar occupations can have fairly limited income potential unless they launch their own businesses.

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I don’t consider myself an expert, but I’m currently on my fifth or sixth business, ranging from my writing and speaking careers to alternative medicine services, to my latest venture, a Ketamine clinic for anxiety, mood disorders, and chronic pain syndromes.

For an example, specific to my specialty, starting a small anesthesia practice with a few buddies is a great plan. You just need a gastroenterologist or ophthalmologist, knowledge of your state’s nurse practice laws, and you’re all set. This will sound shady, but the fewer laws, regulations, and organizations you are at the mercy of, the better. Problems start when insurance companies delay your payments for six months because they need to reach an arbitrary 20% claims denied quota.  If you have a spouse making a steady income, there’s more flexibility to earn profits and make mistakes on your own. I don’t recommend this approach if you’re still in debt from nursing school, even though it’s quite possible to start a business without thousands of dollars.

The DIY Method

Since additional licensing, oversight, and paperwork all increase the amount of time spent on a business without making money, start small and keep your day job if possible. You’re the boss. Money up front can help you scale faster, but relative obscurity allows you to fine tune (screw up) before there’s serious money and reputation on the line. Figuring it out as you go along is only advisable in those gradual cases. Consulting an attorney, accountant, and the like is wise if instead of making ugly badge holders (sorry Sharon, no one wants to wear the tops from twenty Propofol bottles), you’re starting a PPE company replacing masks, gowns, and hoods with ultraviolet carbon polymer shielding. In that case, clients want to know you’re an actual business, while in many others they won’t care. Of course, if you don’t know anything about the process of starting or running a business, it’s difficult to delegate or assess the quality of service a bookkeeper or business expertise service offers.

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Let me tell you how I do it, though the companies I’ll mention are just my somewhat random preferences; also do your own research.

For my state of Florida, once a hobby is profitable enough that I want some tax deductions and legal separation from my personal assets, I visit sunbiz.org and register an LLC for $125. You can do the same with a physical Florida address, even if you don’t live there, or follow the process in your own state. Next, I register directly with the IRS (LegalZoom not required) to get an EIN—basically a social security number for a business–and fill out Form 2553 so they’ll treat my new company as an S Corporation. This just means I owe fewer payroll taxes. There are plenty of boring articles on the Internet about the pros and cons of different setups. Either way, I can create my own retirement plan on Fidelity or another broker and add other benefits just like a big company. When I get new tags for my car every year, I also renew my business licenses in the county where I live.

Conventional advice is that you immediately need a business banking account. Remember that no one makes money off you if you do things simply, so Googling this topic reveals all sorts of recommended fees and licenses and busywork. However, it helps me stay more organized and less likely to use business funds for personal expenses and vice versa if I have a separate account, so I usually get a business savings account at First Internet Bank, since the interest is above 1% and there aren’t any fees if I keep my balance above $1,000. I budget with a program like YNAB and buy business tax software at the end of the year from TaxAct for about $30, though I tend to call their helpline often since, again, I’m not an expert. Let me know in the comments if you’d like more info on investing or starting companies that do require significant amounts of money, and I’ll explain further.

Feeble Attempts to Segue Nursing into Natural Health

 Is it lucrative to start playing for the other team?  Many physician practices have abandoned the insurance model for complementary and alternative medicine cash practices centered around supplements and nutraceuticals. There’s a long continuum between fraudulent and fantastic. If this is a topic of interest, useful alternative medicine clinical skills should be a priority, but you need to research what falls under your scope of practice. A nursing license has more credibility than a string of letters following your name that probably stands for “I Picked up a Degree in Holistic Feta Cheese Management at the International Deli.” Before you drop everything to run a hypnosis studio in your parent’s garage, realize that the spiritual dimension is very important in this line of work. Some people have values that run deeper than even a Snapchat filter, so reflect on why you believe those fabulous quotes that resonate with your soul on Instagram.

 

 

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Transporting yourself back to the secular world, insurance rates differ widely depending on the potential consequences of your business. If you have a small side practice doing something boring, they won’t be interested in you. A budding herbalist taking the types of patients Western medicine can’t do anything more with needs to spend some time assessing liability. My point?  Find your niche, and work tirelessly until you achieve it. Love or greed won’t be enough to excel. Facing your fear, which for me is usually rejection and failure, may prove lucrative as you shape your dream job into what people are willing to pay for.

Strictly Nursing Businesses

So maybe you’d like to stick closer to your regular job rather than inventing ultrasonic bathtubs (think BathFitters meets ESWL). The perspective of an outsider might be enough of a change to let you stay employed in the hospital setting. I was a self-described nurse hobo for years. I never hopped on a train between jobs or split wood for spare change, but there was plenty of couch surfing and penny-pinching during my agency days. The best part of contract work is going to work purposefully, because it’s your choice, as opposed to dragging yourself there because the schedule demands it. I admit; the difference is mostly psychological.  Occasionally, this meant I worked more shifts than were good for my health because I was unsure when the next opportunity would come my way. This uncertainty is part of entrepreneurship even if you’re just selling aged cheeses during your lunch break (I’d advise working on that lavender essential oil pillow simultaneously, though). Working at a higher rate of pay but with a sporadic schedule is only an advantage when there is something valuable to do with time not spent working. For me it was studying, for you, it might be a side gig or seeing those kids you made before starting school. In some ways, this is the opposite of the usual start-up experience, where part of the reason to budget is to make sure you’re making more than $2 an hour spending all that time knitting poop emojis for your Etsy shop.

Dropping out of the Hospital Rat Race: Nurse Entrepreneurship

Hustle

So stupid when you think it through, right? I’m trying to avoid all them slick business words, but “hustle” has been maligned just like sweet, innocent MRSA and tertiary syphilis. You have to take breaks, or even as your own boss you’ll suffer burnout like the nurses who can’t take all the bureaucracy that prevents them from providing the best care for their patients. Many people who start a business just because they didn’t want anyone to tell them what to do discover that debt, customers, and even competitors do exactly that.

Hard work and determination is a must for any business to succeed, but the equation is more complicated than luck and willpower. Otherwise, people wouldn’t have garages full of unsold Tupperware. A very slim minority—no, seriously, those shakes actually worked for them and they’re slender now–can succeed while others tread water at best, but successful entrepreneurship requires the ability to look at personal situations objectively. “Can I salvage this by working harder?” “Do I need to pivot in a new direction, and can I do that quicker than the cash-loaded companies I compete against?” Serial entrepreneurs simply try to sell their business before they run themselves into the ground, but starting a business you might eventually pass on to your children tends to be a more sustainable route. One investment burned me because the company hoped a bigger company would acquire them before they had to do anything crazy, like rent factory space and make their actual product. Oops.

What questions do you have? Hustle is an important facet because sometimes we work hard for the sake of working hard. You’ll just be spinning your wheels unless you can make personal connections with potential customers. I mean, unless that Etsy store sells hand-knit scarves resembling VRE under the microscope because I don’t care who you are, I’m buying that, especially if it comes in Isolation Gown Yellow.

Having an online presence is vital to the success of any nursing business, but maintaining it can seem overwhelming.

This course walks you through the essentials of digital marketing and show you how to build a strong online brand with a blog as it’s centerpiece.  You need to know the rules, the tricks, the short cuts, and the “must dos” to save yourself thousands of hours.

You chose nursing because you wanted to make a different. You’ll pursue blogging because you need to be relevant to make a difference. Take the Nurse Blogging 101 course!

Nick Angelis, CRNA, MSN, is the author of How to Succeed in Anesthesia School (And Nursing, PA, or Med School) and regularly writes or presents continuing education articles on a variety of dry and dreary topics, just like this one. He also has a thing for satire such as The Twerk Vaccine. Nick works as a nurse anesthetist in NW Florida and NE Ohio and enjoys playing several sports poorly. You can connect with him on Linked-InTwitter, or Instagram.

 

What Do Infection Prevention Nurses Do?

What Do Infection Prevention Nurses Do?

What Do Infection Prevention Nurses Do?

What do Infection Prevention nurses not do! There are a variety of titles that cover our job including Infection Control Practitioner, Infection Prevention Coordinator, and most often the Infection Preventionist, or IP. IPs now come from a variety of backgrounds including nurses, medical technologists, and public health professionals, but the profession has historically been dominated by nurses. In fact, Florence Nightingale is not only viewed as a pioneer of nursing, but also a pioneer of infection prevention and control. A day in the life of an IP is never boring.

What Do Infection Prevention Nurses Do?

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The Start of the Day

Most IPs are salary so there is no starting your day at the time clock! With all the unpredictable emergencies that can occur who knows when your day will end (did a kid just come in with measles at 4pm on a Friday?). You may also find yourself coming in at 0530 to catch that operating room morning huddle. The crux of an IP’s job is the infectious disease surveillance across the hospital. This includes, but not limited to, monitoring blood cultures and urine cultures for device associated infections, wound and tissue cultures for possible surgical site infections, and microbiology results in order to identify multi-drug resistant organisms (MDROs) and potential communicable diseases. Potential hospital associated infections (HAIs) are investigated, and infection control measures are put into place if infections are identified that could be spread throughout the hospital.

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Alphabet Soup

In infection prevention there are lots of acronyms! Central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI), ventilator-associated event (VAE). Methicillin-resistant Staph aureus (MRSA), vancomycin-resistant Enterococcus (VRE), carbapenem-resistant Enterobacteriaceae (CRE)…phew! It is almost like speaking another language working in infection prevention, and the basic verbiage and infection criteria utilized among IPs is exactly that. IPs follow definitions of infection developed by the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN). This is how infections such as CAUTI and CLABSI are identified among others. Big take away for those who are used to the clinical setting – surveillance definitions do not always correlate with clinical diagnosis! Surveillance is meant to capture trends using standardized criteria, while in the clinical setting diagnoses are focused on the individual. This is a tough concept for those who are clinical and new to IP to comprehend at first.

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Policy and Procedure Time

As an IP, you are ultimately responsible (or at least play a major role) in the development of policies and procedures around all things infection prevention. For nursing, this includes topics such as central line and urinary catheter management, as well as standard precautions and transmission-based precautions (don’t you love that yellow gown?). There are also some not so fun policies you may be in charge of – hello operating room attire – but are necessary for regulatory reasons (don’t get me started on the IP’s involvement with The Joint Commission surveys!). Do not be surprised if most days you are asked to review, update, and approve various policies within the hospital.

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The Good

There are many fun and rewarding aspects of working in infection prevention as a nurse. You get to know and work with every single department of the hospital. From nursing units to environmental services and plant operations you have a part. It is awesome forming great relationships with all areas of the facility. As an IP, you also get to celebrate the victories such as an intensive care unit going two years without a CLABSI and a potential outbreak successfully avoided. You also get to participate in non-nursey activities such as construction and renovation. Construction dust can harbor mold spores and plumbing work can increase the risk of Legionella, so by default construction in a hospital is a major infection prevention and control activity. How exciting it can be though when you are making friends with construction contractors and climbing across the hospital rooftop in your hard hat and safety goggles!

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The Good…But Not so Good

There are of course some not-so-attractive parts of the job of an IP. First, there is lot of time spent managing data and living in Excel spreadsheets. This can be fun at times, but when you break a link in your pivot chart then it can lead to hours of frustration getting items to work. After all that frustration you still have to submit all that data to the CDC and all the other databases that require all the info! Also, unfortunately as the IP you have to put on your “hand hygiene police” hat from time to time and remind people to cover their beverages. It is also not always glorious enforcing and reviewing the daily audits put into place over an infection problem such as CLABSI on a unit or SSI within a specific operating room. Since you are tied to almost every aspect of a functioning hospital, as an IP it is also important to be able to set work boundaries. While people will want to call you for every bug they see or weird smell they smell, not everything is a true infection risk. You must learn to delegate and defer to the appropriate contact. If only everyone treated MRSA like bed bugs! Yet, that may minimize job security for the IP, ha.

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The Benefit

Although challenging and a job with a difficult learning curve, working as an Infection Preventionist is always excited and rewarding. You never have the same day, and you are constantly learning. Along with the rest of nursing, you will continue to say to yourself “you can’t make this stuff up” and look to laughter alongside your colleagues. You get to develop amazing relationships with personnel of the hospital you maybe never even knew existed, and, above all else, get to make a huge impact on creating positive outcomes for our patients. Infection prevention and control is an increasingly important field, and the involvement of nurses will continue to be a great importance!

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What Do Infection Prevention Nurses Do?About the Author

Whitney Daum holds her BSN from the University of Akron and her MPH from the University of Colorado. She has worked in the field of nursing for over 10 years. She is certified in both pediatric nursing (CPN) and infection prevention and control (CIC). Whitney is scheduled to graduate with her MSN in Infection Prevention and Control through American Sentinel University in October 2018, and hopes to one day teach new and upcoming nurses the importance of infection prevention.

Infection Prevention: New Perspectives and ControversiesInfection Prevention: New Perspectives and ControversiesInfection Prevention: New Perspectives and ControversiesManual of Infection Prevention and ControlManual of Infection Prevention and ControlManual of Infection Prevention and ControlInfection Prevention: Simple Facts You Need to Know, Book 2Infection Prevention: Simple Facts You Need to Know, Book 2Infection Prevention: Simple Facts You Need to Know, Book 2NRSNG PodcastNRSNG PodcastNRSNG Podcast

What Do Nurse Anesthetists Do? (CRNA)

What Do Nurse Anesthetists Do? (CRNA)

Interested in becoming a CRNA? Not sure exactly what that means? This guest post takes a closer look at what do nurse anesthetists do!

What Do CRNAs Do?

Most operating rooms release the schedule the night before. Unlike bedside nurses, nurse anesthetists don’t start their day with Nurse Drama Hour. You know, the hand-off that details all the hard, brilliant work the last shift did. Usually, the more impressive the nurse’s report, the more likely you’ll find a patient who didn’t get their pain or constipation medicine amusing themselves by playing Jenga with their poop. So what do nurse anesthetists do?

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I told myself, “This is going to be a long, serious post. Please act professional.” Oops, let’s start over.

What Do Nurse Anesthetists Do?

Starting your Shift – Preop Assessment

For a typical CRNA, the day begins in the preoperative area where the first nervous patient awaits. For healthier patients undergoing minor procedures, a quick clinical examination coupled with questions about every organ system is all that is required—similar to a yearly physical but with more detailed questions about prior surgeries and anesthetics.  The airway exam is also an opportunity to ask if the patient snores and to assess for other issues that may make intubation and extubation more difficult. I made an unkind meme with Jabba the Hut denying his need for CPAP, but I can’t find it now so you’ve been spared.

Patients and surgeries entailing more risk require extensive testing beforehand. Electrolyte imbalances should be corrected and blood cell counts and clotting ability considered adequate for the procedure. Everything is documented on a pre-op form. During surgery, I will document vital signs every five minutes, along with details about the airway and intubation, positioning, the time and dosage of the drugs I selected for the patient, and anything else that will assist the next provider. Planning for the “worse-case scenario” always involves placing intravenous access sufficient to rapidly administer fluids and blood products if needed. Invasive monitors for arterial and venous pressures may be placed before surgery for critically ill patients. If the patient has heart disease, part of the preoperative work-up can include acquiring an EKG, cardiac echo, stress test results, and clearance from a cardiologist.

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Preparing the OR Room

After seeing the patient, I gather the necessary drugs and equipment, based upon the preoperative assessment and the type of surgery. Drug shortages, cost, efficiency, surgeon characteristics (such as speed and how much blood they typically lose for this type of procedure) and the availability of a good crosswords puzzle are important variables. Well, not the puzzle, but anesthesia truly requires personalized care. A drug perfect for stabilizing the vital signs in one patient could easily harm the next patient. Just to put a patient to sleep, a half dozen different drugs may be used at individualized doses, with several other drugs prepared for emergencies and to keep the heart rate and blood pressure at reasonable levels.

Equipment preparation includes testing the anesthesia machine. Mouth-to-mouth resuscitation is a decidedly “old school” response to an anesthesia circuit leak in most circles, so check that $50,000 piece of machinery thoroughly! Once the surgeon has seen the patient, the CRNA often graciously augments empathy and reassurance with calming pharmaceuticals before the patient travels to the OR. In most cases, I prefer a fun joke and interesting conversation to 2mg of Versed, but everyone has their own “recipe.”

Surgical Overview

The next five minutes tend to be the most exciting of the day. Once monitors are attached, the patient is quickly anesthetized, paralyzed, intubated with an endotracheal tube, and positioned securely for surgery. Since the patient won’t be purposely moving during surgery, nerve injuries would be the CRNA’s fault, so sometimes it’s a balance between the exposure the surgeon prefers and what’s most comfortable for the patient. Depending on the vital signs, the CRNA may give more anesthetic gas, narcotics, or other medications to adjust blood pressure and other variables. This process continues throughout the surgery, but toward the end of the case, the CRNA adjusts the ventilator settings, anesthetic gas, and any infusions to slowly wean the patient off the ventilator and wake them up. After a successful extubation, the patient is merrily transported to the recovery room. Once the CRNA is satisfied with the patient’s condition and reports blood loss, medications used, patient history, and similar data to the nurse, they begin again with the next patient.

There you have it. That’s all we do. Over and over again. The process is slightly different for sedation cases, and epidurals, spinals, and regional nerve blocks are other important CRNA tasks, but most of it happens in the OR or the units immediately adjacent. It’s a narrow, highly specialized field that doesn’t easily lend itself to a “second career” the way a frustrated ICU nurse can go start her own home health care company. As a certain unemployed cardiologist in California can attest, home health anesthesia works poorly—yes, I just went there. If it’s any consolation, few highly specific and sought-after skills do transfer easily, unless your name is Bo Jackson or Charlie Ward. I suppose our potential readership will drop significantly if I explain all of my stupendous conclusions with outdated sports analogies, so an alternative example would be the dismal failure that greets most movie actresses who attempt to also become singing sensations.

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Drugs & Choices

ICU experience at the baccalaureate level is required for prospective CRNAs in part because we use some of the same drugs, though usually in more aggressive ways. I misspelled “baccalaureate” so badly Spellchecker invited me to a bachelorette party and then rescinded the invitation. Moving on, I use Fentanyl or occasionally its more powerful cousin Sufenta to provide analgesia (relief from pain) even while the patient is asleep. Unless the anesthesia for the actual procedure is also delivered intravenously with Diprivan (propofol) and the possible addition of Ketamine, Precedex, or Ultiva, I give Diprivan once. It renders the patient unconscious at about 2mg/kg after some Lidocaine so it won’t sting like 2% milk in the veins (I’ve never tried it, but it’s probably not worth the extra calcium). A Laryngeal Mask Airway (LMA) or similar device doesn’t require paralysis, but most anesthetized patients will cough if you try sneaking a tube through their vocal cords without first paralyzing their skeletal muscles.

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Once assured I can ventilate the patient with a mask and the Ambu-like bag attached to my anesthesia machine, I’ll now paralyze the patient. My choices are a quick-acting depolarizing agent (meaning the muscle contracts before going flaccid) or a paralytic similar to Tracrium or Nimbex, which are used long-term in the ICU since they don’t require much organ metabolism. I’ll have to reverse non-depolarizing muscle blockade at the end of the case (the alternative is Dr. Phil). Using a laryngoscope, I’ll pass the endotracheal tube through the vocal cords, blow up the balloon to keep it there (along with a mess of tape on their face and to protect their eyes), and listen for breath sounds while monitoring end tidal CO2. Besides nitrous oxide, most hospitals have three different anesthesia gasses to choose from. The patient’s smoking or asthma history, my desire to have a crisply awake patient with the same personality they had going to sleep, and my favorite color of the day are all factors in choosing which gas to use.  The gas diffuses from alveoli to blood to brain, so the needed concentration to add to oxygen and air coming out of the anesthesia circuit is much less variable than the way other routes of drug administration interact with liver enzyme systems and renal metabolism. That said, it takes skill and experience for surgery and anesthesia to consistently end simultaneously.

So there are a lot of choices, but like every type of nursing, the question always is, “What is my goal?”

  • Do I just want the patient unchanged, so they leave the OR in roughly the same shape they came in?
  • If not, how far am I willing to go to fix them? Potassium and magnesium drips and beta blockers all around?
  • Is the surgeon using local anesthetic and the patient’s vital signs don’t reflect painful stimulation, or is this a particularly painful procedure and I need to think of multi-modal combinations for pain relief, like Baclofen and Neurontin preoperatively and Ofirmev in recovery?
  • Anesthetized patients lose auto-regulation of temperature and vital signs. Do I need to use vasopressors like Ephedrine and Neosynephrine to support blood pressure, and do they need blood or albumin?
  • If I give a lot of crystalloid fluids, do they have a catheter, and are they prone or in a head down position, increasing the risk of edema near the airway?
  • What’s the plan as I turn off the anesthesia gas near the end of the procedure and the patient is waking up? Do I want to give more narcotic so they won’t cough as much on the tube, or am I more worried about sleep apnea and want to sit them up and insert an oral or nasal airway before I take out the endotracheal tube?

Learning the Culture

Anesthesia is a job similar to a soccer goalie: no one pays much attention unless you mess up. Contrary to the operating room persona of working behind the scenes, CRNA personalities tend to be anything but invisible. Does it take a strong personality to stand up to surgeons when necessary, and a peculiar one to enjoy meticulously controlling the vital signs of anesthetized patients every day? Not necessarily. Dull and boring personalities can be just as successful as sparkling ones. For students, there are certainly traits and attitudes that will increase the chance at success, but I’m going to touch on embracing the paradox.

  • As a main revenue generator for the hospital, management scrutinizes everything that happens in the operating room, but it is a top location for bullying and outlandish behavior.
  • You need to give either more or less anesthesia–a patient’s saturation is decreasing as they cough on the tube that provides them with a safe, reliable source of oxygen.
  • You must exude confidence and take control of situations, but also fly below the radar. Also, please stand your ground and roll with the punches.

These are all examples of paradoxes, and the healthy tension between two opposing truths is often the only way forward. Much like multiple-choice questions on nursing school tests, it can be discouraging for almost identical actions to be the correct choice one time and wrong the next.

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“The way forward” as described last paragraph was as abstract as your patient’s last hallucination, so let me try again. Swallow pride and remember your role as a patient advocate. As always, everyone thinks their specialty or intervention is the most important, but what’s best for the patient? Sometimes, the conservative route of an endotracheal tube and central line can do more damage than an LMA and a patient breathing on their own. Surgeons, surgical techs, nurses in preop, recovery, and in the OR, and anesthesiologists can all be part of the team, depending on where you work. Rather than just slogging through the day and the immediate details, look at the picture holistically as only a nurse can.

Finishing Up

Guess what? Sometimes you still get a chance at Nurse Drama Hour! When relieved during surgery for a break, lunch, or to go home, I get to tell another nurse anesthetist about how awesome I am and all the wonderful things I did for the patient. This is similar to the report I give a nurse in recovery, except it includes details like, “They were a Class III airway so next time I’ll use a Miller 3 blade on my laryngoscope to lift the epiglottis”, or, “Their blood pressure dropped when I gave Dilaudid, but they’re a bit sensitive to phenylephrine so I’m raising their blood pressure with 50 micrograms at a time. Oh, and they might wake up wild and swinging. OK, thanks, Bye!”

I don’t really “K Thnx Bye” anyone, but in line with what I wrote earlier about holistic care, it really helps to check back on how your patients fared. I’m always asking the recovery nurses to make sure the patients didn’t have nausea or pain as soon as I walked away to take care of the next patient. In that regard, this job is almost like ER nursing, so sometimes it takes a little sleuthing to make sure that interventions worked well and should be repeated. This is especially important for clinicians like me who continually stress an individualized approach over cookie-cutter care. Feel free to ask questions in the comments!

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More CRNA Resources:

Neuro Nurse Crash CourseNeuro Nurse Crash CourseNeuro Nurse Crash CourseNRSNG AcademyNRSNG AcademyNRSNG AcademyICU Skills ConferenceICU Skills ConferenceICU Skills ConferenceNurse Anesthesiologist Anesthesia Unicorn T ShirtNurse Anesthesiologist Anesthesia Unicorn T ShirtNurse Anesthesiologist Anesthesia Unicorn T ShirtNurse AnesthesiaNurse AnesthesiaNurse Anesthesia

Top Tips for New Nurses Working With Ventilators – From a CRNA!

Top Tips for New Nurses Working With Ventilators – From a CRNA!

Top Tips for New Nurses Working With Ventilators

Periwinkle is a lovely color. A soft, subtle blue, it looks best as Helen Hunt’s eyeshadow in 1995 or on an Easter egg. It looks worst on your patient’s skin. While waiting for the respiratory therapist to come bail you out, understanding some common sense and troubleshooting will keep your patient pink, or in my case, healthy brown instead of sickly green. Let’s talk about some tips for new nurses working with ventilators.  And, please remind me in the comments to seek professional help about my troubling childhood, because this is not the first time I’ve compared cyanosis to eyeshadow.

Top Tips for New Nurses Working With Ventilators

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The Patient’s Condition

Moving on, the patient’s condition will help prioritize your response to various alarms, whistles, and catcalls from the ventilator.

  • Do they have ARDS and need every possible molecule of oxygen stuffed into those stubborn alveoli?
  • Is this a patient the intensivist didn’t feel like extubating at shift change so we’ll wean them in the morning?
  • Has there been in a change in patient behavior or vent settings?
  • How much time does it normally take to recruit competent help if you need it?

I’m talking real life, not some ideal job where you drop everything to deal with each alarm rather than blissfully ignore irrelevant ones if you’re busy. Alarm fatigue is a completely different discussion and one I’m the wrong person to lead because I’m evil and would set my alarm limits to narrow ranges to see how many times during a shift a meticulous coworker of mine would come over and cancel my alarms for me. Remember to prioritize by what an alarm means, not how annoying it sounds. Otherwise, an Alaris pump going off would mean “I will eat your patient’s soul if you do not flick the air bubble out of this IV line” while sudden onset atrial fibrillation in a patient with an already weak heart is a “meh” moment.   

 

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Vitals With Ventilators

Once you know why a patient has a plastic tube forcing air between their vocal cords, you can better predict what will happen to their vital signs because of the alarm or message on the ventilator. This is how I practice anesthesia–I always care much more about where the oxygen saturation will be in 30 seconds than what’s currently on the screen. Especially on a sick patient, the data from a good looking pleth (and please look at the oximetry waveform every time you look at the number) is much more delayed than the instant electrical impulse from an EKG, and it’s not that accurate below 75% anyway. Am I saying that the saturation could dip below normal and your patient could be perfectly fine?! Yes, just like you can float underwater much longer than you can flail and blow bubbles. Overreacting is almost as holy as “critical thinking” in nursing culture, but even as a new nurse, having a general idea of what you can handle and what requires a few phone calls serves your patients well.

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Are You Touching My Tube?

As a self-proclaimed nurse hobo, I probably worked in 50 different ICUs before anesthesia school. In most of them, the rule from RT was, “Don’t touch the tube or my vent, unless it’s the 100% O2 button so the sat will look better despite the patient coughing.” In some cases, my valuable information above isn’t enough and you’ll need to mess with the tube anyway, since we all know the only unbreakable rule is, “Do what’s best for the patient.” And maybe, “If there’s unattended food on the table in the break room, anyone can eat it.” Always follow the endotracheal tube from where it exits the mouth, between 21-24 centimeters, and the eventual attachment of inhalation and exhalation connections to the ventilator. For adequate ventilation, pressure and CO2 tracings should look like squares, not shark fins or the spiky part of an EKG–er, R wave. A tube pushed down too far only ventilates one lung and results in much higher pressures and usually lower saturation. A patient who suddenly extubates themselves might need an ambu bag (preferably with an oral airway and jaw thrust), CPAP via mask, or a non-rebreather mask whether or not the plan is to reintubate them. The combination of a tube that is no longer between the vocal cords blowing air around and one of the above looks silly and doesn’t work. Shut the vent off. This is not the time to worry about giving the patient too much oxygen, but please remember that 100% oxygen doesn’t help someone who isn’t breathing. In fact, if a partially or completely paralyzed patient gets extubated, you should push the code button, because there isn’t much time to decide whether to reintubate immediately, push sugammadex to reverse paralysis from rocuronium or vecuronium, or continue down the airway algorithm.

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How Ventilators Work

The above .gif of mind-blown Dr. Phil is pretty much what a partially paralyzed patient looks like, minus his vibrant pink hue. Listen, we’ve already established that I’m a terrible person–let’s finish with a quick review of how ventilators work. Yeah, I know, maybe we should have started with this, but I think of Dr. Phil as more of a closer than Helen Hunt. Normally, we inhale because of negative pressure caused by pressure differences between the lungs and the chest wall. This is why you should avoid being stabbed in the lung. Ventilators deliver a consistent volume of air and oxygen into the lungs without exceeding set pressures or allowing alveoli to deflate in the complete absence of pressure. The various acronyms for types of ventilation simply tell us whether each attempt to inflate the lungs is more focused on reaching a particular volume or pressure. Some modes, such as SIMV, are more accommodating when the patient tries to breathe on their own. If the patient’s coughing is continually setting off alarms, it may be time to consider one of those modes, start the weaning process, or increase sedation with infusions of propofol and/or fentanyl, Precedex, or, if your hospital is really poor, morphine and Versed. The important alarms relate to high pressure or low volume. Often this is because laminar flow becomes turbulent. The smooth, golden stream moving through catheter tubing after you insert a Foley into a patient who really needs it is an example of laminar flow. Turbulent flow is what makes whitewater rafting fun but positive pressure ventilation ineffective. Coughing, mucus, or narrowed airways all cause air to slow down and change directions, like cars braking and shifting lanes in heavy traffic. The whole goal of ventilation is to have a ratio of inspiration to expiration that allows air to inflate alveoli and trade oxygen for CO2 from capillaries, but exit the lungs before the next breath. Otherwise, breaths stack together and pressure continues to build. I can go into greater detail about these topics in the comments, or you can contact me via social media and buy my book.

Top Tips for New Nurses Working With Ventilators - From a CRNA!Nick Angelis, CRNA, MSN, is the author of How to Succeed in Anesthesia School (And Nursing, PA, or Med School) and regularly writes or presents continuing education articles on a variety of dry and dreary topics, just like this one. He also has a thing for satire such as The Twerk Vaccine. Nick works as a nurse anesthetist in NW Florida and NE Ohio and enjoys playing several sports poorly. You can connect with him on Twitter or  Instagram.

 

More Resources:

Ventilator Modes Made Easy: An Easy Reference for RRT's, RN's, and Medical ResidentsVentilator Modes Made Easy: An Easy Reference for RRT’s, RN’s, and Medical ResidentsThe Ventilator Book: Second EditionThe Ventilator Book: Second EditionVentilator BluesVentilator BluesVentilator Modes Made Easy: The Complete Guide For Registered Nurse, Respiratory Therapist, And Medical Resident!Ventilator Modes Made Easy: The Complete Guide For Registered Nurse, Respiratory Therapist, And Medical Resident!UNDERSTANDING RESPIRATORY CAREUNDERSTANDING RESPIRATORY CARE

What Do Labor and Delivery Nurses Do?

What Do Labor and Delivery Nurses Do?

What Do Labor and Delivery Nurses Do?What Do Labor and Delivery Nurses Do?

Labor and Delivery nurses work in the happiest place in the hospital.  Where else do you get to go to birthday parties all day and night long?

If you love adrenaline, babies and a little bit of everything, the “Baby Factory” might be the place for you!  Labor and Delivery is a mix of the Emergency Department (ED), Medical-Surgical, Operating Room (OR), Recovery Room, Neonatal Intensive Care Unit (NICU), and Critical Care all mashed together into one exciting unit!

What Does a Typical Day Look Like for Labor and Delivery Nurses?

Your day is different every single time you walk into work.  In Labor and Delivery, you could be assigned to an OR case, an antepartum patient, or a woman in labor.  Job assignments are not cut and dry. They are dynamic and always changing.

A “slow” (Shhh!!) morning could instantly turn into riding on the gurney with your patient, heading straight for the OR.  Why are you on the gurney? Well, your stable antepartum patient’s water just broke and the umbilical cord slipped into the vaginal canal causing fetal distress.

In these situations, an emergency cesarean is the only resolution.  It is the nurse’s responsibility to place their hand in just the perfect position inside the vagina so the baby doesn’t compress the cord, which could cause a lack of oxygen to the baby.  As the decompressor of the cord, you’ll probably be draped in the OR along with the patient because your hand will be inside the patient until the baby is delivered. You might even get to give the doctor a handshake from inside after they get the baby out!  Talk about a rush!

If you followed that patient until they went to the postpartum unit, you’ve had an antepartum patient, an OR case, AND a recovery room experience in the span of a few hours.  Talk about a whirlwind!

Since there are so many aspects to Labor and Delivery nursing, I’ll discuss each type of patient and what a day would look like with them!

Labor and Delivery Triage

If you love the Emergency Department (ED), you might give Labor and Delivery a try.  The labor unit is usually independent of the rest of the hospital, meaning they run their own triage like a mini ED.  Unlike other units where admits come straight from the ED, pregnant patients typically bypass the ED and go to Labor and Delivery triage instead.

Any medical or surgical complaint in pregnancy is evaluated by Labor and Delivery triage.  Whether it’s appendicitis, vomiting, headache, dizziness, contractions… it all is taken care of in Labor and Delivery triage.  If a woman is admitted for labor, they head to a labor room. If someone has appendicitis they might go to an antepartum room for further evaluation.

Once a patient is assigned to you in triage, immediately assess how far along your patient is in her pregnancy and if you have a viable baby.  If the baby is viable, you’ll put on a Toco (which monitors contractions) and a Sono (to monitor fetal heart rate). Typically, this is your number one priority and done before continuing your assessment.

Why is this monitoring a priority?  If you have a baby with a low heart rate, you could be running to the OR minutes after saying hello.  I’ve gone from introducing myself to delivering the baby via emergency cesarean section in 6 minutes flat!  That’s how fast things move in Labor and Delivery.

It’s a good day when a triage patient complains of contractions with no other medical problems.  If you check her cervix and it’s dilated more than 4-5 cm, she’s just bought a ticket to a labor room!

Care of the Laboring Mom

Taking care of a laboring patient can best be described by going through a typical shift change report, or nursing handoff.  The great thing about Labor and Delivery is the majority of your patients are healthy, so report often does not involve complicated medical problems.

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The most pertinent things you’ll ask during a patient report are:

G’s and P’s (Gravida and Para): Gravida is how many times the patient has been pregnant, and Para is how many times she has given birth.  For instance, if you have a G10P8 (a history of 10 pregnancies with 8 births), you’ll be aware that the baby could come FAST with little to no pushing.  With this history, it’s ideal to have the doctor close by! It’s always best if the baby is born with the doctor, not mom sneezing it onto the bed!

Obstetric History: Has the patient had a cesarean section in the past?  Does she have a history of precipitous labor, placenta previa or pre-eclampsia?  These are all things that will shape the plan of care for the patient.

Medications:  It’s rare that a laboring patient will have scheduled medications like Colace. Many times medications on Labor and Delivery are given unscheduled or as needed.  These include pain medication, nausea/vomiting medications… etc.

One medication unique to Labor and Delivery is Pitocin.  Pitocin (a medication used for labor inductions) is used to increase the strength and frequency of contractions.  This medication is titrated by the nurse until an adequate labor pattern is achieved.

Fetal Status:  Fetal monitoring is unique to Labor and Delivery.  Nurses take multiple classes on how to accurately interpret fetal heart rate patterns.  Accurate interpretation is imperative to proper care. For instance, if there is a dip in the fetal heart rate, the nurse needs to assess whether the baby’s head is being compressed, if the cord is getting pinched, or if the placenta is not working properly.  Each of these scenarios has different interventions, which is why the nurse needs to know how to act appropriately. At the bottom of this article, there are some resources if you’re interested in learning more about fetal monitoring!

Once you get the report, it’s time to assess your patient.  As I mentioned earlier, the majority of your patients aren’t sick.  Most of them are in labor, which makes an assessment fairly easy.

Unique nursing assessments in Labor and Delivery include palpating the abdomen for the contraction strength, checking contraction frequency, assessing the baby’s heart rate, and performing vaginal exams to assess cervical dilation.  In many hospitals, nurses perform all assessments and notify the doctor of progress. When it’s time to push, the nurse will assist the patient until it’s time for the doctor to perform the delivery.

Vaginal Delivery

After pushing for a while with the patient, the physician or midwife will arrive for the baby’s delivery.  The nurse is responsible to support the mother as she pushes her baby into the world. During this time, the nurse also cleans the perineum, prepares the delivery cart (which holds tools the physician might need), and retrieves warm blankets for the baby’s arrival.

Once the baby is born, he or she is placed on the mother’s chest as the nurse dries the baby with warm blankets.  At 1 minute and 5 minutes after birth, the nurse will be in charge of assigning an APGAR score, which is an assessment of the baby’s status.  An APGAR score includes the baby’s heart rate (which is obtained from the umbilical cord), breathing, color, muscle tone, and reflexes.

After delivery, the nurse continues to monitor vital signs on mother and baby, measure the baby’s weight and length, give the baby medications, and assess the mother’s bleeding. If mother and baby are both stable, the nurse transitions them to the postpartum unit about 1.5-2 hours after birth.

Cesarean Section

In the case that labor doesn’t lead to a vaginal delivery, an emergency or scheduled cesarean section is needed.  During a cesarean section, the nurse will assist in the Operating Room (OR). In the OR, the nurse acts as the circulating nurse.  Duties include placing an indwelling urinary catheter, doing surgical prep, performing instrument counts, and answering the physician’s pages.  Once the baby is delivered, you’ll have another nurse present. One nurse will assess the baby, determine APGAR scores, and assist with skin to skin; the other nurse will continue taking care of the mother until the surgery is complete.

On the units I’ve worked, Labor and Delivery nurses also perform recovery after surgery.  During recovery, the nurse will be exclusively with the patient and the newborn for about two hours.  Along with administering medications, the nurse checks the patient’s fundus (the uterus) to make sure it remains firm and assesses the amount of bleeding every 15 minutes.

The ideal recovery patient will have had a spinal (a type of medication administration).  With a spinal, the mom’s pain will be well controlled. If the patient was laboring with an epidural prior to delivery, the anesthesia staff can also dose it to use in the OR for a cesarean section.

Unfortunately, if your patient had an emergency surgery without an epidural, the patient will likely have general anesthesia, making the pain more difficult to control.  In this case, the nurse will be busy administering medications during the recovery period. It’s ideal to get a PCA Pump to help manage the patient’s pain. (A PCA Pump is a type of pain management that allows the patient to control the pain medication administration).

What Totally Sucks About Working as a Labor and Delivery Nurse

Although Labor and Delivery is usually the happiest floor in the hospital, 1% of the time it is sad… really really sad.  No one ever wants to hear the words “you’ve lost your baby.”  When a baby passes away in the womb, it is called a fetal demise.  These patients deliver in the same way as other patients. However, the nurses have additional things to include in the plan of care.

Once the baby is born, nurses allow patients to grieve in whatever way they choose.  If they want to hold the baby for hours… that’s okay. This is their time. To make special memories, we often call services like Now I Lay Me Down to Sleep to take pictures of the baby and family.  In addition to pictures, the nurses will do footprints, hand molds, and any other special things the family requests.

Even though it’s heartbreaking, it’s very special to be allowed the privilege to support a family during such an emotionally difficult time.  I’ve even had the beautiful experience of supporting a family through a loss, and a year later, celebrating as they met their next child.

What’s Great About Being a Labor and Delivery Nurse

I could go on all day about why I would never work anywhere else in the hospital!  I LOVE birth. It’s so raw, natural, and beautiful. So, here are my top three reasons why I love working Labor and Delivery:

As a nurse on Labor and Delivery, I love the working relationship between the nurses and the doctors.  Even though nurses and doctors have very different skills and roles, there is a collaboration between these two professions.  The role of a nurse is more of a partnership with the doctors, making for a fulfilling work environment.

Another aspect I love about Labor and Delivery is the diversity in the job.  Nurses participate in a wide variety of areas, such as triage, OR, recovery, and labor.  I know that every day I walk on the floor is going to be different. I love the variety that Labor and Delivery offers.

Perhaps the thing I love most about working Labor and Delivery is that every labor story is different.  As the nurse, I get to be a part of a family’s unique birth story. Being in the room when a family meets their baby for the first time is such a privilege.  So, I try to make each patient feel special. It is so rewarding to witness the excitement of a family welcoming a new baby!

So, You Want To Be a Labor and Delivery Nurse?

Is the prospect of being a Labor and Delivery Nurse exciting to you?  If so, check out some of these resources that can help launch your career as a Labor and Delivery nurse!

 Labor and Delivery Resources:

In “Baby Land,” we have a lot of unique procedures and verbiage that you won’t hear on any other floor in the hospital.  You can check out my Labor and Delivery vocab and a list of procedures unique to Labor and Delivery.

Perhaps one of the more difficult areas to master in Labor and Delivery is reading fetal heart tracings.  If you’re interested to learn more about heart tracings, I suggest checking out this site.  This site is an awesome resource that teaches you the basics of fetal heart monitoring.

Lastly, AWHONN and AGOG are the go to locations for up-to-date information on the field of obstetrics.  You’ll find the latest recommendations and research through these organizations.

I hope that this article sparks your curiosity into learning more about Labor and Delivery nursing.  I am so excited to say that I have found my nursing passion for Labor and Delivery. Who knows… maybe it’s for you too!

What do Labor and Delivery Nurses do? This guest post looks at why Labor and Delivery nurses work in the happiest place in the hospital.

Brianna Babienco, BS, RN, RNC-OB has been a nurse for over 7 years and specializes as both a nurse and clinical instructor on Labor and Delivery.

Outside of work, Brianna is a wife and mother of two beautiful children.  She enjoys swing dancing, scuba diving, and going on game shows. (She is a winner of the Price is Right and Let’s Make a Deal!)

If you want to find out more about Labor and Delivery, connect with Brianna Babienco as she explores the nursing experience on Facebook, Twitter, Instagram, and Pinterest.  Check out her blog at Nurse Gold, where she and her sister Marissa Salsbery blog about all things nursing and specialize in helping nurses becoming more financially prepared for their future.

OB/GYN Peds Notes: Nurse's Clinical Pocket GuideOB/GYN Peds Notes: Nurse’s Clinical Pocket GuideFast Facts for the L&D Nurse, Second Edition: Labor and Delivery Orientation in a Nutshell (Volume 2)Fast Facts for the L&D Nurse, Second Edition: Labor and Delivery Orientation in a Nutshell (Volume 2)Womens OB Nurse, We Help People Get Out of Tight Spaces t-shirt XL Heather BlueWomens OB Nurse, We Help People Get Out of Tight Spaces t-shirt XL Heather BlueMosby's Pocket Guide to Fetal Monitoring: A Multidisciplinary Approach, 8e (Nursing Pocket Guides)Mosby’s Pocket Guide to Fetal Monitoring: A Multidisciplinary Approach, 8e (Nursing Pocket Guides)

What Do Nursing Home Nurses Do?

What Do Nursing Home Nurses Do?

What Do Nursing Home Nurses Do

I think a lot of nursing students, as well as nurses in general, carry misconceptions about what it’s like to be a nurse in a nursing home. Many don’t really understand exactly what do nursing home nurses do. This guest post will walk you through a typical shift and see if it’s what you imagined.

This guest post was written by Diane Lansing, BAN, RN

Every year, our nursing home welcomes nursing students from nearby universities for clinical rotations. When the students meet with the Director of Nursing during orientation on the first day, she always asks how many of them are considering a career as a nursing home nurse.

It’s rare that anyone raises their hand.

 

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A few weeks later, the students again meet with the DON to review their experiences. Again, she asks who is thinking about the nursing home as a career option. This time, it’s typical that several students have decided they might enjoy working as a nursing home nurse.

What Do Nursing Home Nurses Do?

Beginning Our Day

Depending on the nursing home, you’ll most likely work either an 8 or a 12-hour shift. You’ll begin your shift by receiving the report from the outgoing nurse.

Since you’ll be responsible for a large number of residents, nurses can’t go into great detail about each resident during a shift-to-shift report like they do in a hospital. In fact, it’s not unusual for a nurse to be responsible for 30 or more residents in the course of a day shift and even more during the night.

These topics are typically covered during report:

  • Residents with recent condition changes
  • New orders
  • Last PRN (as needed) meds given & response
  • Significant abnormal lab results
  • Appointments scheduled for today
  • Resident or family concerns
  • Incidents such as falls

Some nursing homes employ TMA’s (Trained Medication Aides) to pass medications. These are CNA’s with specialized training in medication administration. If you don’t have a TMA during your shift, you’ll hit the floor running to get your medications administered on time. If you’re fortunate enough to have a TMA, this frees you up to focus on other important tasks.

Our Primary Responsibilities

Your shift might include (in no particular order):

  • Medication administration
  •  Blood sugar checks
  •  Treatments (dressing changes, nebulizer treatments, etc.)
  •  Rounds with medical providers
  •  Receiving and following through on new orders
  •  Care conferences
  •  Completing assessments for MDS’s (more about that later)
  •  Updating families
  •  CNA evaluations
  •  Checking O2 sats and monitoring O2 administration
  •  Team meetings & staff meetings
  •  Assisting residents with meals
  •  Care planning
  •  Obtaining specimens (urine, wound cultures, blood draws)
  •  Consultations with other team members (dietary, rehab, social services)
  •  Ongoing communication with CNA’s throughout the shift
  •  Checking & monitoring vital signs
  •  Skin assessments
  •  Handling staffing issues such as call-ins
  •  Pain management
  •  Lots of documentation
  •  Answering call lights
  •  Assisting residents with personal cares such as toileting
  •  Mentoring nursing students
  •  Resident & family education
  •  Consultations with hospice providers

Best of all, during those precious shifts when you have a bit of extra time, you can enjoy interacting with your residents. This might mean simply visiting, joining them in an activity for a few minutes, or doing something special to pamper a resident. That’s the best part of being a nursing home nurse!

What Happens During A Shift:

Oftentimes, a medical secretary is on staff during the day shift. This is enormously helpful, as they can transcribe orders, make appointments, and field phone calls. If you don’t have a medical secretary, you’ll need to take care of these tasks yourself. As a staff nurse, you’ll supervise several numerous CNA’s. While, of course, you need to get your own work done, it’s also wise to help out the CNA’s whenever possible. You’ll earn their respect and promote a more positive, team-like atmosphere.

Physicians, nurse practitioners, and physician assistants make regular rounds at the nursing home. Not only do they see residents according to schedules mandated by Medicare and other agencies, but they also see residents for concerns that come up from day to day. As a nurse, you’ll need to be up-to-date on the resident’s condition so you can offer information and answer questions. You’ll also make rounds with a variety of other medical professionals that could include psychiatrists, podiatrists, and wound care specialists.

Many nursing homes now employ admission nurses who oversee a new resident’s transition to the nursing home. However, as a staff nurse, you’ll help with this process as needed. In conjunction with the nursing home social worker, you’ll also help assure a smooth transition when a resident is discharged. This includes discharge education, as well as assuring that all follow-up services, medications, and equipment are arranged.

Staff nurses must be flexible and able to multi-task. Frequent interruptions are par for the course. This means responding to requests from residents, phone calls from family members, questions from CNAs, return calls from medical providers and dropping what you’re doing to assess a resident with a sudden change in condition.

Excellent assessment skills are crucial in a nursing home. Since you don’t have a lot of time to spend with each resident, you need to constantly watch for subtle changes. And when a resident develops an acute condition, you need to be able to quickly assess the situation, provide thorough information to the physician by phone, communicate with families, support the resident, and delegate tasks to other staff members—all while keeping your cool.

Interestingly, in many nursing homes, there aren’t a lot of differences between the role of an RN or an LPN. While some roles (MDS coordinator, unit coordinator, etc.) require the nurse to be an RN, the role of the staff nurse is often the same regardless of education level.

 

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When people ask, “Don’t you get bored at night when all the residents are sleeping?”

 Documentation And More Documentation

Nursing home nurses are increasingly being asked to do more documentation in order to comply with state and federal regulations. A huge part of this documentation is something called the MDS.

The Minimum Data Set (MDS) is an extensive clinical assessment required for all residents in Medicare or Medicaid certified nursing homes. While most nursing homes employ a specially trained RN to oversee this process, documentation is required to support all of the information that is entered into the MDS. Therefore, staff nurses are responsible for providing assessments and progress notes to back up the MDS.

The accuracy of an MDS is crucial. It determines how much a resident pays for care at the nursing home drives the resident’s care planning process and is used to help determine if a facility is in compliance with state and federal regulations during a survey (inspection).

What’s Great About Being A Nursing Home Nurse

People often tell nursing students that it’s a good idea to get experience on a general medical-surgical floor of a hospital after graduation. In my opinion, a nursing home is also a terrific place to start out as a new nurse. You’ll have an opportunity to hone your basic nursing skills, as well as develop supervisory experience.

A nursing home is also a great place to establish a career. I love the fact that in a nursing home you get to know residents and families on a long-term basis. At a hospital, a nurse often has a short, intense caregiving relationship with a patient, and then they quickly move on to another unit or perhaps go home. You never get to learn the end of the story. In a nursing home, you have the privilege of working with residents for weeks, months, or sometimes many years.

One of the things I enjoy about geriatric nursing is the fact that you work with such a wide variety of residents with a wide array of diagnoses. As a result, you’re able to keep up your knowledge and skills in many different areas. These include:

  • orthopedics
  • cardiac
  • respiratory
  • oncology
  • palliative care
  • mental health
  • developmental disabilities
  • infections
  • neurology
  • dermatology

Years ago, most nursing homes provided custodial care. However, at today’s nursing home we find more residents coming in for short-term rehab and then returning home. We also provide care for residents with more complex needs such as:

  • Peritoneal Dialysis
  • Wound Vacs
  • IV’s
  • TPN
  • Tracheostomies
  • Vents
  • Tube Feedings
  • PICC lines

There are a lot of exciting changes coming down the pike in nursing homes these days. Rather than working under the traditional medical model, nursing homes are becoming more home-like and focussing on person-centered care. We also see more nursing homes employing universal workers. These specially trained CNA’s fill multiple roles (direct care, activities, housekeeping, dietary,etc.) in order to best meet the needs of the residents.

What’s Challenging About Being A Nursing Home Nurse

One of the most difficult aspects of working as a nursing home nurse is the negative perception much of our society has about nursing homes. Because of bad things that have happened at some nursing homes, the public tends to think that nursing homes are places to be avoided and mistrusted.

What they don’t see are the highly skilled, compassionate, and dedicated nurses and other caregivers who work very hard to provide the best possible quality of life for our residents.

Fortunately, this perception is improving over time and people who work in nursing homes are receiving more respect and recognition.

Of course, nursing home nurses face many of the same challenges as nurses in other types of healthcare: staffing shortages, rotating shifts, physically and emotionally demanding assignments, and hard-to-please physicians, families, and co-workers.

But, at the end of every single shift, we get to go home knowing that somebody’s day was made better because we were there. Now, what could be greater than that?

Diane Lansing, BAN, RN has been a nurse for over 35 years. She currently volunteers at the nursing home where she previously worked as a nurse manager. Her special area of interest is Alzheimer’s disease and other forms of dementia. Diane blogs about her nursing home adventures at Nursing Home Volunteer.

Fast Facts for the Long-Term Care Nurse: What Nursing Home and Assisted Living Nurses Need to Know in a NutshellFast Facts for the Long-Term Care Nurse: What Nursing Home and Assisted Living Nurses Need to Know in a NutshellEvidence-Based Geriatric Nursing Protocols for Best Practice, Fifth EditionEvidence-Based Geriatric Nursing Protocols for Best Practice, Fifth EditionNobody's Home: Candid Reflections of a Nursing Home AideNobody’s Home: Candid Reflections of a Nursing Home Aide

See Also:

What Do NICU Nurses Do?

What Do NICU Nurses Do?

What Do NICU Nurses Do

Being an NICU nurse sounds like a pretty amazing job! I mean you get the word “intense” in your title and there are little babies. While it sounds amazing, many don’t know what NICU Nurses do in a typical shift.  This guest post offers a glimpse behind the curtain.

What Do NICU Nurses Do?

Welcome to the Neonatal Intensive Care Unit! We take care of the tiniest, and sometimes, sickest humans in the hospital. It is important to understand that premature infants are not only small, their entire body is premature and underdeveloped- their brain, their heart, their lungs, the GI system, their skin.

Ninety-eight percent of our days are great, but the 2% that are bad are really bad. Some days are feeding and cuddling babies that are close to going home, some days are holding a new mom’s hand as the team explains that it’s time for her to hold her baby while he dies. I love my specialty and wouldn’t trade it for anything.

There are several different levels of nurseries, ranging from a Level I (which is a well baby nursery) to a Level IV (which are the most advanced, usually part of a large children’s hospital or academic medical center). I work in a level III NICU that does not perform surgeries.

Every day in a NICU looks different from the last. Every shift in the NICU looks different from the one before it. And every NICU looks different from another.

Remember that everything in NICU is smaller. Our patients are measured in grams and centimeters. Our medications are often measured in tenths of mLs. 2L of oxygen is considered high flow in here, but don’t panic if you see a patient with oxygen saturations in the high 80s, that might be acceptable for that patient. We measure our feedings in mLs as well, sometimes only giving drops. We use the smallest blood pressure cuffs you have ever seen and sometimes those are too big. NICU nursing is delicate work.

I’m going to lead you through 2 scenarios, one featuring a nurse 1:1 with a critically ill or premature infant, and another with a nurse caring for 3 feeder-grower infants.

Regardless of the assignment, NICU nurses are usually the first in the hospital doors. Before our unit meets for huddle (where the off-going charge nurse gives updates on the status of the unit, who the Neonatologist and Neonatal Nurse Practitioner are for the day, and any other important updates), and we scrub in. Leave your jewelry and watches at home, your arms will be bare from the elbows down as you scrub with soap and water, clean under your fingernails, and use a no-rinse surgical sanitizer.

After huddle begins report. A NICU report looks much different than an adult world one.

  • History of the pregnancy and delivery
    • Age
    • Weight (gain or loss)
    • Head circumference
    • Length of the patient.
  • Diet
    • OG or NG tubes
    • How well the infant takes oral feedings
    • Last stool
  • IV access
    • Umbilical lines
    • PICC line
    • Peripheral IV
  • Is the baby on TPN and lipids? (We run TPN and lipids separately)
    • Or D10W?
    • Any replacement fluids, like sodium acetate?
  • Respiratory support

Specific settings are covered and discussed, placement and size of the endotracheal tube is covered if the patient has one, how often the patient is being suctioned (and what it looks like!), and what the patient’s oxygen demands have been. If there have been any recent radiology studies, like chest x-rays, head ultrasounds, or echocardiograms, we review those as well as any that might be scheduled for that day. Finally, we review the most recent lab results and go over all of the orders together. It is practice in our unit to “walk the line” together with the off going RN. No matter what type of line the patient has, a feeding tube, IV access, ET tube, we confirm proper placement and proper infusions/settings and connections at the start/end of our shift.

Caring for the 1-on-1 patient

Let’s say this nurse is caring for a baby that was born at 24 weeks gestation. The bed area is going to have the following (most likely): a High Frequency Oscillating Ventilator (these things are BEASTS but are SO gentle on little lungs), multiple IV pumps and syringe pumps with a variety of medications running, a cardiopulmonary monitor displaying heart rate, oxygen saturation, and respiratory rate, and possibly a bili-light used to assist the body in breaking down bilirubin (increased levels cause jaundice).

Report should’ve finished by 7:30, and shortly after that you would begin your first round of cares on this infant. Let’s say an ABG is ordered as well as a blood glucose level for 0800, along with a chest x-ray. Because the infant has an umbilical arterial catheter (UAC), we can draw a blood gas (and the rest of our labs) directly from that line. Extreme caution should be used when doing so in small infants. Even withdrawing 1-2mLs of blood can be a large enough change to cause hemodynamic instability.

After calling the respiratory therapist to confirm that they can run the ABG, I would draw my ABG off of the UAC, obtain my blood glucose, and start recording vital signs. While listening and counting the heart rate and respiratory rate, I am working on my head to toe assessment as well.

A NICU Head-to-Toe Assessment Example

  • What does the patient’s head feel like?
  • Are the sutures separated or overlapping?
  • Do I hear a murmur? (Actually, while the piston is running on a HFOV, you cannot hear heart sounds!)
  • What do the lungs sound like?
    • Crackles?
    • Wheezing?
    • Clear and equal?
  • What about bowel sounds?
    • Is the abdomen soft
    • Distended
    • Bowel loops visible (they look like sausages under the skin)
    • Scaphoid?
  • How is the patient’s muscle tone?
  • Does the infant have full range of motion with their limbs
    • Does one stay still?
  • Is the patient vigorous and “fighting” me
    • Or are they flaccid?

After obtaining blood pressure measurements (with the tiniest blood pressure cuff you have ever seen!) and an axillary temperature, I work on several other checks from head to toe. I perform oral care with any colostrum that we may have available, check the OG tube to remove any air from the stomach, suction out the ET tube and make note of the secretions, and finally change the infant’s diaper. We weigh diapers from admission to discharge. Hopefully, all of that can be completed before the x-ray techs arrive. You would shield yourself with a lead apron and position the infant for the x-ray. After the x-ray is complete, you position the infant in a comfortable way, close the doors to their isolette, turn down your bedside light, pull the isolette cover down, and let that baby sleep.

By now you should have your ABG results back along with the x-ray image, which may result in some HFOV setting changes. While waiting for new/changed orders, it’s time to chart your heart out before bedside rounds begin at 0900. As the bedside nurse, you are actively managing the patient’s oxygen concentration to keep their saturations between the ordered parameters. Too high for too long can be detrimental to the infant’s developing retinas, and too low is starving the body of needed oxygen.

Bedside rounds

During bedside rounds, the offgoing Neonatal Nurse Practitioner (NNP) gives report on the past 24 hours and suggests a plan for the next 24 hours to the oncoming NNP. This is all in medical speak first and then our Neonatologist explains it to the parents if they are at the bedside for rounds.

During rounds the people present at the bedside include: the Neonatologist, the offgoing NNP, the oncoming NNP, the bedside RN, Respiratory therapy, PT, OT, SLP, Social Work, the unit manager, and the parents. The plan of care for the day is discussed but you won’t change anything until your orders are written.

At 1000, monitor vitals are recorded. It is practice in my unit to obtain vitals on patients receiving oxygen support every 2 hours. Every 4 hours, at 8/20, 12/00, and 16/4, the RN performs hands on cares: a full head to toe, diaper change, oral care. On the off hours only monitor vitals are obtained to allow the patient a chance of having a period of undisturbed sleep. Of course, all of this is dependent on the acuity of the patient, vitals may be needed more frequently, or the RN may be disturbing the infant more frequently to keep the patient safe and alive.

The whole morning repeats again starting at 1200, except for rounds. As the bedside RN for a critically ill or premature infant, you really are not ever leaving that bedside. You will be continually watching the patient’s vital signs, reporting changes in status to the Neonatologist and NNP, explaining changes to the parents, and charting EVERYTHING. You could have to transfuse multiple blood products, administer pressors or other medications, or request assistance in repositioning your patient. It is on days like this, when your brain is going a million miles an hour, that all of your critical thinking skills are used. It is such a rush.

During all of this, you or your coworkers might be working on placing another peripheral IV in a baby… using a 24 gauge catheter!

Most procedures are done at the bedside in the NICU as well: PICC lines, lumbar punctures, chest x-rays, and head ultrasounds to name a few.

Caring for the 3-to-1 patients

On the complete other end of the spectrum from caring for one critically ill baby, is managing the care of three! Report would look similar to that of the critical baby, but information on discharge planning would also be shared.

Infants that are close to going home are cared for and fed on a 3-hour schedule:

  • 8, 11, 2, and 5
  • 9, 12, 3, and 6 (to avoid having to feed a baby at shift change)
  • Or may be on an ad lib schedule:  getting to eat whenever they want

Managing these 3 patients might involve coordinating care times with speech or occupational therapy, assisting parents with feeding skills, having parents complete parts of discharge education, administering car seat screens or hearing screens, or simply just care for the three patients and getting some snuggles in.

While caring for the three infants may not seem as stressful as caring for the 1 critically ill baby, the days where you have 3 patients are stressful. Some days feel as if you are just moving from feeding one patient, to another, to the next, charting it all, and then repeating all day long, but other days you feel like a chicken with their head cut off attempting to run around the unit while keeping all your patients organized.

Life can change in the blink of an eye in the NICU. One minute the unit is calm, the next, a crash c-section is performed and a 24-week gestation baby is being admitted and your team comes together to make it as smooth as possible. Quite often, when it rains it pours in the mother-baby world and the NICU is no stranger to that phenomenon.

When I tell people that I am a NICU nurse, they often respond by saying: “I could never do that!” While I think NICU is a sometimes scary specialty, it is addicting. You get addicted to helping these families through the toughest part of their lives and seeing these tiny babies eventually grow into roly-poly toddlers.

What Do NICU nurses do?

If you are looking for a high risk, high reward nursing specialty, the NICU might be the place for you.

Charlotte Minnema, BSN, RN, CLC is a registered nurse in a Level III Neonatal Intensive Care Unit in Michigan. In addition to being a wife, momma, and nurse, Charlotte is pursuing her Doctor of Nursing Practice degree to become a Primary Care Pediatric Nurse Practitioner.

In her free time (HA! Free time…) Charlotte enjoys going for walks with her husband and son, knitting, reading, and trying new recipes.

Follow her journey of juggling married life, mom life, nurse life, and student life on Instagram @drnursecharly

 

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What Do Emergency Nurses Do?

What Do Emergency Nurses Do?

Day in the Life of an ER Nurse

As many of you know, I am not an emergency department nurse. However, I receive many questions about emergency nursing. In going along with our “what do nurses do” series, Susan DuPont, fellow nurse blogger and emergency nurse, will go over what emergency nurses do!

Emergency departments come in all shapes and sizes, and Susan works in a very large and busy hospital. When her Level I Trauma Center Emergency Department is full, they are at 123 beds (which includes hall beds), and no one gets sent out of their ED… people are flown into them. She sees the sickest of the sick! So let’s see what it’s like to spend a shift in Susan’s nursing shoes…

What do emergency nurses do?

Let’s dive into what emergency nurses do. Click on any bullet point to jump to that section.

Besides being awesome, we see and do some pretty crazy things.

And not coincidentally, when someone finds out that I am an ER nurse, they always say, “I bet you’ve seen some really crazy things.”

Yup.

But that is not all my day consists of. Mostly, I am running around managing multiple patients with a sharp eye on picking out life-threatening conditions.Many nurses will tell you that they did not like the ER; it’s hectic, very fast paced, and nerve-racking… But it is also exciting, more autonomous, and builds confidence. Not everyday will be excitement, not every day will be heroics, and yes, I will admit, that sometimes I feel like my job is putting out the fires closest to my feet.

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But I wouldn’t have it any other way.

Wanna know if you have what it takes to be an emergency room nurse? Let me show you what a typical day in the life of an ER nurse is like.

Clocking in and starting your day with huddle

In the ER, we have new people coming onto shift every 4 hours. You have many different opportunities for which time you’d like your shift to be. You can work 3 twelve hour shifts a week, 2 twelves and 2 eights, 5 eights, and you can come in all around the clock.

Once you have clocked in, you will have huddle where the charge nurse and managers hand out assignments and cover the current state of the department. This typically includes how many patients are suicidal, restrained, critically ill, and what is happening in the resuscitation bays.

Resus Bay: A resuscitation bay, or “resus bay,” is a special room in the emergency department for the sickest patients and the most time-sensitive interventions. From traumas to medical mysteries, any type of patient can be cared for in the resus bay(source).

It is important to listen to this information because you may potentially be taking care of one of these patients, but also because those patients require extra hands so be prepared to help out a lot.

We typically have a ratio of 4-6 patients to one nurse, however, this is not the rule, rather the hope. In the ER you cannot, by law, turn away a patient who comes in the doors. On the floor, you can refuse to take any more patients. If we can’t move patients upstairs, the waiting room fills up. When patients are waiting in the waiting room, the nurses that are in triage are responsible for these patients. Depending on how many nurses are assigned to the triage area, will determine the ratio. If you have 2 triage nurses and 20 patients, your ratio will be 1:10, if your waiting room fills up with 50 patients, the nurse to patient ratio becomes 1:25. That can be scary, but the scariest part is that they are solely relying on your ability to assess them correctly because a physician doesn’t see patients in the waiting room.

This is why, when a patient has a ready bed upstairs on the floor, you need to make haste getting that patient to the floor so we can pull one of those 50 people in the waiting room into a room to be seen by a physician.

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You will see anywhere from 10-30 patients in your shift. The ER is fast moving, you will not have a lot of time to get to know your patients well. Movement is vital in the ER, or patients get backed up in the waiting room.

Focused care and patient flow

It is important to know a little bit about everything to care for every type of patient. This is why floor nurses are vital to the health care system. For example, I know how to recognize the need for a chest tube, set up for insertion of the chest tube, troubleshoot the chest tube and then I hand over the patient to nurses who care for patients with chest tubes. I do not, however, know long-term care of chest tubes, nor have I ever pulled one out. This is a big difference in ER nursing versus floor nursing.

As an ER nurse, you will be trained to recognize life-threatening situations, stabilize them, then get that patient to the proper place where they will be cared for long-term. Everything in the ER is short-term and fast moving.

Having empty rooms in the ER is fairly rare. So if you have a patient assignment, you will be full capacity all the time. But not all nurses will have a specific assignment. From the time a patient comes into the ER, they will pass through many nurses.

  • A screener nurse will quickly assess their airway, breathing and circulation (ABC’s) and chief complaint then determine if the patient is able to wait to get a full triage or if they need to be seen immediately and go to the Trauma or Resuscitation Bays.
  • The triage nurse will gather a story, get vital signs, screen the patient for potential infectious diseases, potential abuse, review history and meds, etc. then order any testing that the patient is going to need.
    • Hand injury gets an x-ray
    • Chest pain gets an ECG and blood work
  • Then you have nurses that have a room assignment. These nurses will carry out physician orders and coordinate the patient’s care.
  • Finally, you have nurses that are dedicated to Trauma and/or Resuscitation bays where the sickest patients get immediate medical attention. These are usually a one patient to one nurse ratio.

What is ER nurse report

This is a very different kind of report than what you probably get anywhere else. It consists of pertinent information and a plan of care.

Pertinent information is vastly different in the ER than it is on the floor. We do not cover things such as IV access, treatment team members, allergies, ability to get up to the bathroom, etc. unless it is pertinent to the patient.

Couldn’t get IV access and needs IV access?…This.is.pertinent.

Does the patient have diarrhea and is quadriplegic?… This.is.pertinent.

Now, if a patient had a laceration repair and is going to be discharged home?… I do not need to know they are allergic to everything but Dilaudid because this.is.not.pertinent.

Giving pertinent information leaves out a lot of information that can be easily looked up or assessed if you really need to know it, but there is a very good reason for this type of report. It helps the oncoming nurse remember everything that was said and quickly triage each patient so they know who to see first. On the floor, you will likely get stable patients, in the ER, you get more variation on stability. If you think about it, we take care of the patients who are going to the med-surg floor along with the patients who are going to the ICU, cath lab, and OR, along with the patients that we haven’t figured out if they are sick or not.

When talking about the plan of care, it often includes, performing tests (labs, imaging, etc) and/or waiting for results to come up with a plan of care. If tests have already resulted then the team needs to either discharge, admit or monitor.

Here is an example of getting report in the ER:

“Room 1 is here with chest pain and a significant cardiac history. His initial EKG showed a long QTc and he has had 5 runs of V-tach with the longest run being 2 minutes. He received a bolus of 300mg Amiodarone and is now on an Amio drip. He also received 2 grams of mag and has been normal sinus rhythm with a normal QTc. We are waiting on Cardiology to come see the patient.

Room 2 is here with a small bowel obstruction. She has an NG tube already placed and is on low intermittent suction. She is admitted and waiting for a ready bed upstairs. She has been hypertensive that has been controlled with pain meds. Last BP was 130/85.

Room 3 just got here, they are complaining of right flank pain, I haven’t gotten blood work yet, they are in the bathroom getting you a urine sample, and a provider still needs to see the patient.

Room 4 is here with nausea and vomiting. They have received 2 liters of normal saline, 8 mg of zofran and need a PO challenge in an hour. They will be discharged if they can tolerate the PO challenge.”

Initial assessment of ER patients

No matter what, every patient you see will need to have an assessment done on them. However, the most important part of emergency nursing is which patient you’ll see first. This is a skill that takes time to learn and is carried out with a lot of teamwork.

I like to go into all my patients’ rooms and introduce myself, grab a set of vitals, do an ABC assessment and quickly review the plan of care. This should take no longer than 30 minutes to see all the patients. It is not a full assessment, rather it is to make sure that you have laid eyes on all your patients and can make your own judgment on who to see first.

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Initially you decide who to see first based off of report, but then you lay eyes on all your patients and make that determination yourself. It is not that I don’t trust the judgment of my colleagues, rather I cannot go to court and explain, “I didn’t go see that patient for 45 minutes because the previous nurse said they were stable.” (We mentioned that in our previous post in this series from the ICU Nurse perspective.)

Your name is legally assigned to their care, you are responsible, you better be able to explain your actions and it cannot be based on someone else’s opinion. Especially in the ER where patients can become unstable very quickly.

Here is an example of me initially seeing a patient:

“Hello, my name is Susan, I have taken over as your nurse. I was told in report that we are waiting on lab results, as soon as the results come in, I will let you know. Do you have any questions?”

While I am talking to them, I am hooking them up to the monitor for continuous vital signs if they are not already hooked up. I update the whiteboard with my name, make sure they have their call light and as long as their ABCs are intact, and then I move on to the next patient.

I will then sit down at the computer and start compiling a to-do list. I order that to-do list based on timing, importance, and patient condition. If a patient has a breathing treatment due and another patient has IV antibiotics due, I will get both medications, go to the patient who needs a breathing treatment first (ABC’s!), grab a spirometer reading, start the breathing treatment and then go hang the antibiotics. After hanging the antibiotics, I will swing back and grab a post-treatment spirometer reading.

Now, I mentioned that I hook almost everyone up to the monitor. Some people say that is excessive, I say that is working smarter, not harder. To each their own. But, I will say that the patient who got a breathing treatment will need to have their pulse ox and heart monitored and the patient who got IV antibiotics should be monitored for a reaction, thus having them on the monitor will alarm you if something is going awry.

(As always however, follow your policies and procedures at your facility regarding monitoring!)

Actual assessment of ER patients

Once I have made sure that all my patients are stable and have any time-sensitive tasks performed, I do my own full assessment of each patient.

Now, this is not like a head to toe assessment on the floor, rather I look at each body system and eliminate issues that are concerning and acute.

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The bruise on their leg from tripping a week ago? Not really important to focus on.

The open laceration on their arm from broken glass? Important to chart details on.

Every single patient needs to have cardiac, respiratory and neuro exam at a very minimum. If a patient is here for altered mental status, I do a detailed neuro exam. If they are here for chest pain, I do detailed cardiac and respiratory exams.

A good example of an assessment in the ER versus the floor is bowel movements. In the ER it is pertinent to ask if there has been any change in their normal bowel movements. If there has been a change a more detailed assessment needs to be performed. On the floor, it is pertinent to ask when the last bowel movement was, even if they haven’t had any changes in their bowel movements because on the floor you will be with the patient long enough to track their bowel movements.

In the ER you are trying to find out what has changed in their life to make them come to be seen. Spending time with a chest pain patient on if they have pooped today is not only time consuming, but it delays potential immediate life-saving care they should be receiving. They could be having a heart attack and time is tissue! Now if the patient is here for abdominal pain, you will ask when the last time is that they pooped. It is not the same assessment for every patient.

It needs to be said that if you come across something concerning during your assessment, you stop the assessment and get a physician. If I am doing a neuro exam and the patient is having facial drooping and slurred speech, I don’t continue with my assessment by asking them when their last bowel movement was. I get help. Time is tissue. If this patient is having a stroke, we don’t have time to assess further, I need to get this patient to the CT scanner and have a physician see the patient immediately.

If the patient is having a stroke, the best place for them is with nurses and doctors who specialize in caring for stroke patients. ER nurses specialize in recognizing life-threatening conditions, while floor, stepdown and critical care nurses specialize in the care of those patients. Often times, you may have had the patient for an hour before they are assigned a bed in the neuro ICU and all you know is they had facial droop, slurred speech, CT was negative for a bleed and they received tPA. You have done the first neuro exam and they are going to the unit. This can make giving report difficult. There will be a lot of questions you don’t know the answer to.

As an emergency nurse, you need to understand that there are limitations in place for patient safety and the floor nurses are just trying to keep your patient safe, so give them a break. And floor nurses give the ER nurses a break, they are standing in a pit of fire trying to keep the patients in the ER safe.

What is a Primary Assessment in the ER

A primary assessment includes neuro, cardiac, and respiratory. This is done on every single patient no matter what they came into the ER for. The following is a list of basic assessments you will do on a patient in the ER. You will do a more detailed assessment if the situation warrants.

      • Neuro assessment
        • Orientation status
        • Facial symmetry
        • Motor movements
        • Cranial nerve assessments
      • Cardiac assessment
        • Rate
        • Rhythm
        • Heart sounds
        • Capillary refill
        • Skin perfusion (pink, warm, dry?)
        • Pulses
      • Respiratory
        • Rate
        • Chest rise and fall/symmetry
        • Breath sounds
        • Breathing effort
        • Oxygen saturation (pulse ox)
        • Skin color

What is a Focused Assessment in the ER

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This is the ER nurses bread and butter. You must be able to recognize when to dive deeper into a particular assessment and what to ask or be looking for. There are many chief complaints that you will come across and it is your job to ask the right questions.

For example: a 65 year old female presents to the ER with complaint of epigastric pain. She has been nauseous and feeling dizzy.

This patient will likely get a cardiac workup along with a GI workup and you need to focus the majority of the assessment there.

What is a Secondary Assessment in the ER

Secondary assessments are not always performed. These are case by case assessments. I personally try to do a secondary assessment on every patient I see, but sometimes it is just not possible. Secondary assessments include everything that is not in the primary or focused assessments.

Stages of caring for a patient in the ER

You will either be receiving new patients, getting all testing done on patients, admitting patients, monitoring patients, or discharging patients. Any of these stages can happen at any time and you will likely have multiple patients in different stages throughout your day.

Receiving patients in the ER

When I receive a patient in the ER, assuming the ABC’s are intact, I gather their story and discern a chief complaint. After reviewing their history, meds and getting vital signs, I assign the patient a level of urgency. Each ER has a different triage process but generally speaking patients are assigned a number that rates them on a scale between non-urgent to urgent to emergent.

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After rating the patients level of urgency I will start my assessment. I always do a primary assessment and a focused assessment. If I am able or have the time, I put in a secondary assessment.

I then try to anticipate any orders the provider (MD, DO, PA, NP, etc.) may want. For example, someone with a fever will need a CBC, or someone with abdominal pain will need a urine sample. I start IV’s, gather labs, place the patient on the cardiac monitor, order some basic medications if indicated among other things. Once the provider has seen the patient, I carry out any further orders.

Once all tests have resulted, the provider will decide to either admit, monitor or discharge.

Admitting a patient from the ER

The provider will work with providers in different areas of the hospital to come up with the right placement for the patient. Every floor has specific parameters of vital signs they can work within, medications they are allowed to administer, types of diagnoses they can care for and level of “sick” they are trained and able to maintain on their floor. Some providers will accept the patient but need further treatment performed in the ER before they are safe to come to a specific floor. For example, if a patient has a high BP, they may need to be medicated and monitored until their BP is within the limits that are acceptable for that floor before they can go to the floor.

Once all parameters have been met and the bed is ready, report needs to be given to the accepting nurse and the patient needs to be transported to the floor. If the patient needs to be monitored, that is the job of the ER nurse. You will leave your assignment and transport that patient to their room on a monitor.

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Monitoring patients in the ER

Sometimes a patient will need to stay in the ER to make sure they are stable for a period of time. A patient who had an ingestion, an allergic reaction, a medication or other situations, may need to stay in the ER but don’t really need to be admitted. These patients require vital signs every so often (depending on the situation) and intervention if anything goes awry.

For example, if you give a patient morphine before discharge and they don’t have someone else to give them a ride, they need to stay in the ER until they are safe to drive.

Discharging patients from the ER

Most patients will be discharged after they have been evaluated and all life-threatening causes are either eliminated or taken care of. Stable patients that don’t need hospitalization will be discharged with instructions to follow up with either their PCP or a specialist. Patients need to have their vital signs taken within one hour of them leaving the ER and their discharge instructions need to be reviewed.

Power Hour

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During the last hour of my shift, I go into beast mode. I make sure all my vital signs are up to date within an hour of when the new nurses shift will start, I update a plan of care note, I make sure all testing that I can control has been accomplished and I pack up my workstation.

Clocking out for the day

I give report, put my coat on, clock out and leave the building. Deuces my friends!

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Susan DuPont, BSN RN CEN is an emergency nurse at a Level 1 Trauma Center. She is a nurse blogger at bossrn.com where she inspires nurses to be the best version of themselves by promoting education and preparedness.

A few more resources

Kati here! I wanted to provide some additional helpful resources for the ER nurse.

The Power of Nurses Embracing Discomfort

The Power of Nurses Embracing Discomfort

Nurse Discomfort

This guest post was written by Monica Moore, MSN RNC

As a nurse-educator, I often role-play with nurse clients as I find it is an important teaching tool which exposes nuances of patient care gaps that aren’t obvious by using traditional methods. I use this format when reviewing how to have challenging conversations, dealing with emotional patient-care situations or conveying negative results. I pretend to be the ‘patient’ on the receiving end of bad news, or the relative who is angry and frustrated and the nurse is, well, the ‘nurse’. Last week, during a client coaching session, I was a patient who presented to the offices actively miscarrying her pregnancy.

My ‘nurse’ took care of me medically, gathering supplies, reviewing next steps, but made limited eye contact and seemingly wanting to be anywhere but there. When I (as the patient) asked my ‘nurse’ why this was happening to me, she responded by telling me a story of when she had a miscarriage. When we later analyzed the conversation, I pointed out her body language, lack of eye contact, and “conversational narcissism” a term coined by sociologist Charles Derber where you focus the conversation on yourself in an effort to empathize with another person. My ‘nurse’ admitted that she knew she was not being fully engaged and present, but was afraid that I would ask her something that she didn’t know or would express an emotion that she couldn’t handle, one that would make her uncomfortable. But nurse discomfort can be a potent tool, enhancing the patient experience, particularly during an emotionally-charged interaction like this.

The Power of Nurses Embracing Discomfort

Learning to embrace nurse discomfort was a lesson that I learned 20 years ago in a yoga class, when my teacher told us that once we get deeply in the pose, that we are actually just getting started. The ‘work’ of the pose is what you do from there, when your legs are shaking and you are sweating and hoping that she remembers to count the seconds you are in the pose and not talk to another student and forget. Do you stay, let up, or go deeper, curious to explore what happens after that, never to the point of pain, but not skirting the feeling of deep sensation, sensation that is uncomfortable. The times that I persevered, I discovered something new. Maybe that my legs were weaker than I thought, maybe that my right side was stronger than my left, and, after years of practice, maybe that I had feelings that were stuck, that needed permission to be released. I even found myself tearing-up without any warning in class, which is not uncommon, according to my teacher, particularly during hip and shoulder opening poses since many of us hold onto stress in those spots.

And this taught me something else about discomfort. It is the result of many factors, not the least of which is that it is a sign that you may have triggered something unresolved in your own life. But had I not pushed, not crossed that threshold from content to discontent, I would have missed out on growth potential by discovering an insight that, in retrospect, has proven to be important in my personal and professional life.

Ok, back to how this applies to being a nurse.

When I worked in Labor and Delivery, I became the nurse who was often assigned to the rooms in which there was a loss or other difficult circumstance, and I learned to be humbled and honored by this role. Of course, I don’t enjoy the part of my job where I have to deliver bad news or be in the midst of an intensely personal and private situation, such as mourning a loss. I do, however, realize the weight of my contribution to this challenging situation, and even though I can’t change it, I can try positively affect the experience of the patient during it. I find that applying this perspective gives my role the appropriate level of reverence and gravity that it deserves.

I invite you, as the nurse, to experience what it feels like to settle into the pause after giving bad news.

I would ask you, in a sad or emotional situation, to make eye contact with the patient and act as if you want to be there, even if you want to be anywhere else but there.

I would hope that you can allow the patient to express whatever she is feeling and just listen, as awkward or uncomfortable as this may make you. No empty words or platitudes, no story about your own life or other patients’ journeys. By pausing and just listening with full attention, you are creating an environment that gives her permission and space to mourn a loss. If she asks, “why”, you can answer honestly, and appropriately, that you don’t know, that she may never have an answer to this, but that she can rely on you, that you will be there for her to guide her through her next steps.

Realize that, at this time, the person who needs to feel heard is the patient, not you.

At worst, she will be upset or angry and you won’t know how to respond, maybe all you can do is express regret or apologize. Allowing yourself to be vulnerable also has its benefits by promoting human connection, just ask Brene Brown.

Daring Greatly: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent, and LeadDaring Greatly: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent, and Lead

Just a disclaimer, I am just asking you to listen, not advocating that you absorb the patient’s pain. This can lead to secondary trauma or compassion fatigue, a very real and damaging potential consequence of being a health-care provider.

I hope, after reading this, that you will experiment with how to navigate uncomfortable circumstances, and consider that settling for complacency can lead to missed opportunities for both you and your patient, even when dealing with patient deaths.

Many nurses are not fully engaged and present when dealing with patients. But nurse discomfort can be a potent tool, enhancing the patient experience, particularly during an emotionally-charged interaction.As the Founder of Fertile Health LLC, Monica travels the country training fertility nurses and their teams in her area of expertise, reproductive endocrinology. Earlier in her career, she was patient-focused working in the Neonatal ICU, Labor and Delivery and a busy infertility practice. Through this experience, she identified a clear need for better training embodying evidence-based science that would empower patients in their personal health and fertility choices. She calls Ponte Vedra Beach home.

You can follow Monica on Twitter, Facebook, and Instagram.

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Inpatient to Outpatient: Transitioning from the ICU to Primary Care

Inpatient to Outpatient: Transitioning from the ICU to Primary Care

 I am currently two semesters away from graduating with my masters as a family nurse practitioner. I plan to work in family practice in an office setting. It’s a stark contrast and it’s reasonable to ask why I made such a big move from ICU to Primary Care.

Transitions are hardly ever easy, but sometimes changing it up is the best move.

Inpatient to Outpatient: Transitioning from the ICU to Primary Care

For the first nine years of my nursing career, I worked as in a trauma/surgery intensive care unit nurse, at a Level One trauma hospital. I started there as a baby nurse, fresh out of school and clutching my NCLEX in hand as proof (or reassurance) that I could work in such a place. Needless to say, the ICU far exceeded my expectations. I learned how to take care of intubated, sedated patients with open bellies and extensive wounds. I learned how to manage CRRT on patients with complex comorbidities. I learned what a productive code looks like and how to avoid a chaotic one. It was a hard, all-encompassing experience at times. And while there were some tears and self-doubt early along the way, I grew to be a proficient nurse in a stressful environment. I grew to love everything about the ICU.

Now I am currently two semesters away from graduating with my masters as a family nurse practitioner. I plan to work in family practice in an office setting, far away from crash carts and codes and people with trachs who cough up phlegm. It’s a stark contrast and it’s reasonable to ask why I made such a big move from ICU to Primary Care. I’ll attempt to answer that questions as well address some of the advantages and challenges to steering my career in an entirely new direction.

So why did I decide to move to outpatient as a family nurse practitioner (FNP) instead of pursuing a career as an acute care nurse practitioner (ACNP) in the ICU? Most of the reasons are very practical and a few are more complicated.

Family

First of all, I have a family and want to work weekday hours with no nights, weekends, or holidays. I am a mother and a nurse and I believe you can do both jobs well, but I hate not getting to see my two year-old daughter on the days that I work at the hospital. I also want a slower pace with less daily stress. After nine years in the ICU, I’m not ashamed to say that my back and my feet want a change to something less strenuous. And although I won’t be making as much in outpatient as I would in the hospital as a nurse practitioner, I decided that was worth it to me for all the reasons that I just discussed.

New Responsibility

Secondly, I want to take on a new kind of responsibility as a provider but I don’t want those responsibilities to include taking care of thirty critically ill patients (kudos to those of you who are up for that challenge!). I want to try something new and after years of dealing with the most complicated patients in the hospital, I suddenly find the idea of diagnosing coughs and managing diabetes very appealing. I want to round out my skills and family practice provides me with a whole new environment of care.

Emotional Well Being

Lastly, I will admit that I have experienced some degree of emotional fatigue. I am tired of seeing people die everyday, of taking care of the worst-case-scenario patients. Some part of me has started to believe that every car wreck ends up in paralysis and every pneumonia ends up in ARDS. I know it has been taking a toll on my family and me, so now I look forward to managing common complaints, promoting prevention, and developing long-term relationships with my patients. It’s a much-needed change that I think will provide me with a little bit more balance.

Downsides

There are some downsides to completely changing environments. One of those disadvantages is that many of the ICU skills that I’ve spent years honing will essentially go unused. It doesn’t matter anymore than I can get an ABG in one stick or that I can help with an intubation or that I can manage four pressors at once. Much of my expertise is not applicable in a primary care setting. Additionally, I will miss the adrenaline of the ICU. I will never again help run a hospital code or rush STAT to a head CT. A part of me will grieve the loss of my first love (trauma), my first nursing job, and my coworkers whom I have grown to love with the fierceness of a family. Although I know I will come to make many new friends in the outpatient setting, I will be saying goodbye to a certain type of patient, experiences, places, and most of all, people.

Advantages

I can’t honestly tell you that I know all the advantages yet of going from inpatient to outpatient, from the ICU to primary care. I do know that I enjoy stretching myself in new ways academically, professionally, and emotionally. I love developing solid kinds of relationships with patients and getting to see their progress over time. I enjoy getting to see my daughter in the morning before I leave and getting to have dinner with my family at night when I come home. I enjoy getting to use all my new knowledge in a provider role and advocate for nursing from a new vantage point.

If you’re considering changing practice environments, you need to recognize that it will take adaptability, humility, and a willingness to learn. You may find it more difficult than you thought or better than you could’ve imagined. A big change like this means risk and you will be taking a risk in moving from the familiar to the unknown. So as a confidence booster, I will offer this one piece of encouragement: you know more than you think you do.

No matter where you started or all the places you’ve worked during your journey to an advanced degree, you’ve been working as a nurse and that means you’ve developed your nursing intuition. You know what I’m talking about.

You know when someone has an acute abdomen versus something innocuous just by looking at them. You can pretty much pick out when people are lying about their pain medications or when someone is struggling with a mental illness. You can navigate those difficult patients with ease because of my experience with high-pressure situations. This skill is more amorphous than being able to get an IV but invaluably useful. It’s a learned skill and we’ve all worked very hard to acquire it no matter what background we came from. You’ve got the gut feeling and it will continue to steer you in the right direction as you go down a new path.

The transition from ICU to primary care has been full of growing pains and I’m sure more are to come as I become an independent provider. There are aspects that I will love and things that I will miss. But in the end, I think it’s a trade off, some advantages here for some advantages there. At the core of it all, I get to work with people and that’s the reason that I chose healthcare in the first place- to hear, to heal, to comfort, to encourage. And now to prevent, to diagnose, and to treat.

ICU to Primary CareI know that I’m walking into a whole new world that may be challenging at times, full of learning curves and inherent risk, but I believe it will be worth it. I will be a different kind of nurse, but still a nurse all the same.

And I have found that nurses are almost always up for a challenge.

Natalie is an RN who is working towards her masters degree. She is moving from the ICU into Primary Care. Natalie blogs about this move at Nurse Natalie. You can also follow her on Twitter at NurseNatalie15 and Instagram.

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The Role of the Nurse Preceptor: A Three Part Series

The Role of the Nurse Preceptor: A Three Part Series

The role of the nurse preceptor? Responsibility, Preparation, and Personalities
Let me introduce myself. My name is Melissa, though most people at work know me as “Stafford,” a nickname that was given to me because we had 4 Melissa’s in our unit at one point.  Can you imagine that? I graduated nursing school back in 2000, though that seems like last year to me. After spending a year and a half on a surgical floor, I have spent the rest of my time in neuro critical care. I am not an expert, but I’ve functioned as a nurse preceptor over the years, from student nurses all the way up to experienced nurses.

You are probably prepared for what to expect during your orientation, whether it be from discussions during nursing school, friends, or from personal research on the web (In case you don’t know, this very website is filled with wonderful information and links to other resources for orientation).

The role of the nurse preceptor? Responsibility, Preparation, and Personalities

I want to talk to you about orientation a little differently. I want to share with you orientation from my point-of-view, as a nurse preceptor. It is important to me that you understand…

Yes, I am a nurse preceptor… but I struggle too. Let me share with you some of the reasons why.

1. Responsibility

Being a preceptor, in my opinion, is a huge responsibility. It’s similar to a teacher/student relationship, especially in the beginning of orientation. Your success as a new nurse in my unit, in large part, depends on my ability to be an effective teacher. If I don’t do my job well, how can I expect you to be successfully independent after orientation? This is a responsibility that I take seriously, which means… just by agreeing to be a preceptor, I take on additional stress. Yet, despite the stress, it is something that I greatly enjoy doing.

2. Preparation

Hopefully the leader of the unit has done some planning. In an ideal world, they have:

  • Chosen a nurse preceptor, in advance, of your first day
  • Chosen the best preceptor based on your prior experience
  • Given the preceptor some background information on your prior experience (or lack thereof) so he/she can anticipate where and how to start.

The reality, though, is that I may not get much information, such as any prior experience outside traditional clinical rotations. And, in some cases, like if your “regular” preceptor unexpectedly calls out sick, I may not get any notice at all.

3. Personalities/Learning Styles

While I look forward to getting to know you personally over time, my focus in the beginning is understanding you as a new nurse.

  • What kind of background do you have? Meaning…
  • New graduate: Someone fresh out of school. Something I keep in mind is that experience varies greatly between programs.
  • Did you get a wide variety of hands-on experiences during clinical rotations or some type of ‘internship’, or
  • Were you restricted either by school or hospital policies on what you could even attempt?
  • Were you a CNA, or is your experience limited to the controlled environment of the program?
  • Transitional nurse: In my case, this is a nurse that has worked in some other department and is now new to neuro/critical care.
  • Did you work on a med/surg floor with experience related to my unit. Or,
  • Did you work in an unrelated area of practice, but are excited to try something new.
  • Experienced nurse: Slightly different than transitional, in that I consider this to be a nurse who has experience working in critical care.
  • Are you new to the neuro speciality? Or,
  • Do you have experience in neuro critical care, but are new to my facility?

Regardless of your prior experience, other important considerations for me are:

  • Do you learn best by first reading, seeing, or doing things hands-on? Does it depend on the specific scenario?
  • Are you a direct person who is going to tell me what is or is not working?
  • Are you more introverted, so I need to observe your non-verbal cues more closely?

It’s important for you to understand there isn’t a ‘wrong’ response to any of these points. I need to understand what types of experiences you’ve had (or not had) in the past, as this will help me plan our path during orientation. Knowing the starting point is how we build effectively on your existing foundation as a nurse.

It’s also important for you know about me. More specifically, my style as a nurse preceptor. For example, I am often perceived as intimidating, as I take a pretty business-like approach to orientation. For this reason, I take the time at the beginning of orientation to talk about the things I do in an attempt to avoid being intimidating. I assure you that I am always open to questions and encourage you to give me feedback if you become overwhelmed. My intent is to set the stage for an open, two-way dialogue at the beginning, as this is essential to a successful orientation.

However, regardless what information I get at the beginning of orientation, I feel it is my responsibility to adapt and adjust both the assignments and my teaching style based on my ongoing observations. I hope that you will give me direct feedback, but even if you don’t.. I’m always looking for signs of success as well as signs of struggle.

Sometimes I am better at this than others….

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The Unexpected Patient:  Tips for Nurses Caring for the Seriously Ill from the Family Perspective

The Unexpected Patient: Tips for Nurses Caring for the Seriously Ill from the Family Perspective

Tips for Nurses Caring for the Seriously Ill from the Family Perspective

I’ve written many posts about how to provide care to patients in various scenarios. However, I have yet to provide any information from a very vital perspective; that of the patient and family.

A long-time personal friend had a very lengthy experience deep in the depths of healthcare. She and her family encountered many nurses during this period of time. I asked her if she could write a post describing tips for new nurses on how to be supportive when caring for patients with very serious and life-altering diagnoses.

Thank you, Renee for sharing your experience and insights.

I am deeply honored to share this with all of you and hope you find it helpful in your growth as a nurse.

Caring for the Seriously Ill

Caring for the Seriously Ill

So the challenges of nursing school are behind you and you are credentialed and ready to ply your skills. You’ve specialized in oncology care and are now assigned to the cancer floor where for a time, you’ll be paired with an experienced nurse who will help you get the feel of the unit and supervise you while you practice the administration of chemotherapy, work with various feeding devices for patients unable to ingest anything orally and monitor the multiple vital signs made more complex by the severity of the patients’ conditions. You are scared, but confidant that you can become skilled at caring for the seriously ill.

As you go through your 12-hour shift, an unexpected gnawing anxiety starts brewing in your gut as you go about completing the checklist for each patient and examining the chart to ensure that the proper medications are delivered and taken and that you make astute assessments intended for the attending physicians. The anxiety isn’t what you expected-it’s unrelated to the sick person lying in the bed.

The worry is about the unexpected patients, the family members sitting anxiously with their loved ones. They are frightened and ill-prepared for the experience they find themselves immersed in, thrust by one phone call from the doctor’s office following a scan, a biopsy or a blood test, into a world of complicated words, strange equipment and unfamiliar science.

The wives, husbands, children and parents of these newly and often suddenly sick people were leading a normal daily life that now resembles nothing of the familiar. Their person in that bed looks different, perhaps bald, perhaps with the weeping skin of the newly radiated or the pustular rash of allergy to a new medication. And they hurt. Their pain meds make them loopy and they say strange things. Their mouths may hang slack and open, their tongues covered with cloud-like patches of thrush. Their skin is delicate and papery and there are bruises from too many needles and IVs. Their bodies are skeletal. They are being forced to adapt to the great equalizer, the disease or physical condition that is robbing their loved one of what was once normal. Vitality is replaced by weakness. There is silence. And except for brief conversations which are often vague and unsatisfying, they are alone and frightened. The unexpected patients with no one to tend their needs. They are sad, short-tempered, grieving and angry.

You weren’t trained for these people’s needs. You watch your mentor for clues. Some of them perform their chores with efficiency and little acknowledgement of what is clearly an issue right in front of them. Others make an attempt to say something comforting. You notice a look of irritation on the wife’s face-whatever the nurse said was evidently a poor choice for what that woman needed.

This is a common situation that occurs every day in hospital rooms all around the country where the sickest patients are housed with their desperate families beside them, needing comfort and answers as they face the fact that death is a likely outcome for that husband or child or parent.

What are you supposed to do for these people?

Your training hasn’t addressed this most common issue.

As the wife of a patient with leptomeningeal carcinomatous cancer, who spent 32 days round the clock in the hospital to advocate for my husband, I learned valuable lessons about what works and what nurses can do or shouldn’t do to help people like me.

Here’s a list of suggestions to help you ease your own anxiety about working with this population’s families and to truly help those who must bear up under the pain and worry.

1) Acknowledge the family as well as the patient. Patient advocacy is so important but the patient is not the only one in the room. Try to explain what you’re doing and why you’re doing it. Don’t just give them a perfunctory greeting and act as if they’re not there watching what you do. Knowledge empowers them and helps them understand what to expect.

2) Listen. Take a few minutes to ask the family what their concerns are, whether they understand what’s happening with their loved one, whether they need more information or assistance from the social services available in-house. Then help them make the connections they need.

3) Don’t assume that your belief system will work for everyone. Don’t offer the tenets of your religious preferences and ideas to the families. If they express an idea which seems in common with what you believe, you can share. But otherwise, keep those thoughts to yourself. Nothing is more alienating than being told what to feel or think by a nurse or doctor who doesn’t know your beliefs. The families feel even more alienated and unhappy. Assuming you know how they feel creates even more distance and discomfort.

4) Pat a hand or shoulder. Sometimes there is simply nothing that you can say that will be of any real benefit to the family. A pat on the hand or shoulder provides an invaluable human contact which makes the person feel connected to the world. The human touch is critical as the very ill patients often cannot provide a reciprocal touch or hug to the people sitting next to them. Having a friendly touch can help with the increasing isolation. Of course, we understand that there are limits to be observed, but they should not preclude basic kindness.

5) Be proactive in seeking the assistance of your medical teammates. If you feel that a family member is in trouble, consult with those in counseling or pastoral care. Have them pay a visit to the patient’s room to see if they can offer support and advice. Often, the family is too befuddled to ask for help because the needs of the patient are dominating their thoughts. Self-neglect is common among family members and caregivers.

6) Empower yourself. Read and explore what is to be expected when a family is facing death. As with anything else, knowledge is power. Our culture has a poor track record of normalizing death. As a result it has taken on a mystical and alien spot in our collective consciousness. Our own issues about how we feel about death and loss can clutter our behavior around those actually experiencing the feelings incumbent on their current situation. By demystifying your own understanding, you will feel more comfortable with the people you’re serving. Shutting down and acting as if death is business as usual is a convenient way to avoid your own fears and discomfort. Owning your feelings and confronting them can make you a much more able nurse and source of relief to those in the midst of facing death. Mutually beneficial acts are the goal. Breaking down some of our own internal barriers can relieve the anxiety and feelings of inadequacy that arise when things get rough.

So, these are some views from the patient/family perspective. On our journey, we were lucky to have some exceptional nurses who were able to grapple with the both the tough and simpler parts of my husband’s illness. Others were less than adequate.

Thanks to Kati for letting me use this forum to share what I hope will be helpful to you who follow this blog.

Renee Pollock

Any reproduction of this content without permission from the author is prohibited. Renee Pollock has licensed Kati Kleber and Kleber Media Incorporated to publish this content on the FreshRN Blog.

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How to be the Unit’s Favorite New Grad Nurse

How to be the Unit’s Favorite New Grad Nurse

The new grad nurse must learn to manage a sick person while becoming part of the crew. These tips will help you be the best new grad nurse on the unit.

The new grad nurse must learn to manage a sick person while becoming part of the crew. These tips will help you be the best new grad nurse on the unit.

Graduation is upon us and there will be many new grad nurses among hospital units very soon if they have not started already. Starting a job in nursing can be very overwhelming. I would argue that learning the ropes of the healthcare culture is quite possibly one of the most difficult jobs. In addition, the new grad nurse must learn how to manage a sick human being, physiologically and emotionally. Therefore, learning to be part of the crew from the beginning can certainly help with the transition. The following are ways to be everyone’s favorite new grad nurse on the unit.

Help with admissions

Admissions can really put a hiccup in anyone’s day. However, they go so much faster with teamwork. Working on a cardiac surgery ICU, my unit had admissions down to a science. One person would chart, one person would connect the patient to the monitor, one person would write down time of arrival, vitals, intake and output on the white board, and the primary nurse would do a quick assessment of the patient, check the IV pumps and lines, then we would do a group report. Having a team of nurses help you admit your patient, even if for only 5-10 minutes, changes everything.

Also, for the benefit of the new grad, helping with admissions is a great learning opportunity. There is less pressure when you are not the primary nurse of the incoming patient. Also, helping with admits can help you learn to prioritize tasks and time management.

Keep your rooms cleaned and stocked

There is nothing more aggravating than starting your day having to clean and restock your patient’s rooms. I have worked on units where nurses had to do this and units where techs did it. Whoever is responsible, make sure it is done and help each other out. Although it seems like a small task, it can be the last thing you feel like doing at the end of the shift, but can make an exponential difference in the day of the oncoming nurse. It’s all about the little things.

Check the dates on dressings and IV tubing

Another task that should always be completed before leaving, is changing expired dressings or IV tubing. As a neurotic ICU nurse, I have difficulty focusing on other things when they are not done. Never, leave this task for another shift unless you absolutely are so busy you could not complete it. Also, not to mention, changing dressings and tubing are done to prevent infection, therefore, it’s more about the patient than anything.

Realize there is never down time

Recognize there is rarely down time. If you are caught up on all of your work and having a chill day, walk around the unit and see if anyone else needs help. Inevitably, there will be a nurse who needs help. Instead of just asking, “Do you need help,” offer specific help. Specific help would include: turning, bathing, cleaning up poop, drawing labs, emptying catheter bags, dressing changes, taking out the trash, or trach care. Sometimes nurses do not know what they need, they just know they are drowning. Realizing what needs to be done and just doing it, can change a shift from terrible to tolerable.

Bring coffee or coffee creamer

Coffee is liquid gold in the healthcare community. As a new grad, maybe you’ve never been a coffee drinker, but soon you will likely start to drink it. Nurses love coffee. It’s not necessarily about the taste, or even the caffeine buzz, it’s about the culture. Coffee brings us together. There is just something about someone saying, “I made a fresh pot of coffee if anyone wants some,” or offering to bring some to a nurse who is too busy to make some.

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My cousin started a job in an ICU a couple years ago. She was not a new nurse, but was new to the ICU. She instantly recognized the “coffee culture” and started making homemade coffee creamer. The nurses on her unit went crazy over it because creamer is something we’re always wanting. Most of the time, we just take milk out of the patient refrigerator and use it. Of note, she took a large glass jar, mixed half almond milk with half almond cream, and added whatever flavors she wanted like cocoa powder, vanilla, almond, or caramel. This could be done with regular dairy milk as well, but it was the thought that counted.

Most importantly

Any nurse recognizes how difficult it is to start from the beginning, but despite these other suggestions, your teammates will recognize hard work the most. Work hard to understand why you are doing what you are doing. For instance, why is norepinephrine the first line vasopressor in sepsis? Why are you giving mannitol for brain swelling? Why are you starting a statin on every cardiac patient? If you care enough to work hard, you can’t go wrong, the rest of these things are just a bonus.

Welcome to your new career!

About the Author:

Danielle LeVeck is a critical care nurse, doctoral student, nurse advocate, blogger, and social media influencer. Danielle institutes a comical, but straightforward approach in her writing to discuss issues in nursing. She strives to achieve her overarching goal of empowering and inspiring nurses from different backgrounds and encouraging all healthcare providers to work together. Find her blog at Nurse Abnormalities or follow her on Instagram.

For more info on being the best new grad nurse you can check out:

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Master of Science in Nursing: Choosing a Program for Success

Master of Science in Nursing: Choosing a Program for Success

This guest post is for anyone who may be considering a master of science in nursing program, but doesn’t have anyone to refer to for advice.

This guest post is for anyone who may be considering a master of science in nursing program, but doesn’t have anyone to refer to for advice.

Few nurses hold a master of science in nursing degree, so finding someone to discuss graduate nursing education with can be challenging. Even for myself, I remember many of my questions went unanswered when I first began to consider graduate school, as I knew no one who had pursued that level of education. In the end, I was able to navigate courses and deadlines on my own that first year of graduate studies, but I truly feel that I would’ve benefited from some guidance beforehand. Learning from this experience, I hope to share some of my knowledge with you, the FreshRN reader who may be considering a master program, but doesn’t have anyone to refer to for advice.

Master of Science in Nursing: Choosing a Program for Success

Now, whether you just decided graduate studies interested you 5 minutes ago when you saw this post, or have been contemplating a return to school for decades, I assure you that nothing is more important in this process than taking your time in choosing a master of nursing program. Since requirements to earn a master degree vary greatly between colleges, you must consider how the unique features of each program will impact your life today, and in the future.

To help you in this selection process, I want to outline in this post what I consider to be the top three most important differences between master of nursing programs:

  • Course or Thesis Based
  • Online or Brick-and Mortar
  • Full or Part time

Though these options may seem straight forward, each choice has unique consequences that can hurt or help you on the road to academic nursing success.

Course or Thesis Based?

Choosing between course or thesis work is basically deciding between lots of little projects, or doing one big project. Although variations exist, most master of science in nursing programs offer one year of general course work followed by either another year of courses or a thesis. During your thesis, you will not attend class, but work closely with a faculty member on a research project, and then write a substantial report on the work you did.

A common misconception about thesis work is that only students who want to go onto doctoral work do such in-depth research. I would say this is not true because there are many nursing research positions that only require a master degree, and thesis work would be great preparation for these jobs!

via GIPHY

 

In my opinion, your final decision to become a course or thesis work student should be based on two components. First, you must be okay with writing and problem-solving independently to write a thesis. Realistically, you may only see your supervising faculty member a couple times a month, so you need to be productive between these meetings to finish the project. Second, you need to look at what will be the content of either the courses or thesis project you will undertake, and determine if this interests you. Because honestly, graduate work will be long and difficult if you hate it.

Online or Brick-and-Mortar?

Recently, online master of science in nursing programs have become really popular, and more nurses than ever before are enrolled in online graduate courses. Wondering what the benefits of online learning were, I took a peek at the research and found that graduate nursing students of online programs report less stress related to family and work thanks to the flexibility in their studies. Meanwhile, brick-and-mortar students feel their in-person courses provide them with better accommodation for their unique learning styles, and closer relationships with other students.

In my experience, brick-and-mortar programs hold their value for students interested in future careers in nursing education and research, but are not already connected with anyone in those fields. For example, being on campus can provide you with opportunities to teach undergraduate students, assist in faculty research projects, and network routinely with experts in your research field of interest.

For nurses in remote places, you may feel you have no option other than to pursue online education. If true, I would still ‘shop’ around the numerous online programs available to you looking for colleges that have both easy-to-access technical support, and forums to contact other online students and faculty outside of the classroom.

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Full or Part Time?

Depending on who you speak to, the choice to be a full or part time graduate student can be a controversial subject. I have heard some faculty encourage students to take the program at their own pace, and adjust course timelines to suit their personal life. Yet, I have also heard different faculty state, “Get the program done in case life circumstances stop you from finishing”. Even research on this subject is mixed, with students enjoying part time course loads more, but then taking a greater number of education leaves related to caregiving of children or elderly parents.

In my case, the decision to be full or part time boiled down to one question:

Do I have the funds for full-time education?

Graduate school is a ‘catch 22’ situation where the less you work, the more time you have for school. But at the same time, the more you go to school, the less money you have to fund your education. In the end, I did have to get a student line of credit to begin my graduate studies full time. But if you have a mortgage or other debts then part time schooling may be the most financially responsible option.

Another factor to consider when choosing full or part time studies is the amount of time that has passed since your undergraduate education.

If working now:

  • Part time studies are a good way to slowly get back into the groove of academia.
    • Especially if you haven’t written a paper since undergraduate!
  • Full time studies are awesome if you need to take a break from the clinical setting, and decompress from years of practice. I know that may seem strange, as graduate studies can definitely be stressful. But trust me, they can be very therapeutic too.

If in undergraduate now:

  • Part time studies are ideal for many new nursing graduates, as you can get some clinical experience while not falling out of practice with schoolwork. Also, some employers may be hesitant to hire you if pursing full time master studies, as they need a nurse flexible to work.
  • Full time studies are ideal if you are driven to do research. With a master and doctoral degree combined taking over seven years to complete full time, your likely right to just get started!

With all this new information in mind, I leave you with my opinion that no master of nursing program is better than another, and that your decision to enter a graduate nursing program should not be based on the academic prestige of the school. Instead, choosing a graduate nursing program should be driven by your personal characteristics, life circumstances, commitments, and career aspirations. The disadvantages and benefits of different graduate nursing programs discussed in this post are only meant to act as stepping stone in your ultimate decision of choosing a master of nursing program.

This guest post is for anyone who may be considering a master of science in nursing program, but doesn’t have anyone to refer to for advice. About the Author: Crystal McLeod is a master of nursing education student, in her final year, at the University of Western Ontario, Canada. McLeod’s research interests include continuing education for rural nurses, intergenerational conflict in the clinical setting, Indigenous health, and childhood disease. Before embarking on graduate education, McLeod worked for several years as an emergency and obstetrical nurse in rural southwestern Ontario.

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Are you a Nurse Bullying Target…or a Snowflake?

Are you a Nurse Bullying Target…or a Snowflake?

Nurse Bullying can’t objectively be justified by a reasonable code of conduct. Are you really a target of nurse bullying?

We had to quickly use the word “snowflake”, because it is so overused and abused that it won’t mean anything within the week—it already refers to anyone with a different opinion than you do, as opposed to referring to someone easily hurt.

Nurse Bullying doesn’t necessarily take place when someone gets offended or disagrees with your beliefs, no matter how deeply-rooted they are. Sometimes a situation is more “clickbaiting” than bullying. You’ve come across fresh news about how bad President Trump is, but it’s actually irrelevant, mildly positive drivel about Ivanka’s clothing line. There’s not really a story there.

For example, one of us had to tell a surgeon last week, “I’m putting the patient’s needs in front of your ego.” Without knowing the intricacies of the situation, it’s hard to judge behavior as self-righteous, “caring for the patient”, or a devious power play. Are the personalities involved Type A, or Type Jerk?

Bullying can’t objectively be justified by a reasonable code of conduct and has the potential or realized cumulative effect to threaten, undermine, constrain, humiliate or harm another person or their property, reputation, self worth, or ability to perform.

Are you a Nurse Bullying Target?

“Incivility” and “disrespect” are more gentle synonyms for bullying. Let’s also define lateral and horizontal violence and another half dozen terms so you can tell if you’re being bullied. Actually, that’s not necessary because even when we couldn’t define it (probably around kindergarten), we’ve all felt the injustice of unfair treatment. As busy adults, sometimes we need to slow down to fully comprehend a hostile work situation. It’s more subtle because your clinical instructor or charge nurse isn’t throwing dodge balls at your head and stealing lunch money.

nurse bullying

Judging by social media, snowflakes walk around continually outraged or offended, even at unintentional slights. However, corporate bullying is an increasingly complex issue and is repeated, health-harming mistreatment ranging from verbal abuse and humiliation to threats, sabotage, and worse. As evidenced by the recent lawsuit concerning an anesthesiologist who insulted her sedated patient, the power of media makes headline news out of events that otherwise only garner interest in the break room or hospital cafeteria.

Signs of Student Bullying

The top five bullying behaviors nursing students experience are nonverbal innuendos, verbal affront, undermining actions, withholding information, and sabotage (setting up to fail). The experience of one loyal FreshRN reader involved a clinical instructor, but nursing students bully each other too through repeated behaviors creating risks to health and safety and intended to control, diminish, or devalue. Nurses eat their young and each other in part because of the stiff hierarchy of healthcare dominated by physicians and administrators. The three of us at Behave Wellness occasionally deal with cases that resemble office politics and sexual ultimatums of the 1960’s like the show Mad Men more than nursing or anesthesia school programs.

Professors can also demean students, treat them unfairly, or pressure them students to conform. This results in students feeling traumatized, powerless, and angry. Of course, many of us felt that way because of the stressful nature of nursing school, but faculty behavior can create a culture of bullying through condescending and rude remarks and nonverbal behavior, exerting rank, and being distant, cold, and unavailable during and outside of class. Underreporting of these activities occurs due to lack of confidence in the institution to have a system in place and do something about bullying. Students might not report bullying out of fear of retaliation, looking like a snowflake, or the fear of being the target of more abuse if acting as a whistleblower.

Many targets of bullying “self-blame” when in reality they did nothing to provoke the “more than inappropriate” behavior and abuse–it is all the bully! This can prevent targets from taking steps to end the bully’s psychological violence and can spiral into self-destruction. Targets are often individuals who are well liked, highly educated, morally and ethically correct, non-aggressive, and do their job well.

Are you being bullied? Bullying takes on many forms and signs and symptoms vary. All of a “sudden” is your performance not good enough? Are you accused of incompetence despite a history of objective excellence? Do you find yourself feeling sick to your stomach the night before work or obsessing about clinicals on your days off? If you answered “yes” to any of these questions, you may be in a bullying situation. Tell us your experiences in the comments, and make sure to check out Kati’s post about responding to bullies.

The Next Step

Do you know a target? Can you help? You CAN! You can act as a source of support by being an empathetic and nonjudgmental listener to the target’s reality. Confirming and validating their story is significant. Educating and encouraging targets to document what is happening to them, obtaining other co-workers’ experiences, and referring them to outside sources of advice such as a therapist and/or attorney will assist in the healing process. In healthcare, there is potential for patients to become indirect victims, thus compromising their safety in an already vulnerable state. A bullied employee won’t function at peak physical and mental health and may even be questioning their own ability to perform effectively. It is imperative that you become aware of your surroundings as well as the internal and external resources available to you should you find yourself or another co-worker being a target of this phenomenon. When confronted with this epidemic, your health and well-being need to come first!

Maintaining health and wellness is of paramount importance. What do you like to do to unwind and relax? What are you grateful for? Feel free to answer these questions in the comments as a reminder and keep you grounded by providing a sense of comfort. See, you already have your first tool to maintain positivity and prevent and eliminate the self destruction that bullying creates. Not that anyone’s life has been changed through a blog comment, but tell us your story below and we will do our best to help.




Nick Angelis, CRNA, MSN, Shannon Spies Ingersoll DNP, CRNA, APRN, RYT, and Gina Chiplonia-Swircek DNP, CRNA, PhD (c) are authors, speakers, nurse anesthetists, and the founders of BEHAVE Wellness (Bullying, Elimination, Health Advocacy, and Violence Education), which provides health and wellness training and strategies to decrease and prevent bullying.

BEHAVE training encompasses bully elimination, health and wellness promotion, advocacy for the target, and violence education.

Education should be fun–maybe even hilarious. The serious, corruptive topic of workplace bullying is not an exception to this philosophy. Despite such light-hearted mannerisms, BEHAVE Wellness is no joke. We bring personal training from bullying expert Gary Namie, raw data from peer-reviewed research studies we are currently conducting, and years of experience in mentoring students and writing/presenting about the specific bullying and hazing issues they face. On the wellness front, we successfully run businesses combining the wisdom of alternative medicine and holistic care meant to promote emotional healing and health. Subscribe on the right to get our latest news and updates.

When My Alcoholic Uncle Died: And How It Impacted Me as a Nurse

When My Alcoholic Uncle Died: And How It Impacted Me as a Nurse

When My Alcoholic Uncle Died

As many of you know, I am a huge fan of Tumblr. I follow many nurses, physicians, EMT’s, nursing students, and other healthcare professionals. I am a fan of the short posts with great images and rarely sit down and read long posts. However, when I started reading this nurse’s post, I simply couldn’t stop. My nurse heart just connected with this nurse, niece, and patient. Many people suffer from addiction to alcohol, and arguably most nurses will find themselves taking care of someone with this particular affliction at some point in their career.

This following is a guest post, written by a nurse who walked through this experience herself, and obtained permission from all involved.

alcoholic

I had an uncle who was a terrible alcoholic. It ravaged every aspect of his life, his work as a union tradesman, his ability to be a father or husband and his relationships with his brothers and sisters.

My mom and I often visited him when he’d get admitted to the floor. I could never bear to see him in the ER. Dirty, belligerent, withdrawing in the DTs.

I was embarrassed because I knew he was a frequent flier.

I was embarrassed that I was embarrassed.

We tried to drop him groceries and buy his Dilantin every month, but he moved around a lot, mostly renting rooms above taverns. He wanted nothing to do with sobriety. He used drugs when he could, but whiskey was his poison. In the end, he only tolerated a few beers a day to keep away the shakes.

To any nurse or medic or doc who knew him, he was a local drunk… but to me he was my uncle.

I knew him as a kind loving man as well. I remember family BBQs and him tossing me up in the air as a kid. I remember him showing up drunk to Thanksgiving and not making it out out of the car before passing out. I remember the disappointment in my family’s faces. I remember the shame in his eyes. I remember driving around his neighborhood looking at the entrances of taverns to see if he was passed out.

I wondered if anyone would know to call us if he died. I even wondered if he had any identification. But they did call. And I knew when I saw him at age 55 in the ICU weighing 90 lbs, dying of hepatitis C and esophageal cancer that he didn’t have a lot of time left.

How It Impacted Me as a Nurse

I was a nursing student and an ER tech, but I knew in my heart this time was different. I saw people fear him. I saw nurses treat him as if he was a leper. One yelled at him to be still while she gave him a shot of heparin as he grimaced in pain.

Nurses came in one by one to start an IV… and he grimaced in pain. Despite knowing better, only until after the 4th nurse was unsuccessful I begged them to stop and give him a break.

My hospital accepted him into inpatient hospice. I was relieved.

When he arrived, I saw the 2 EMTs toss him on the hospice bed and walk out without saying a word while he grimaced in pain. They probably got held over and he probably didn’t seem like an urgent transport.

They didn’t want to touch him.

I didn’t say anything.

I was scared to touch him too.

He was emaciated with a huge head and a gaunt appearance. I wondered if he had AIDS. I felt bad for thinking that. I still kissed his forehead and told him he was going to be okay. Because I loved him. He was my family.

And then I saw nurses treat him with kindness. I saw the beauty of a non-judgemental hospice team make his last 96 hours on Earth a time where he could make peace with his demons. I saw Roxy drops for the first time and I saw him get some relief from the pain of his untreated cancer and impending death. I saw them allow me break the rules and lift his frail body into a wheelchair, fashion a Posey to hold him up and take him down stairs for his last cigarette on Route 30.

I was able to spend my breaks with him. I got to suction him and help give him a bed bath. I got off my 3-11 shift and spend a few hours with him watching a baseball game on replay. I sat with him in silence and I held his hand. I finally knew what people meant when they said the dying watch their life play out in their minds. I swear I could see it happening. I asked him if he was thinking about things.

He said, “Yep.”

I asked him if he wanted me to stay or go and he said, “Stay”. So I stayed.

I heard the death rattle for the first time. I cried to a veteran hospice nurse and she explained how the Scopolamine patch would help. I finally felt what it was like to be helpless to a family member in need and her words of comfort and years of experience meant everything to me. She said he probably had 48 hours at the most. I read Gone From My Sight, the blue book of hospice by Barbara Karnes.

The whole family trickled in. His kids, all his brothers and sisters and nieces and nephews. His children told him they loved him and they forgave him. We kissed his forehead and washed his hair. My mother shaved his face. His daughter said words of kindness that relieved him of any guilt or regret.

My cousin watched me suction him and asked how I could be so calm and so strong. I didn’t feel strong or knowledgeable, but when you are the “medical person” in the family, they see things in you that you didn’t know you had. We surrounded him with love and light and he died surrounded by everyone who ever meant anything to him. The nurses even cried.

I got to see the dying process for what it was. It was beautiful and at the same time so humbling it brought me to my knees. I have never forgotten that feeling and I pray I never do.

Is alcoholism a disease? We debate it as health care providers and wonder about the others whose lives have been impacted by the actions of an alcoholic. The amends that never got made. I guess I don’t care if it’s a disease, a condition, or a lifetime of conscious choices and poor judgement. In the end, it’s a human being… usually a dirty foul smelling human being with missing teeth who may or may not be soiled in urine and vomit. Sometimes kicking, hurling obscenities, racial slurs, or spitting. Often doing all of the above at once. It’s hard to empathize with a human being who arrives packaged up that way. It’s hard to care or to want to go above and beyond. And I don’t think you should ever feel guilty if you don’t have those feelings. That is okay. It’s natural to wonder about the damage these people may have done to others… wonder about how many lives they might have ravaged.

Please don’t take their pain as your own… at least try not to. It is not your pain to carry. And we all know that is easier said than done. But please, treat them with dignity.

They feel.

They hear you.

Give them the care you know you are capable of giving. I can tell you, I hold a special place in my heart for every nurse who touched my uncle with a gentle hand… who cleaned him for the fifth time when he was vomiting stool…. who asked him to smile… who smiled back at him… who stroked his forehead and put a cool washcloth on it.

I am eternally grateful for anyone that saw beyond his alcoholism and saw a person. A human. A child of God (if you believe in God). A father. A son. An uncle.

And I believe in my heart he felt the same way, even if he didn’t or couldn’t say it.

So, if you have that patient… that difficult, hard to like, dreadful patient… Don’t think you have to love them or even like them – you don’t. But if you can preserve their dignity and show them the kind of nursing care that anyone would deserve.

You are the reason we are the world’s most trusted profession. And even though you don’t know it, someone saw and felt it, and it meant the world to them. Go to bed and sleep soundly because you deserve that.

This post was written by Jocelyn Rangel, RN. She is from Chicago, and after being an ER technician during nursing school, she is now on a critical care transport team. If you’d like to check out more of her writing, you can find her on Tumblr at Lake Front Nurse or on Twitter at JR_AngelRN. Please join me in thanking Jocelyn for sharing this incredibly powerful and difficult event of her life with the nursing world, in hopes to positively impact the way nurses provide patient care to patients suffering from alcoholism. I know it has profoundly impacted mine.