Discharge Planning Tips for New Nurses

Discharge Planning Tips for New Nurses

This post was sponsored by Hippo

Discharge Planning Tips for New Nurses

Discharge planning can be a challenge for any nurse, let alone a new nurse. I’ve discharged many patients since I became a nurse in 2010 and would like to give you some discharge planning tips!

Now, we’ve all heard that old nursing saying of: “discharge planning begin on admission” – but what I would like to focus in on is not big picture discharge planning, but day-of discharge planning. Meaning, you’re the patient’s primary nurse and he or she is going home today. What do you do?

Let’s go over what you practically need to do get your patient successfully discharged during your shift, whether that means to their home, an extended care facility (ECF), rehab, skilled nursing facility, or somewhere else. A successful discharge includes everything from timing to transportation and even prescription help with the Hippo app.

Discharge Planning Tips for New Nurses

Click on any link below to jump to that portion of the discharge tips.

Assess the needs

Figure out during report which patients are being discharged and ask some specific questions, either directly to the patient, the off-going nurse, or by looking in the chart.

  • Where will they be discharged to?
  • Are there any tests (labs, x-rays, scans, evaluations) that are must be completed before discharging
    • For example, the patient may be a possible discharge pending a transthoracic echocardiogram, chest x-ray, follow-up basic metabolic panel (BMP), or some other test.
  • Will they need anything set up?
    • Home care, in-home therapy, DME (stands for durable medical equipment, so things like walkers, shower chairs, blood glucose monitoring supplies)
  • What kind of transportation will they have?
  • Are there any financial concerns?
  • Do they need any extensive teaching?
    • Patients going home with a blood sugar monitor for the first time, on a new blood thinner, after a major surgery, or with a new diagnosis like congestive heart failure will require more time to educate them and answer question than others

Knowing these things early in the shift are important because they can really impact your time management. You may need to expedite tests in order to facilitate a timely discharge, need to set up transportation, get specific orders from the physician, and so forth.

The Inevitable Question

“So, the doctor said I may go home today. What time will that be?”

Without fail, almost every single patient being discharged wants to do know when. I completely understand, however it’s not that straight forward.

For patients to get discharged, the attending physician must write discharge orders.  This means they’ve got to sit down and put all of the medication orders in correctly, sign any printed prescriptions for narcotics, and a few other things.

My go-to answer is something like this:

“So, to get you discharged, the physician has to enter quite a few things into the computer. Things like follow-up appointments, specific things they want you to do or not do, medication changes, prescriptions, and more. Once this has been done, I can complete your discharge. Typically, I tell patients to plan for an early afternoon discharge. This gives the physician time to decide on and enter the information. Sometimes it happens earlier, but mentally planning for an early afternoon discharge time is the most realistic.”

If people are looking for a specific time to facilitate a ride, I’ll tell them between 2-3pm.

Physicians typically round on ALL of their patients, then sit down and write discharge orders. What I see happen a lot is the physician rounds around 9:00 am or so and says they can go home, but doesn’t usually put discharge orders in until around 1:00 pm.

By telling people between 2-3pm, that gives me enough time to compile the discharge paperwork, correct any errors, address any deficits, facilitate prescriptions, and balance it with my other patients discharging the same day as well.

It is especially important to give yourself ample time if a patient is being discharged to another facility and is being transported by ambulance, medic, or some other transportation service.

Work with your team

With discharge planning, I typically rely heavily upon my case managers.  They’re amazing getting things set up with facilities, DME, etc.

Also, for a patient to get things like outpatient physical therapy and/or occupational therapy, some forms of DME, or to go to a specific type of facility (like rehab), CMS requires there to be a note from therapy saying the patient requires such. Therefore, touch base with your physical therapist and occupational therapists and read their notes to get a better idea of what they’re recommending for your patient.

Tip: if your patient says hey want something specific (a cane, walker, shower chair, to go home and not rehab or vice versa) look at the latest notes from physical and/or occupational therapy and see what they recommend.

Also, make sure to check out the latest notes from case management (CM) and social work (SW) as well. They typically document any facilities they’ve sent referrals to, if the patient has been accepted, who you need to call report to, the time of transportation, etc. Don’t make my rookie mistake of calling CM or SW before simply looking in the chart! It can save you (and them) time if you take a look at their notes before paging/calling.

Think about transportation

Asking about this first thing will save you quite a bit of headaches. Sometimes, the person who will bring them home is already sitting in the room, but most likely they’re going to have to call for a ride. Maybe their ride can only come during a certain period of time, or only after a certain time, or can’t come at all and we’ve got to find a ride.

I’ve gotten everything together for a discharge, only for the patient to tell me (at 5:00 pm after CM has left for the day) that they have no way home. I’ve also been ready to discharge a patient and they tell me they can’t get a ride until tomorrow.

Ask early so you can plan appropriately!

Paying for prescriptions

This can be another big headache if you haven’t asked the right questions or planned for it. Multiple times, I’ve created all of my discharge instructions and the patient is ready to walk out the door and suddenly they tell me they can’t afford their prescriptions. This even happens at 4:30 pm when I barely have time to get a hold of CM or SW to let them know. This delays discharge because I can’t just quickly get someone to the bedside to address the issue, especially if it’s late in the day.

There is one really easy thing you and the patient can do when paying for scripts is a concern – use the Hippo app. Basically, it will tell you what the cost of the medication is at various pharmacies in the area so you can go to the cheapest one.

Medication can costs vary widely from pharmacy to pharmacy.

For example, a medication that I frequently discharge patients on is metoprolol tartrate (Lopressor). After a quick search, I can see that it costs anywhere from $3.89 to $26.95 for a 60-pill 25 mg tab supply in my area. Another medication frequently prescribed is warfarin (Coumadin), which costs anywhere from $2.78 – $27.14 in my area for a 30-day supply of 2.5mg tabs. Atorvastatin (Lipitor) is anywhere from $6.25 to $95.91 for a 30-day supply of 10 mg tabs.

Go to the wrong pharmacies and you could spend as much as $150 for those 3 scripts, but go to the right ones and your bill would be closer to $12.92. It may require going to a few difference pharmacies, but it can result in exponential savings.

This can make a huge difference for a patient as we all know cost is a huge barrier for many individuals. This also makes the patient a more informed consumer of health care. They know where they can get their medications for the best price and have that dialogue with their primary care provider in the outpatient setting as they require refills and are on medications long term.

The Hippo app is easy to use, signing up is a breeze, and it saves your previous scripts.  If your scrips are at another pharmacy, you can request them to be transferred all within the app as well.

As the discharging nurse, what’s important is making sure which prescriptions your patients wants where and ensuring the physician either e-prescribes them to the correct location or you do that yourself per your facility’s policies.

Once the patient or their loved one picks up their medication, they just show their Hippo card (in the app, pictured below) to the pharmacy staff on checkout.  And that’s it!

Check it out on iTunes.

Discharge Planning Tips for New Nurses

Completing paperwork

Make a list and check it twice.

Seriously.

There are typically quite a few things you have to enter into the computer for the patient, but also for your documentation as well. Care plans need to be closed out, education needs to be resolved, IVs and telemetry need to be removed and documented, documentation requirements need to be met (like core measures), the next dose due for each medication needs to be indicated, and more.

If the patient is being transferred to another facility, even more needs to be completed. These things include calling report to the receiving facility, printing and faxing additional paperwork, printing information for whomever is transporting the patient, and so forth.

Write yourself a little list and check it off as you complete tasks so that you do not forget them.

Giving discharge instructions

Before sitting down to give instructions, double check that the information is correct, paying particular attention to follow-up appointments, medication due times, prescriptions, and any important teaching points that need to be included.

Going over instructions can be pretty overwhelming for patients and should not be rushed. If you’re able, grab a chair and sit down next to them. That lets the patient know you’re not just going to quickly go through it and run out the door (even if that’s what you want to do!) and allows them to more time to ask clarifying questions without feeling like a burden or bother.

Remember the potential mental state of someone going home from the hospital: they may be overwhelmed, excited, sad, tired, scared, or any combination thereof. Therefore, make sure all important information is written down. They will forget a lot of what you talk about during discharge instructions and you must have something to refer back to.

And finally, make sure you have included phone numbers for follow-up questions. They need to have the phone number of someone they can call with concerns both during and after office hours.  This will prevent follow-up phone calls to the nursing unit, but also will facilitate the patient speaking to their physician’s office – which is who they should be speaking with for follow-up questions and/or concerns.

To summarize

Assess needs early on so you can manage your time while addressing their needs, provide realistic expectations related to timing, leverage your healthcare team, ensure transportation is secured, make sure they can afford their prescriptions, make sure your paperwork and documentation is complete, and take your time while giving discharge instructions.

It sounds like a lot, but you will get used to the process and develop your own discharge routine!

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What Patient Advocacy Really Looks Like

What Patient Advocacy Really Looks Like

This post has been sponsored by Campbellsville University Online.

Patient Advocacy

Please note: as many of you know, there was recently a rather controversial blog post about patient advocacy, written by a surgeon, which has since been deleted. Ironically enough, this sponsored post was written and scheduled before the post, response, and removal occurred.

 

If nursing is the heart of healthcare, patient advocacy is the coronary arteries.

Nurses simply cannot function, the heart of healthcare cannot beat, if we are not advocating for our patients. Otherwise, we’re simply pencil-pushers, task-completers, and yes-men/women.

As hands-on caregivers, we have the primary responsibility of ensuring quality, ethical care for our patients. If you haven’t already read the American Nurses Association’s Code of Ethics, I really encourage you to. It states, “the nurse promotes, advocates for, and protects the rights, health, and safety of the patient.”

Nurses see it all

Nurses oversee the healthcare of many patients and can be privy to concerning practices. Nurses can see the behind the scenes happenings… we know the protocols, procedures, the personalities, the tendencies, the barriers, the culture, the unwritten and written rules, what’s supposed to be done and what’s actually done.

It’s funny how the nurse is the one with whom many feel most comfortable being honest, unedited, frustrated, mad, relieved, and even literally and figuratively exposed. It can be quite a burden to bear at times, as a healthcare provider.

Hospitals are required to look after their own financial well-being, legal obligations and other factors that can sometimes cause patient care to deteriorate.  Occasionally the healthcare team makes mistakes and people miscommunicate. When this happens, someone who practices patient advocacy steps in and looks out for the patient’s’ well-being in a way that maintains professional composure.

Patient advocacy challenges

American Nurse Today (ANT) defines nurse advocacy as “using one’s position to support, protect, or speak out for the rights and interests of another.” This practice is vital in healthcare, because errors, miscommunication, and oversights can result in severe injury or illness, or death. A nurse patient advocate must not only catch these errors, but also argue for their correction in the future in order to promote safety and patient health.

However, patient advocacy is not without its challenges. Because nurses are the constant presence at the bedside, we’re the ones in continual communication. We set expectations, clarify what others have said, correct the patient when they’ve misunderstood, and facilitate many things throughout the day and night. Naturally, when a communication breakdown, error, or oversight occurs… the nurse is typically the one on the front lines dealing with it. And sometimes, we’re the ones who are at fault.

Being a patient advocate can mean going up against some of the most intimidating and challenging leadership at times.  Here’s an amazing example of two nurses going to bat for their patients, against all odds. And here is the American Nurses Association’s news release on the matter. Both their state board of nursing and the American Nurse’s Association stood with them and provided support.

If patient advocacy is the coronary arteries of healthcare, I think Vickilyn and Anne just put in some stents. I cannot imagine how difficult it must have been to be in that position in the first place, and then take those difficult, yet incredibly necessary steps that needed to be taken for the sake of their patients.

Preventing major communication breakdowns

Let’s face it: with so many moving pieces in healthcare delivery, communication breakdowns occur. I find that the most common breakdown is due to a failure to meet expectations.
When an expectation has not been met (and in healthcare, this can even mean life and death), frustration, anger, and even verbal assault can occur. The stakes are high, therefore tension can soar.

Hopefully, we can avoid this in the first place by empowering everyone around us (the new grad nurse we’re training, the first year medical resident, the seasoned surgeon, our patients) to be comfortable asking questions in a calm, respectful manner. We do this by providing a safe, non-judgemental space whenever someone does come to us with questions or appears as if they may not understand, and by simply asking someone to repeat what they understand about the situation.

  • “Tell me what you heard me say.”
  • “Tell me what you heard me say, because this can be kind of confusing and I want to make sure we’re on the same page.”
  • “What’s your understanding of the situation?
  • Or conversely, “So what I hear you saying is, ___________________, is that correct?”

These are great open-ended, nonjudgmental ways to assess understanding and provide an opportunity to correct. Asking if anyone has any questions while you’re halfway out the door is a terrible way to communicate. When someone does that, it can feel burdensome to ask even basic clarification questions. We must not do this to our patients or to one another. If we don’t get why the physical therapist recommends something, or why that physician put in that specific order, it’s helpful to use one of those open-ended questions to create dialogue. We must be comfortable and confident enough within ourselves to ask others questions, even ones that may seem obvious.  This is essential because this simple act of vulnerability in admitting I don’t know something can in turn inspire others to inquire when needed.  Asking someone we perceive as smarter, above, or more powerful than us is scary, whether or not they actually are who we perceive them to be. But if we can break through that and ask the questions we need to, and occasionally insist upon them, it facilitates communication and makes it less personal and more about what is best for the patient.

Remember, there is no such thing as over communication in healthcare. What’s routine for the healthcare team is typically not routine for our patients. Even if we know our stroke patient isn’t going to get water until they’re cleared by a speech therapist and that’s stroke care 101, our patient’s most likely don’t know that.  And maybe the doctor forgot to tell them they’re NPO… or maybe they said “NPO” and the patient had no clue what that meant.  Therefore, we must communicate, even the most basic things that we do without thinking, to prevent a breakdown.  Otherwise, that family member of the stroke patient may think we’re starving their loved one when really, we’re just following our protocol and forgot to tell them that aspect of the plan.

Furthermore, the American Journal of Critical Care suggests that the best way to avoid such conflicts while practicing patient advocacy is to embrace a spirit of collaboration with other healthcare professionals, rather than taking the attitude that it is the nurse’s job to protect patients from the mistakes of others. This team mentality instead of an “us versus them” mentality is crucial.  We cannot create or perpetuate sides, even if someone truly messed something up.  A house divided cannot stand.

If we’re all working together towards a mutually agreed upon goal with the patient at the center, checking our ego at the door, and feeling comfortable asking (and calmly insisting and activating your chain of command if asking isn’t working) questions, we can hopefully prevent many situations in which advocacy would have been necessary.

What to do when advocacy is necessary

While we’d like to prevent these scenarios from ever being necessary, it’s not always realistic… especially if things are happening at an incredibly fast rate (like the unstable or time sensitive patient in the emergency department).  So what do you do when you find yourself in a situation in which you need to advocate for your patient, or your patient is advocating for themselves to you?

It’s essential to first calm the situation, especially if tempers are high. If you feel unsafe, or are being verbally assaulted, stop the conversation until the other party has control over themselves. (And if we’re not calm, cool, and collected, we must also step away and gather composure.)  This may include interrupting them on the phone and saying, “I will not be spoken to in that manner. Please call me back when you can speak to me appropriately. (Click)” Or, it may include verbalizing this face to face and walking away. It may even include calling security or an administrator on-call. It may also be necessary to refer to your institutional policies and procedures to ensure appropriate action is taken and the correct chain of command is followed.

Once the situation is calm, it’s helpful to first ask the person what the understanding of the situation is. Then, empathize with how they’re feeling about the situation (and this may include a “I’m so sorry this has happened”) while hopefully they’re empathizing with how you’re feeling. Next, communicate your understanding of the situation, and rectify it to the best of your ability.  Circle back with the patient to ensure they fully understand what’s going on and their needs are met.  You may need to facilitate a conversation with multiple members of the healthcare team at once as well  if the situation is more complex.

This is like saying:

You and I are not on the same page. Let’s chat about specifically which page each of us are on, recognize and consider how one another feels, and then both get to the same page together. Deal?

And finally, if there was a system-wide, big-picture problem which was the reason behind this issue, or if something needs to be expedited but doing so is out of your control as the bedside nurse, pull in management and/or administration to see if we can avoid this in the future for others. It’s helpful to do this early than later, again facilitating the team mentality with the patient at the center.  Consider consulting your institutions policies and procedures, your state board of nursing, respective nursing specialties professional organization, as well as the American Nurses Association if needed, as they all have helpful resources for the bedside nurse in particularly challenging patient advocacy scenarios.

Ensure safety.  Identify the error, miscommunication, or need.  Empathize.  Leverage your resources.  Rectify.  Circle back.

Widening your knowledge base with a BSN

This post was sponsored by CU Online, who offers an online RN to BSN degree program which enables diploma or ADN nurses to further expand their nursing knowledge by completing their BSN degree. I encourage you to check them out. Thank you, Campbellsville University.

How Changing Demographics Affect Nursing Practice

How Changing Demographics Affect Nursing Practice

I personally have noted that as a nurse you run into people from tons of different cultural and socioeconomincal background.  And as a nurse caring for an adult population, I’ve noted that taking care of a 42 year-old patient is quite different than taking care of an 85 year-old patient and it’s important to be aware of their specific needs.  

Please enjoy this sponsored guest blog post, written by Tricia Hussung at Campbellsville University

Recent demographic shifts will have major implications for the U.S. healthcare system, both in terms of the delivery of patient care and the practice of nursing. According to experts at Kansas State University, improved public health and clinical care have led to an increase in the average life span, meaning that by the year 2020 more than 20 percent of the population will be age 65 or older. In fact, individuals over the age of 85 make up the fastest-growing group. This will lead to extended treatment of long-term chronic conditions, challenging the healthcare system’s ability to provide efficient care.

In addition, the diversity of the general population is a relevant topic on the minds of many nurses. Because multiculturalism affects the nature of illness and disease as well as morbidity and mortality, nurses must learn to adapt their practice to various cultural values and beliefs.

Such changes in the population are significant for nurses. Nursing practice, education and perspectives must adapt and respond to changing demographics because nurses play an increasingly important role in healthcare delivery.

Understanding the Aging Population

As the baby boomer generation ages, the number of older adults in the United States is expected to increase exponentially. Combine this with a longer average life span, and the healthcare system needs to adapt — quickly.

The National Institute of Health estimates that about 80 percent of people over the age of 65 have at least one chronic illness, such as heart disease, diabetes or arthritis. In addition, the number of older adults with multiple chronic illnesses is substantial. Chronic illnesses are one of the most central issues facing nurses in terms of the aging population because they impact quality of life for patients and garner considerable expenses.

Key considerations for elder care delivery include the following, according to Grady:

  • Identifying ways to improve healthcare and quality of life for older adults across care settings, from the nursing home to the community
  • Interpersonal interactions, either between older adults and family members or nursing staff, or among different levels of staff in a nursing home, which can influence older adults’ quality of life and health-related outcomes
  • Nurses as integral members and leaders of interdisciplinary healthcare teams to solve complex health problems and provide for older adults
  • Assessing multiple types of intervention, analytical parameters and environmental settings to fully understand the complexity of healthcare issues facing older adults and to produce the most positive health outcomes

In general, nurses will be required to provide care for more adults (and older adults) than ever before — patients who have complex healthcare needs. However, nurses are also in an ideal position to communicate with older adults about self-care strategies to prevent further illness while maintaining their independence, functioning, and mental and physical health.

Diversity and Multiculturalism

Another critical element involved in patient demographic shifts is diversity. In today’s healthcare system, the relationship between culture and health is central to delivering quality patient care.

The National Student Nurses’ Association encourages nurses to provide customized, culturally specific care that fits with a patient’s values, beliefs, traditions, practices and lifestyle. The association promotes diversity awareness, which is defined as “an active, ongoing conscious process in which we recognize similarities and differences within and between various cultural groups.” Diversity awareness also involves cultural assessment and cultural sharing among healthcare professionals with the overall aim of understanding the complex definition of diversity, as based on the writings of Marianne R. Jeffreys, Ed.D., RN.

While there are many factors to keep in mind, ignoring diversity may lead to unequal nursing care and negative patient outcomes. Under the Process of Cultural Competence in the Delivery of Healthcare Services Model, nurses are encouraged to use the following mnemonic, ASKED, when caring for any cultural group.

Have I ASKED Myself the Right Questions?

  • Awareness: Am I aware of my personal biases and prejudices toward cultural groups different from mine?
  • Skill: Do I have the skill to conduct a cultural assessment and perform a culturally based physical assessment in a sensitive manner?
  • Knowledge: Do I have knowledge of the patient’s worldview?
  • Encounters: How many face-to-face encounters have I had with patients from diverse cultural backgrounds?
  • Desire: What is my genuine desire to “want to be” culturally competent?

Looking Ahead

Providing high-quality nursing care to an aging, diverse population is no small task, but it is one of the most important responsibilities of nurses today. You can gain the advanced skills you need with the online RN to BSN degree from Campbellsville University. With an experienced faculty providing real-world knowledge and understanding of nursing, Campbellsville’s program is the ideal opportunity to advance your nursing career.

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Medication Administration Basics for Nursing Students

Medication Administration Basics for Nursing Students

One of the major things you learn in nursing school is how to give medications. I’d like to explain some basic things because when I was in school, no one told me this stuff.. it was just assumed we knew all of this.  So here are some basic, yet essential, things to know about giving medications to patients. So let’s go over some medication administration basics for nursing students.

Why these meds?

One of the most important things to know is why your patient is taking these specific medications. So take a look at their diagnoses and their medical history to identify why they might be on them.

Also, if you’re looking up medications and can’t figure out why the heck a medication was prescribed, never fear! Sometimes patients take things for an off-label use. So don’t forget to take a peek at off-label uses for the medication before you freak out.

Typically nursing students have to look up the meds that their patient is on the night before their shift.  Therefore, you’re looking things up without physically seeing them.

Quick tip: if it’s something weird that you’ve never heard of or it mentions percents of fluid… it’s probably some sort of intravenous (IV medication)

Routes

There are a few different ways you can give meds.  These are the most common.. there are a few others that I won’t go into now because we’re talking basics.

PO

Orally.  Easy enough, right?

via GIPHY

IV push

IV push, meaning you have a syringe of the medication and you push it directly in their vein.  If you’re not sure how quickly you can push something, look at your medication reference guide.  Most meds are to be pushed around 1-2 minutes, but always check!  Sometimes you need to reconstitute with some normal saline, but most IV push meds are ones that you draw up from the vial and administer without diluting/reconstituting with saline.

IV infusion

IV infusion meaning it’s going through their IV and typically set up on an IV pump to deliver the appropriate amount at the appropriate rate.  So, if the order says to infuse normal saline at 75 ml/hr, you’re going to grab a liter bag (1000 ml) of saline, prime your tubing, and hook it up to your pump.  You will program your IV pump to administer 75 ml every hour.  Then flush your patient’s IV with a syringe of normal saline, attach it to your patient’s IV, and press start.

via GIPHY

IV piggyback

IV piggyback (IVPB) means you hook it up at the port before the IV pump on your maintenance fluid (or a dedicated medication line).  You set the appropriate rate for the medication to infuse (so 100 ml/hr, 200 ml/hr, etc.) and once it has infused all of that medication, the pump automatically flips back to the main line fluid to flush it through to make sure all of the medication was administered.  (This may vary from facility to facility, but this is how these are commonly administered.)

Transdermal

A patch on their skin.  Pretty straight forward.

Sublingual

This means under the tongue.  Again, not too bad!

PR

Rectal. Um. Yea. I probably don’t need to explain that one, right?

IM injection

As a floor or ICU nurse, you don’t give these too often.  They are usually immunizations, but there are a few others you may give.  Typically given in the arm or – gasp – the tush area!  I’d look this up prior to giving one to insure you’re doing this correctly, referencing appropriate landmarks and using the correct technique, as it differs depending on the site.  I’ve probably given less than 5 in the last year, honestly.

Subcutaneous injection

This is very common.  The most common med given this way is insulin!  So, so much insulin.  Another common one is subcutaneous heparin (for DVT prophylaxis).  You’ll give so many insulin injections, you’ll lose track after the first two weeks.  It’s a smaller needle and you pinch some skin in various approved areas and inject.  It’s very simple but can be intimidating at first.  Again, take a peek at your clinical handbook prior to doing this!

Compatibility

When you’re giving IV medications, it’s important to insure everything is compatible. What does this mean?

When IV fluid is running, it is running through a primary line. So their primary IV fluids (normal saline, half normal saline, D5, D10, normal saline with potassium added, etc.) are the main fluids running. When you need to hang an IV antibiotic, you typically “piggy back” (hence the term IV piggyback) this onto your primary fluids, provided they are compatible. The antibiotic is then considered a secondary line. It is connected to the primary tubing. You set the pump to run your antibiotic at the prescribed rate and then it will (typically) automatically switch back over to your maintenance fluids.

For example, if my patient has normal saline with 20 mEq of potassium chloride running at 75 ml/hr and I have a dose of Ancef due, I need to check to see if my normal saline with potassium chloride is compatible with Ancef. If it is not compatible, then I need to start another IV or if they have a PICC line (peripherally inserted central catheter, midline catheter, or central venous catheter), I have to use a different port.

However, please make sure to follow your hospital’s policy because some require people have a dedicated line just for antibiotics (typically called a “med line”), rather than piggybacking it to a maintenance line.

Another thing to consider, as mentioned in the comments below by Katie, is if the maintenance fluid can be paused to administer the antibiotic.  Think to yourself, do I want this paused for the duration of that antibiotic?  Is that okay?  If you have someone on an insulin drip and you’re piggy-backing Zosyn (which can take 4 hours to infuse) on their only dextrose source, you’re going to have a mess on your hands.  I typically only piggyback things to maintenance fluids like normal saline.

To crush or not to crush

Many patients cannot swallow whole pills. This is typically due to impaired swallowing. I don’t mean to brag, but I am a fantastic applesauce mixologist and can get even the grumpiest patients to take their meds. However, before you crush medications you must know if they can be crushed! If it is an extended release med, chemo, or capsule.. don’t crush it!

There are also some meds that for whatever reason cannot be crushed. Depending on the medication administration process at your hospital, your EMR may tell you when you can and cannot crush your med. However, you must be diligent before crushing and double check before doing so.

Overwhelmed much?

There are so many medications for nurses to learn, but don’t lose hope! No one expects you to know all of the medications ever made, their dosages, interactions, trade and generic names, etc.

You’re just building the medication foundation right now – and you’re not just building a house, you’re building a skyscraper.

When you get out of school and start your first job, you will get very used to the medications you give day in and day out. You will learn them inside and out. If you’re a cardiac nurse, you will know Amiodarone, Lopressor, Cardizem, and Epinephrine. If you’re an L&D nurse, you’ll know Pitocin and Magnesium. If you’re a neuro nurse, you’ll be rocking 3% saline, Mannitol, and Keppra. Once you know what you need to focus on, I promise it will get much easier.

 

More resources

Updates

  • Updated Dec 22, 2015
  • Updated Feb 15, 2017
  • Updated Oct 25, 2017
Noticing Subtle Neuro Changes for Nurses

Noticing Subtle Neuro Changes for Nurses

 

Subtle Neuro Changes

Neuro changes are tough!  It is really hard to know if someone is truly changing or if they’re just exhausted because we keep waking them up.  Here are some of my neuro nurse tips..

Neuro nurse tips for newbies

If your patient is in the intensive care unit, intubated and sedated on propofol, and you need to complete a neuro assessment, you MUST pause the sedation for an accurate assessment.  The only time that we do not pause the sedation is if we have a specific order from a physician not to do so (for example, for a patient in status with propofol infusing for seizure suppression).  Otherwise, all patients need to have their sedation paused for all assessments.  You cannot accurately assess someone’s neuro status (whether they’re a neuro patient or not!) with propofol infusing.  This usually takes about 5-10 minutes for it to wear off to a point where you can get an accurate assessment.

I usually press pause on the propofol right when I start getting report from the night nurse, so by the time they’re done talking, I can get a good assessment done really quickly with the nurse still there and turn it back on right away.

Herniation doesn’t heal

If they stopped following commands, you must elicit pain to see how they respond. Neuro nurses are really good at sternal rubs, trap pinches, and nail bed pressure.  I know this sounds barbaric and mean, but if they do not respond to that and they were responding before, that is a major change.

Make sure you give them enough time to respond to your painful stimuli. It can take as long as 30 seconds for it to register in their brain that they’re in pain and that they need to do something about it.  Pinching a trap for 1-2 seconds and charting that they don’t respond to pain would be inaccurate.

I’ve gone to check out a patient for someone before that was worried because the patient wasn’t waking up like they had been. So, I called out their name, grabbed their hand, shook their shoulder… no response.  The next step is a sternal rub. You’d be surprised how much this will wake someone up who is not changing neurologically!  This will wake patients up that are annoyed with you, ignoring you, or just sleepy and not having true neuro changes. Again, I know this sounds mean but it is essential. If they don’t respond to a sternal rub or other acceptable forms of painful stimuli, the doctor needs to know, like, STAT.

Assessment tips

  • Give them credit where credit is due.  When you’re scoring the Glascow Coma Score, you need to give them credit for their best response.  So if one arm localizes pain and the other has abnormal extension, they get credit for localizing.
  • Don’t give pain meds or sedation unless it’s absolutely necessary.  These meds will make the patient more sedated and therefore it will be more difficult to tell if they’re having neuro changes.
  • Make sure you explain to the family what you’re doing before you use painful stimuli. Also, always warn the patient.  My go-to line is:  “Mr. Smith, you’re about to feel some pressure!”  ((painful stimuli)) “I need you to come get my arm and stop me!”
  • Notice spontaneous movements.  Are the movements purposeful (meaning, are they doing things that makes sense like reaching for their ETT or scratching themselves) or are they just spontaneous non-purposeful movements?  The physician needs to know this.
  • Don’t just let them sleep all day and defer your assessment because they seem to be resting.  They may not be resting, they may be obtunded.  I know it sucks waking someone up all the time, but we have to do regular assessments to see if they’re changing.  Always warn these patients on admission that we are going to be waking them up frequently.
  • “That’s how they’ve been all day,” is not an assessment.  If they look the same as they did this morning when you got report from the night shift nurse, that still might not be good. Are they following commands?  Are they waking up?  Are their pupils reactive?  Does the family think they’ve changed?  Are they engaging in conversation?  Etc, etc.
  • Always ask direct orientation questions to patients that seem to be with it. Patients can carry on a normal conversation, but then you ask them what year it is and they reply with, “Well, it’s Ju-ly of 1942 of course!”  Make sure you ask direct questions.
  • What’s their sodium? Hyponatremia can make people super lethargic.  So if it’s been 24 hours since their last BMP and their sodium was 133, they may have dropped. It’s amazing the difference a little salt can make in someone’s level of consciousness.

Talk it up

The mark of a good neuro nurse is not only solid assessment skills, but also being able to articulate it to the physician, PA, or NP.  It’s really hard for them to decide what orders to put in if you call them with vague changes.  Know specifically what they were doing before, what change occurred, and how to communicate it to the provider.

In addition to knowing specific neuro changes, make sure you have other pieces of key information for the physician.  Know when their last head CT or MRI was – what did it show?  Pull up the scan, look at the stroke/tumor/mass and think about what assessment you should find with an injury in that area.  If you’re calling about seizure activity, be able to articulate exactly what they did and how long it lasted.

Know the patient’s lab values (neurologists/neurosurgeons care about a patient’s sodium like cardiologists/cardiothoracic surgeons care about potassium), and any meds they have received that could have affected your neuro exam.  Also, know if they’re on a steroid, mannitol, or an anti-epileptic (med for seizures).

Something that’s important is to warn the patient and their family when they are admitted what they’re in for.  This also will keep you from feeling bad for waking them up – it’s part of the job!  Here’s my general “welcome to no sleep” speech:

“While you’re here with us in the hospital, we are going to wake up frequently to make sure things in your brain are not changing.  When your brain changes, it doesn’t show up on the monitor or in your vital signs, it shows up in these little tests/assessments that we do frequently and that’s why it’s really important for us not only to do them, but for you to do the best you can with each assessment.  We will be asking you to do the same things over and over again, but it is very important to see how your brain is doing.  Take advantage of the times that we’re not in here to nap and we’ll do the best we can to cluster our care to allow you time to sleep.”

When to freak out

There are some emergent neuro nurse situations.  Keep in mind, there are *usually* tons of warning signs (however, some people herniate very quickly, before anything could be done even if you knew what was going on).

Blown pupils (4-6 mm, non reactive) are late neuro changes.

Vital sign changes (sudden hypertension and bradycardia) are very late as well.

If the patient is not intubated and you’re noticing periods of apnea or worried that they’re not protecting their airway (new snoring, agonal respirations, etc), call the MD because they may need to be intubated.  If you’re waiting for an SpO2 to drop before becoming worried about their respiratory status, you’re just waiting to call a code.  Always make sure the patient is protecting their airway – this is a neuro issue, not a lung issue.

If you’re just letting your sedation ride all day, waiting for pupillary changes to occur to call the doctor about neuro changes.. that’s basically saying, “I’m going to wait until my patient herniates before I do anything about it.”  You cannot be reactive – you must be proactive.

When brain cells die, they die. It’s a big deal if you miss something because it’s not like you can un-do that. Blood pressures can bounce back, hearts can be restarted, clots can be removed, but when brain cells are gone.. they’re gone.

Pause sedation.  Assess your patients.  Communicate to physicians appropriately.  Educate your patients.

Neuro nurses unite!

Need more in-depth neuro info? Check out the Neuro Nurse Crash Course brought to you by FreshRN® where we discuss essential topics like essential neuroanatomy and disease processes, primary and secondary injury, neuro nursing report, meds, time management, mastering the neuro assessment, and more!

Enroll in Class

More neuro resources

FreshRN Podcast episodes specifically related to neuro:

NRSNG Podcast Episodes specifically related to neuro:

Neuro-specific blog posts:

Some books:

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The NeuroICU BookThe NeuroICU BookMarino's The ICU Book: Print + Ebook with Updates (ICU Book (Marino))Marino’s The ICU Book: Print + Ebook with Updates (ICU Book (Marino))Becoming Nursey: From Code Blues to Code Browns, How to Care for Your Patients and YourselfBecoming Nursey: From Code Blues to Code Browns, How to Care for Your Patients and Yourself

 

 

Explaining MRSA to Your Patient

Explaining MRSA to Your Patient


mrsaimage

With every single shift that I work; there is at least one patient that is on something called contact isolation precautions for MRSA (methicillin-resistant staphylococcus aureus). What is that and why is that necessary, you ask?

Because antibiotics were overprescribed for years, organisms developed that are resistant to the antibiotics that used to work on them. This is why your doctor tells you to make sure you take all of your antibiotics, as prescribed, and not to stop taking them even if you feel better.

Here is an awesome generalized explanation of super bugs and how they came to be.  It’s about 10 minutes, but it’s so good and worth your nursey time!

This presents quite a problem when a patient shows up to the hospital and the antibiotic of choice for their infection won’t work because they’re resistant to it.  Therefore, we need to do as much as possible to prevent the spread of these resistant strains!

Today, most patients are screened for MRSA when admitted to the hospital so that we know who has this specific resistant strain. We don’t want to spread this multi-drug resistant organism from patient to patient as we care for them throughout the day and night.

Keep in mind, there is a difference between an active MRSA infection and a MRSA colonization.

An active MRSA infection means someone has gotten sick because of this bacteria. And you, as the nurse, would know this because it would be part of their admitting diagnosis.

A colonization means that the person is healthy, but carries the bacteria and it can be spread to others.

So when you swab your patient’s nose, send it down to the lab, and 1 hr later they call and say, “Ummm.. yea Mr. Smith in room 872 is MRSA positive,” that means that they have a colonization of MRSA, not an active infection.  Then you have to go put them on contact precautions so they don’t spread this resistant organism to other patients.

Not only can this can be kind of hard to understand as a new nurse, but it is also difficult to explain to the patient and their family as well. This is my basic explanation to someone that comes in and screens positive, and we therefore have to put them on contact isolation precautions. 

“Do you remember when we swabbed you when you came in? Well, what we were testing you for came back positive. What we tested you for was something called MRSA. It’s not an infection; it’s an organism that is resistant to some antibiotics.  This is important for us to know to insure you get the appropriate antibiotics, if they’re needed, and so that we are not passing along this resistant organism to other patients. So, whenever staff members come in, they’re going to be wearing gowns and gloves to protect themselves from passing this along to the other patients that we’re caring for.”

Most hospitals have written patient education that you are required to discuss with them, so make sure you’re following your hospital’s policies and procedures on what to do when someone comes back with a positive MRSA screening.  It has answers to the typical questions (“where did I get this,” “how is it spread,” “will you give me more antibiotics to treat it,” etc.).  And it’s good to give them something written that they can refer to later.

I also tell the family that’s in the room that we’d like them to wear and gown and glove when they’re in the room and make sure they wash their hands. It’s important not to spread it to one another so everyone isn’t acquiring MRSA. Make sure you document your face off when you do your job by educating your patient and family!

 Source: MayoClinic.org

 Some of you may have had patients get CRE (carbapenem-resistant Enterobacteriaceae), a new and terrifying resistant organism.  Here’s a great video explaining this craaazzzy super bug!  I also like that he looks like he’s about to sneeze.  The perfect screen shot.

Nurses on the Front Lines: How Do You Handle Patients Addicted to Prescription Pain Killers?

Nurses on the Front Lines: How Do You Handle Patients Addicted to Prescription Pain Killers?

Have you seen this video posted on KevinMD this month about drug seekers in the emergency department (ED)?  Take a look at this 4:31 video made by an ED physician.  Spoiler alert! If you love Taylor Swift, you will totes love this.

 Disclaimer:  If you are someone who does not manipulate physicians and nurses to obtain narcotics, then this video does not apply to you.  This video is referring to people that are not in physical pain; they are addicted and will do anything to obtain these substances.

This satirical video discusses the epidemic in America of prescription drug abuse.  As a bedside nurse, many have attempted to manipulate me into receiving copious amount of pain medication.  Conversely, I have also advocated many times for appropriate pain relief.  There are definitely two sides of this issue.  Regardless of the situation, opioid pain medication abuse is truly an epidemic in America and we, as nurses, are on the front lines.

After reading the comments on the video, I realized that people in society don’t see what we, as health care providers, see every single shift.  Most people don’t see or realize how many people really are addicted to these medications.  However, those of us that work in a hospital and administer medications see it all the time.  The scenario discussed in the video (the man back in the same ED again, saying he lost his pills even though he was prescribed many recently or that they only lasted a day, requesting medications by their street name) happens many times in the emergency department every single day.  It happens in the clinics.  It happens on nursing units.  It happens everywhere, all the time.

Every day 46 people die from an overdose of prescription pain killers in the United States

The Center for Disease Control discusses this issue in depth here.  Take a look at this graphic.. for every single person that dies from an overdose, there are 825 people that use narcotics who are not using them for their intended purpose, and 130 people that are abusing the substances/are dependent.  WHOA.  That is an insane number.

photo credit: Center for Disease Control, http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

photo credit: Center for Disease Control, http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

So, as health care providers we’re stuck between a rock and a hard place.  You cannot believe every single person – otherwise the death tolls from overdoses would skyrocket (even more so).  But you also can’t NOT believe everyone either, because many people are truly suffering and need pain relief.  Desperately.

It’s hard because as the nurse you feel like you can’t win.  You either believe everyone or you believe no one – it’s so hard to discern who truly needs it and who is lying to your face.

Just give ’em what they want

I know what some of you may be thinking, “why can’t you just give them pain meds when they want it?  Is it that big of a deal?”  Yes.  It is a huge deal, guys.  The type and amount that people request by name is astonishing.

Patients know which medications and which doses to request specifically.  Some will claim they are allergic to all pain medications except the heavy hitters and claim they need high doses to feel any relief at all.  Some will say oral pain medication won’t do and demand IV pain medication until the physician says they can go home and suddenly Norco will do just fine.  People know what to say and how to say it so that you’re left with no other option but the most potent pain medication in the highest allowable dose.

Additionally, these medications are no joke.  They are chemically very similar to highly addictive street drugs.  For example, we give a medication called Fentanyl frequently in intensive care.  It provides great pain relief for those in severe acute pain (think multiple broken bones after a car accident with a breathing tube), during bedside tracheostomy placements, for managing chronic severe cancer-related pain, or with hospice patients, but not appropriate for many other scenarios.  The Institute for Drug Abuse noted that, “Like heroin, morphine, and other opioid drugs, fentanyl works by binding to the body’s opiate receptors, highly concentrated in areas of the brain that control pain and emotions. When opiate drugs bind to these receptors, they can drive up dopamine levels in the brain’s reward areas, producing a state of euphoria and relaxation” (2012).  It causes people to relax so much that causes respiratory depression.  Your respiratory drive can be so suppressed that you just stop breathing.  And you die.

Also, did you note that they compared it to heroin?  Heroin, guys.  Heroin.

We would be negligent health care providers if we pretended this wasn’t a problem and just continued to give a script to everyone claiming they needed one.  People are literally dying because of this.

Here’s another phenomenal article written by a physician that explains this epidemic in a really black and white, evidence-based sorta way.

Why does this happen?

A few years ago, a nurse from the United Kingdom was shadowing on our unit.  I was curious about her thoughts on socialized medicine and our health care system in America, so I asked what she thought about working as a nurse in both systems.  Her response surprised me, as we weren’t talking about pain medication at all.  She said, “when I got to America and started working, I was absolutely astounded at how much IV pain medication is given.  In the UK, patients never get IV pain medication, everything is oral and rarely are narcotics prescribed.  I just couldn’t believe it.”

Needless to say, that’s not what I expected her to say.  I just assumed that everyone, everywhere, administered pain medication this way.  I had no idea people handled pain differently outside of America.

So, why does this happen?  Why America? Why us?

An interesting thing to consider is the influence of the Press Ganey Patient Satisfaction survery.  These are surveys given to patients after their visit to a medical facility.  In most facilities, an aspect of reimbursement from the government is based on patient satisfaction.  So, if your patients are happy, you get reimbursed for the care you provided (this applies to physicians and nurse practitioners/physician assistants, and hospitals as a whole, not nurses individually).  Keep in mind, this is just an aspect of reimbursement.

So the scenario is that a patient comes to a medical facility with their mind made up on what they need.  They think they need an antibiotic for the minor viral illness from which they’re suffering.  Or they decide they need 2 mg IV morphine for their sprained ankle and a Percocet script for the road.  And if they don’t get what they’ve decided they wanted, even though it is not medically appropriate, they will fill out a negative Press Ganey survey after their visit.  The hospital is then not fully reimbursed for this visit, and therefore suffers financially.  Physicians are encouraged to increase their Press Ganey scores.. but how does one go about doing that exactly?

Now, I’m not saying that these surveys are the direct cause of this epidemic in America, but it is definitely something to consider.

Here’s an article entitled I’m Addicted to Prescribing Pain Medications, written by a physician experiencing this stressor.  And here’s another article written by a physician called Why Patient Satisfaction Surveys are Riddled With Problems, which explains surveys a little more in depth.  And according to a 2014 article in Medical Economics, two US Senators are urging the Centers for Medicare and Medicaid (CMS) to investigate if Medicare’s patient satisfaction surveys are contributing to the abuse of prescription opioid pain relievers.

This is a very real and very serious issue that has not only resulted in deaths of epidemic proportion, but it also negatively affects the physicians being pressured into prescribing and the nurses manipulated into administering these medications.

What about the nurses that are actually giving the medications?

In nursing school, you’re taught to believe everyone when they tell you they’re in pain.  And let me tell you, it’s not as easy and straight forward as it sounds.

It is truly stressful when you’re caring for an unstable patient and their  family, and your other patient hits the call bell every 2 hours, on the dot, to remind you to bring in their 2 mg dilaudid, 50 of benadryl, and 25 of phenergan, and to push it fast … all while their vital signs are stable, and they’re talking and laughing on the phone.  And this was after a standard procedure that typically has minimal pain and they have no medical history.  You ask them to rate their pain on a scale of 1-10, 10 being the worst pain in the world and they rate it a 12, as they yawn and send a few Snapchats.  You defer to the doctor, who then discontinues the medications.. and then it’s your job to tell the patient.. who is not happy and says the oral medications you give never work and they must have IV medication.  And they demand you call the doctor back.

You feel manipulated.  You feel tired.  And your other patient needs you.  You just don’t know what to do.

Let me tell you – nursing school did not prepare me to handle patients addicting to prescription pain medications.

How do you handle this?

So.. what do you do?  Have you ever been in a similar situation? What did you do?  What worked, what didn’t work?  And have you ever thought that you were being taken advantage of but you misjudged the situation and the patient actually was in pain?

How many of you actually gave the patient the ordered pain medications, only to get yelled at by the physician for over-medicating them?  Been there.  That was so defeating.  What a terrible bind to be in.

And to those of you that are not nurses in America – how do you handle pain management in your country?  Do you administer IV pain medications frequently or is that unheard of?

Again – I realize so many people are in real pain and I don’t want to take that away from anyone.  I want to use this post for nurses to talk about how they manage pain within this specific patient population and how they professionally and respectfully handle patients that repeatedly request/demand/pressure them into administering alarming amounts of pain medication.  

I am a nurse.  I want to care for the sick.  I want to alleviate suffering.  I want to emotionally support patients and their loved ones.  For those that are addicted, I want them to receive the specialized rehabilitation they so desperately need in the appropriate setting.  Not in the emergency room.  I don’t want to spend time arguing with someone demanding an unsafe amount of pain medication, when I could be hugging the crying daughter whose mother is dying in the next room.

Note:  all sources that were cited contain links to the original article

Addendum:  Beth over at nursecode.com posted about this topic as well!  Here’s her article, which I think you may find helpful!

Guest Post: Giving a Voice to the Silent Sufferers

Guest Post: Giving a Voice to the Silent Sufferers

As Domestic Violence Awareness Month comes to a close, I wanted to feature a guest post about the topic.  It’s important that we, as nurses, are keenly aware of the prevalence of domestic violence, how to identify it, what to do, and how to care for ourselves.  If you have a personal nursing experience related to this, please feel free to share it in the comments section.  I think it’s important to share information regarding how to handle this when we see it in our patients.. what worked?  What didn’t?  What will you always remember?  What helpful hints can you give newbies?  (Please remember to keep all information HIPAA compliant)

domesticviolence

Did you know that, on average, 24 people per minute are victims of rape, physical violence, or stalking by an intimate partner? Or how about the fact that nearly 1 in every 10 women in the United States has been raped by an intimate partner in her lifetime?

Domestic violence is extremely prevalent throughout society, yet many people don’t quite understand just how rooted it is in our culture. Many victims of domestic violence are afraid to talk about their abuse for a variety of reasons including fear, threats, coercion, or lack or resources. Because of this, nurses play an essential role in identifying the signs and symptoms of domestic violence, and giving victims the support and resources they need to leave their abuser.

Recognizing the signs of domestic violence is not an easy task – while there are some more obvious symptoms (bruising that doesn’t match the explanation the patient gave, broken teeth, a history of broken bones), many symptoms are not easily identifiable and can require a nurse’s full sensory awareness. Some of these symptoms include:

  • Strange or intimidating behavior between the patient and partner during the visit
  • Signs of patient fear from his or her partner
  • A history of drug and/or alcohol abuse from the patient and/or partner
  • The partner trying to dominate the visit and not allowing the patient to speak for his or herself

If a nurse notices any of these signs or symptoms, it’s important to carefully and sensitively follow-up with the patient regarding the possibility of domestic violence. This should be done in a safe, private area away from the abusive partner. If your concerns are confirmed by the victim, giving the victim options of local government organizations, religious groups, and community nonprofits is one of the best ways to guide them towards leaving their abuser. Counseling services, emergency services, and housing services are all resources that can easily be found online. If a victim is hesitant to leave their abuser, simply providing a web address to one of these services could be enough to resonate with the victim and eventually help him or her make the decision to flee his or her abusive relationship.

Treating a patient who has been a victim of domestic abuse can be very psychologically challenging. It is not uncommon for nurses to feel extremely affected by seeing the damage an intimate partner can do to someone he or she is supposed to love. After the patient has been discharged, nurses should try to be very in-tune with their emotions; if one starts to feel down or depressed after treating a victim of domestic abuse, one of the best things to do is talk about it with a peer or write it down. Research has shown that this is one of the most psychologically beneficial things individuals who have been through a harrowing situation can do.

Preparation is key when treating a patient who is the victim of domestic violence. By understanding the proper way to handle the situation – both for the victim and personally – nurses can help ensure that everyone involved takes the necessary steps towards leading a safe and healthy life. Nurses see many traumatizing things in a day, but sometimes the most traumatizing situations are where the victim is silently suffering. By raising awareness for domestic violence, we are giving a voice to the millions of victims who aren’t yet ready to speak about their abuse.

If you or someone you know is experiencing domestic violence, it may be difficult to know what to do. The National Domestic Violence Hotline has highly trained advocates available 24/7 to give you anonymous and confidential help. Call 1-800-799-SAFE (7233) or visit www.thehotline.org.

Carly Dell Headshot

Carly Dell is the community manager for the innovative online rn to bsn program offered through Simmons College. In her free time, Carly enjoys traveling, binge-watching HGTV, and trying new restaurants. Follow her on Twitter @carlydell2 and Google+.

NURSE.HACKS.

NURSE.HACKS.

You’ve heard of Life Hacks?  Well, here are my NURSE.HACKS.

  1. Put 1-2 drops of normal saline (from one of the hundreds of flushes you accidentally bring home) in your mascara that’s starting to dry out. That’ll moisten it up and make it last longer.
  2. Contacts hurting or dry at work? Grab a flush and irrigate your eye. It’s the same as your solution at home, minus some of the extra ingredients to cleannursehacks the contacts overnight.
  3. Isolation gowns are great for protecting your scrubs during messy meals.
  4. Double or triple glove when heading into a serious code brown situation.
  5. If you have a really chatty patient or family member and are in a big time crunch because your other patients need you, ask someone to come in and grab you after ten minutes.
  6. Patient getting a bedside central line and feeding tube placed? Wait and get both xrays at the same time.
  7. 0700, 0800, and 0900 meds? Ask the patient if they normally take them together at home – if they do, give them all at the same time and chart patient request for the reason you’re giving them early. Use nursing judgment though; some meds are purposefully scheduled that way (blood pressure meds or meds that must be given on an empty stomach or with meals).
  8. Coffee grounds can absorb even the stinkiest of stinkies. Throw a bag of coffee grounds in one of those useless tiny emesis basins and set it in the room to be sneaky about your odor absorption.
  9. Soak your dobhoff tube in ice water for a few minutes before insertion; it stiffens it up and allows it to glide through their nasal passages easier.
  10. Can’t find a vein? Warm up a moist washcloth and set it on their skin for a few minutes. This can make veins pop better than a tourniquet!
  11. Super sad or grumpy pa3tient? Many hospitals have therapy dogs. See if the patient likes pups and arrange a surprise visit! You could even see if you can get a dog that is similar to one they may have at home.
  12. Can’t get a female foley? Have someone hold a pen light, aim high, and if you don’t get return just leave it in place and grab another and aim higher! If you’re worried you won’t get it, bring a few extra in the room before you start.
  13. O2 sat won’t pick up? Try the earlobes or toes!   The neonatal O2 probes are awesome on adults. They stick better and are less bulky.
  14. Can’t get a blood pressue on a patient in afib with an elevated heart rate? Get a manual pressure. Uncontrolled afib is hard for those automatic cuffs to read properly and probably isn’t accurate anyway.
  15. Family and/or patient very emotional or upset and don’t know what to say? Your presence can speak louder than words. Just being there with a reassuring shoulder pat or taking really, really good care of their loved one will mean just as much, if not more, than saying the perfect thing.
  16. Confused patient picking at EVERYTHING? Activity aprons are a Godsend. Move the O2 probe to their foot. Put their ECG leads on their back (not for an extended period of time due to skin breakdown). Give them something to do, like fold washcloths.

What other NURSE.HACKS do you have to add to the list?  Tweet me / pin / tumblr post some of your favorite nurse hacks with the #nursehacks hashtag!  I’ll make an awesome master list to reference.

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Becoming An Awesome Nursing Preceptor:  Phase Three

Becoming An Awesome Nursing Preceptor: Phase Three

This is my third and final post in my nursey series about precepting new graduate nurses.

Here’s the link to the first post.

Here’s the link to the second post.

Thanks for catching up!  Onward..

Once your orientee has mastered caring for 1-2 patients, it’s time to start putting the on the heat. Phase three is where you begin to back away completely and they are running the patient-care show. They should become more confident in completing tasks and starting to think more and more about the big picture.

They should be able to anticipate obstacles. They should be figuring out their time management style. They should be appropriately discussing the plan of care with other members of the health care team. They should be delegating appropriately.

What I like to do in this phase is really step back. I have a little conference at the beginning of the shift right after report and outline our goals for the day. When deciding on goals, I think about the things they are struggling with and make those the priority.

Your goals need to be measurable so at the end of the day you can say whether or not they met the goal and discuss why. I try to stick with 3-5 specific goals.  I didn’t mention this before, but I do this goal-setting throughout the entire process.  I also document this every shift using the same sheet.  I save them, go over them at the end of the week with the orientee and we both sign them saying that we agree with we’ve discussed.  This protects you if they do not progress appropriately and you need to be able to tell your manager why.   This will help your manager determine the appropriate next steps.

Example: “Alright, today starts week 7 and we have a few goals today. First, I want you to make sure you’re acknowledging new orders that come through within 1 hour of them being placed. Our second goal will be to give all medications on time unless extenuating circumstances present themselves. And our final goal is to delegate appropriately all day today so that you are working at the top of your license consistently. At 1100, I will check your charting. At 1500, we’ll see where we are with our goals and what we can do or change to insure we’re on track to meet them. If you encounter any roadblocks, please come ask me.  However, want you to try to be as independent as possible.”

Whenever they come up to me to ask a question, I basically ask the question back to them to see what their thought process is. Typically at this point they know the answer and they just need reassurance.  And if I can tell they always know the right thing to do but just want me to confirm it’s right, I don’t reassure them.  They need to learn to trust their thought processes and critical thinking, so not giving them the reassurance is what they need to push them to be independent.

Additionally, while they’re figuring out their own time management, I let them drown a little. When I talk to them at 1100 and 1500, I talk about things I observed that could have been done more efficiently to save them some time.  I also look at how they prioritize their tasks and if there’s any room for improvement.  The tendency is to do things that they know how to do first, not necessarily the things that are the priority.  For example, if they need to hang a unit of blood or go give scheduled PO meds early.. they’ll probably head to give the meds first.  Redirect them as needed.

It’s important to empower them to take responsibility for their patient load as soon as possible.  The scariest part of being out of orientation is knowing that you are ultimately responsible for your patient’s well being without anyone checking behind you.  The earlier you can empower them to take responsibility for them, the better.  When giving and getting report, make sure the off going nurse is giving report to your orientee and not you.  Make sure they’re paging the physicians and rounding with them.  Whenever any asks any questions about the patient, refer them to your oriented and say that they are the orientee’s patient, not yours.  At this point, you’re in the background to help PRN and to double check behind charting and task completion.

Furthermore, praise is super important in all of these phases. It is really sacry and humbling to be a brand new nurse.  You’re constantly being told you’re wrong. So when they do something well or right, make sure they know it. It can go a long, long way.

If throughout this entire time you’ve been giving them homework and quizzing them on issues that face your patient population, you’ve really sown a lot into this brand new nurse. You’ve set them up for success. Not only that, you’ve set them up to be an awesome and reliable coworker. If you take the time to sow into them confidence and solid nursing skills, it’s a win-win situation.

Precepting a lot of work, especially at the beginning. You really have to be on top of them, teaching, encouraging, and holding them accountable. It can be a really rewarding experience.

However, not everyone is keen on doing things the way they need to be done during the orientation process. Stay tuned for an upcoming blog post about how to deal with people that aren’t progressing through orientation appropriately!

If you are an awesome and experienced nursing preceptor, please comment below!  I would love to hear about your routine and things that you do to insure your nursling is ready to be out on their own.

Becoming An Awesome Nursing Preceptor:  Phase Two

Becoming An Awesome Nursing Preceptor: Phase Two

Hello good friend!  Welcome to my second post in a series of three about how to become an awesome nursing preceptor.

Please keep in mind that this is aimed towards the orientation of a new graduate nurse on a general medical-surgical floor.  However, it’s pretty general so it can be adapted to fit the needs of speciality units.

In my last post, we discussed the first phase of orientation. Here is the link:  Becoming An Awesome Nursing Preceptor:  Phase One

I’m now going to discuss the ever-important second phase of the orientation process.

Phase Two:

During this phase, they’ll take a patient on their own. After seeing how you take care of a patient, they should be able to adequately care for one person while you’re nearby for questions.

They will take and give report on their patient. They will do everything for them, even call physicians and support staff, as needed. They will complete all of the documentation. They will talk to their loved ones. They will educate the them.

Again, if they don’t know how to do something, always direct them to the policy first. With one patient, they should have time to go look up the policies for everything.

Continue to give them homework. Print off information about your patient population and quiz them the next day.

During this time, I start to ask all of my why questions.  Depending on their progression and knowledge base, I try to challenge them with the questions.  I also try to think of questions that patients may ask about their care plan.

  • Why do you think they’re on subcutaneous heparin?
  • Why are they on Colace and Pepcid?
  • Why do we need to do a bladder scan if they didn’t void 6 hours after you removed the foley?
  • Why do you think you needed to put your patient with CHF on oxygen after he got two units of blood?
  • Why do you think we need a central line when initiating vasoactive medications?
  • Why is it imperative that you lay them completely flat when removing their PICC line?
  • Why are we still giving them IV pain medication when we have oral pain medication ordered?

Whenever they ask me a question, I just ask it back to them to see what they think. I want them to develop their critical thinking skills. We need to go from being task-oriented to being big-picture oriented. While developing these skills, it’s important to not give away the answers quickly.  Let them think.  Furthermore, if other members of the health care team (docs, MD’s/PA’s, CNA’s, etc.) ask them questions about the patient, don’t answer for them.  I’m terrible at this.  I have to try really, really hard not to answer for them.

You want to encourage them to ask questions, so don’t act like they’re stupid if they get one wrong or do something incorrectly. Handle those situations with grace. Please don’t use that opportunity to make someone feel bad about themselves.   That’s that terrible nurses eating their young thing.

It is really important that during all phases of orientation that you are treating everyone around you with the utmost respect.  If you are talking badly about other people in front of your orientee, they see and hear that. If you’re not being respectful of the CNA’s, you’re telling them it’s okay to do that. If you are nice to someone’s face and once they leave you talk about them, you’re not being a good role model to your orientee.  They are watching how you do everything, including how you interact with others.  If you want them to be a good nurse and supportive coworker, it is imperative that you model that yourself.

Amazing nursing preceptors out there – what is your routine with your newbies once they get their nursey feet under them?  What tips/tricks/advice do you have to share?  Please comment below!

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Becoming An Awesome Nursing Preceptor:  Phase One

Becoming An Awesome Nursing Preceptor: Phase One

I was very fortunate to have some amazing preceptors both when I started nursing and again when I transitioned into critical care. I’ve also had the privilege of precepting people myself. I pray I was a tiny fraction of the awesome that my preceptors were to me.

Because of an awesome question I received via my Tumblr (http://nurseeyeroll.tumblr.com), I am writing a three-part series on the process in which I have been precepted and also how I’ve done it myself.  It is much more involved and requires planning, patience, and grace.

When I look at orientation, I divide it into three chunks. All three require different levels of assistance that you’ll give your orientee. I’ll go through each of them in a series of three posts. The duration of each phase depends on the entire length of their orientation as well as their personal progression. As a rule of thumb, phase one is the shortest and phase three is the longest.

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After 2-4 years of learning that everything is important in nursing school, your job as a preceptor is to get them to focus on what is important for your patient population.

Something to keep in mind is your newbies will be entirely task focused. This is the normal progression. They will be focused on completing tasks, not critically thinking/anticipating problems. Again, this is how it should start. We will add the critical thinking piece later.

Phase One:

The first few shifts are utilized for observation. They need to see the flow and culture of the unit and patient population. The patients are still your patients, however your orientee is going to be given tasks to complete, all while getting familiar with the flow of the unit.

During your patient care, have them perform simple tasks; drawing up medications, calculating dosages, administering IV/subcut medications, starting IV’s, putting in feeding tubes, documenting appropriately, using foley insertions, putting people on telemetry, etc. When they ask how to do certain things, show them how to look up policies and procedures. You’ll find yourself saying, “what does the policy say?” over and over again, but you need to get them into that habit.

Another important thing to remember is to give your orientee a consistent routine.  Once they’re out on their own they can start to improvise and change how they manage their time.  But right now they don’t know what all of their options are so they can’t make an appropriate judgement on what they like best.  During phase one when you’re showing them the ropes, show them your awesome and efficient time management skills, and your routine of how you walk through your day.  They can decide what they like and what they don’t like for themselves once they’ve gone through it a few times in the later phases.

Something that expert nurses forget (because they’re experts!) is the “why” behind everything.  The things we do become so normal and natural, we just don’t have to think about the “why” anymore.  Remember, these newbies need to know the “why”.  This is important in their professional development into a safe care provider.  Even if it seems menial, you must explain the “why” behind everything.

Things you need to do in Phase One

  • Formally introduce them to everyone. CNA’s, MD’s, PA’s, NP’s, transporters, etc. They are now part of your team and what better way to welcome them and make them feel part of it all than by you taking the time to introduce them to everyone.
  • Explain your time management technique and why you do things in the order that you do them.
  • Explain your prioritization that is ever-changing throughout the day.
  • Demonstrate appropriate delegation as well as accountability when tasks are delegated.
  • Have them observe how you interact with patients/families, physicians, and support staff.
  • Get them familiar with documentation.
  • Have them take report right along with you so they can choose the report sheet they want to use and get familiar with it
  • Get them familiar with your IV pumps and tubing.
  • Find information specific to your patient population, print it off, and have them read about it at home. Quiz them on it the next day. Start building that foundational knowledge about the disease processes that affect your patients.
  • Show them how to look up policies and procedures.
  • Get them familiar with the house phone numbers and departments. Take them wherever you go in the hospital to show them around. Again, introduce them to people.

Depending on their progression, this can last 2-3 weeks before you move on.

In my next post, I’ll discuss Phase Two of the nursing orientation process!

Are you an experienced preceptor?  What’s your routine during the first few weeks?  What worked and what bombed?

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Something You’re Dying to Talk About

Being a critical care nurse, I’ve witnessed quite a few people pass away.  I’ve assisted in taking people off of the ventilator to allow them to pass naturally.  I’ve cared for patients that are donating their organs.  I’ve been there for people when they take their last breath because their loved ones could not bear to watch.  I’ve watched the monitor flatline.  I’ve carefully removed wedding bands and given them to crying spouses.  And I’ve gently cleaned patients after they’ve passed and sent them off to the funeral home to await their last goodbye.

I don’t know why, but it doesn’t really phase me too often anymore.  Sadly enough, I guess I’m used to it.

But there’s one thing I just can’t get used to:  people that have never talked about death with their families and loved ones.

Death is a part of life.  It is never if you die, it is when you die.  We will all have this experience.  No exceptions.  Even those people in your life that are so important you, the ones you could never live without.. they’re going to die someday whether you acknowledge it or not.

Once I talked about this with someone that was close to her dad.  She said, “My dad isn’t going to die.  I wouldn’t be able to live without him.  That’s not something to even consider or talk about.”

She said this, as if she had a choice in the matter.  The fact is, her father will die one day whether it’s in a car accident tomorrow or drifting slowly to sleep when he’s 96.  Regardless of when, pretending that it is never going to happen is going to make it all the more traumatic when it does.

So why don’t we talk about it?  Why do so many families/loved ones come into the hospital, never having spoken about death.. ever?

I honestly don’t know the answer to that. Maybe that “I’m invincible” thing you naturally develop in your teenage years never went away.  Maybe no one close to you has died before and you’ve never been forced to deal with it.  Maybe you’re so caught up in your day-to-day that you’ve never had to think about the finality of life.  Or maybe it brings up emotions and you just can’t go there.

I don’t know.  However, regardless of the reason for not talking about this, there is one thing I do know:  the absolute worst time to talk about this for the first time is when you’re standing at the end of a hospital bed, looking at your dad on a ventilator after a massive heart attack with four vasoactive drips, barely maintaining his blood pressure, with his ribs cracked from multiple rounds of CPR.

That’s traumatic.  That’s really, really hard.

And it gets worse.  Now you have to make a decision for him (not for you, for him), never having talked about it before.

That’s even more traumatic.

Because we don’t talk about this stuff when we’re healthy, we’re forced to make the hardest decisions of our lives in the midst of the most terrifying nightmare we could ever imagine.

Many people do not get to pass peacefully because they had not talked about this with their loved ones.   Some people go to the trouble of advanced directives and living wills but don’t share it with their loved ones so they don’t truly understand or appreciate the importance.  Or even worse, they designate someone who cannot see through their own personal desires and pain to make the right decision.

I implore you, as health care professionals and as people that will die one day.. have this conversation with your loved ones.

Identify someone you trust (and it’s not always your spouse!) and talk to them.  Talk to them about what you would want if the decision was either to pass away or to live out the rest of your days in a nursing home, requiring 24-hour care.  Make sure they will be able to see past their personal pain and make the right decision for you.  Make sure they know you specifically chose them to advocate for you.  If you don’t think your legal next of kin will agree with this, it is absolutely essential that you get health care power of attorney paperwork completed.

I argue that this conversation and this trusting relationship is much more important than a legal notarized document with your signature on it.

WebMD explains this in much greater detail here.

Wikihow explains how to go about doing this here. 

Have these crucial conversations now, not in the middle of the night after you’ve been up for 36 hours, staring at your wife who just had a massive stroke with no brain stem reflexes and is on a ventilator.

Do it now.  When you’re sitting down for coffee in the morning, thinking about how much you love her.

Tips for Switching From Night Shift to Day Shift – From a Nurse!

Tips for Switching From Night Shift to Day Shift – From a Nurse!

Many nurses start out on night shift but then transition to day shift.  While the work is technically the same, the flow of the day is quite different.  Here are some tips/tricks for the nurse transitioning from night shift to day shift.

#1 – Pay attention to meds with meals

Insulin is the major medication to take note of.  When you’re looking at what meds you have to give for the day, pay particular attention to AC/HS blood sugar checks with insulin coverage, and any other meds that need to be given with meals and manage your time accordingly.  I got burned on this at first.  I wasn’t paying attention and before I knew it, dietary delivered their tray.   They ate without getting their sugar checked first and they had sliding scale + scheduled insulin due.

Also, keep in mind meds for dialysis or pancreatitis patients that have meds that must be given with each meal and again, manage your time accordingly.

#2 – Try to chart in real time as often as possible

On nights, I’d chart a few things in real time, but once everything settled down, I’d sit down to complete all of my charting at once.  Keep in mind, you don’t always get time to be able to catch up so chart as things happen if you can!

#3 – Anticipate obstacles for discharges

If I find out in report that a patient will probably be discharged that day, I immediately ask them about transportation.  Many times family members that are their rides are only available during certain times, so find out early so you can manage your time appropriately.  Otherwise, they’ll put on their call light and say their ride is waiting downstairs and the doctor hasn’t even put in the scripts yet.  Also, make sure they can pay for their scripts.  Too many times I was giving discharge instructions and suddenly they said they couldn’t pay for their meds, but their ride was already on the way.

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#4 – Know what time the physicians begin call

And make sure you get routine needs addressed before then!  This is usually around 1700.  Nothing frustrates on-call physicians more is calling at 1730 for something routine that the attending physician or their advanced practice provider could have easily addressed.  Manage your time so that you have all of the orders you need before it switches to the on-call doctor.  You also want to make sure you do this so you don’t leave night shift hanging.

#5 – Don’t try to get absolutely everything done before you let yourself eat lunch

I would do that on night shift because it was more feasible.  There weren’t any discharges and much fewer admissions.  I would see everyone, medicate them, chart, and round again before I would eat.  This isn’t realistic on day shift because once you’re done with 0900 meds and charting, it’s time for 1130-1200 meds.  Usually you start to get discharges (and therefore admissions) around this time as well, which means you won’t be eating lunch until 1600.  Try to get your lunch whenever you can.

#6 – When family members call for an update, take a message if you’re busy

They like to call at shift change, around 0900, and 1200-1300… you know, the busiest times of the shift.

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I know, it’s frustrating, but most people don’t realize how big of a headache that is.  Simply, don’t take phone calls mid-med pass unless they’re urgent. .  That’s when you make errors.  Have whomever answered the phone get a number and call them back, or ask them to call back in an hour.

#7 – Round with the physicians

Do this to build rapport and establish a professional trusting relationship. On night shift, you’re working with on-call physicians typically, getting them to the next day and prioritizing most decisions to be made the following shift with the attending. On day shift, you’re working elbow-to-elbow with the attending physician about decisions, concerns, and plan of care.

Make your face known to them, shake their hand, and give them an update on your patient before they ask.  The nice thing about day shift is you really get to know the doctors.  Having a good relationship with them can make your job much easier.

#8 – Don’t call physicians about non-urgent/emergent issues that can easily be address during rounds

We need to be respectful of their time, as we want them to be respectful of  ours.  If we call for every little need that can be addressed during rounds, it takes them away from other patients.  If it’s something that’s not going to change your plan of care between now and then, wait until they come by for rounds if possible. Consolidation of calls/pages is appreciated by all!

#9 – Don’t linger around, chatting it up with night shift

You’re already behind! Seriously, day shift feels like you just hit the ground running immediately. If you hang back to catch up with your BFF night shift bud, you may already be late on some meds, missing the resident’s pre-rounds, or missed a pre-breakfast Synthroid dose!

Seriously, my first few weeks on days felt like –

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#10 – Take some time to touch base with your CNAs/PCTs first

After report, double check to make sure they know who needs a bath today and who has blood sugar checks and if you need to be notified for specific vital signs (for example, for a systolic blood pressure above 160).  Don’t assume the night shift tech gave communicated everything they need to know. Again, been burned here. Never assume anything – double check with your nursing staff, especially those with whom you’re sharing tasks for patients throughout the shift. This also builds rapport with them as well, which is essential because you will rely on them heavily.

If you’re struggling with some specific clinical things

If you’re a new graduate nurse, or a nurse switching to a new unit, or a nurse having trouble grasping some important patient-specific issues, you’ll want to spend some time on your days off going over some concise and helpful information.  This makes a world of difference and helps connect the dots sooner. You can focus on practical steps at the bedside, while filling in the why at home when you have a little more time to process the information.

YouTube has tons of great free videos (Khan Academy, for one), or check out your speciality nursing organization (the American Association of Critical Care Nurses has tons of great resources for critical care), or you can check out the NRSNG Academy.

NRSNG Academy is primarily an NCLEX resource, but there is a ton of information applicable for the new nurse.  The EKG, Lab Course and MedMaster Courses are specifically what I’m thinking will be particularly helpful for the new grad.

They go in depth on mechanism of action, nursing considerations, contraindications, and more within MedMaster. The EKG Course dives deep into each rhythm, nursing considerations, pathophysiologically and electrically what’s occurring, and more.  The Lab Course does a deep dive into specifically what each lab is measuring, why it’s important, and more.

    

 

You can buy each course individually, or you can try them all with a trial NRSNG Academy membership for $1 and cancel any time.

NRSNG Academy works like a monthly fee, so once you feel like you’ve extracted the value and knowledge you need to be more successful at the bedside, you simply cancel. There is a ton of information in the entire academy that would be applicable to the newbie nurse and it would take a few months of membership to equal the cost of purchasing each individually.

Click here to try the NRSNG Academy for $1

Even more resources for new nurses

           

Enjoy day shift!

Getting up early is the worst, but sleeping at night (every night) is the best!

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How to Manage Your Time in Critical Care for Nurses: Part II

How to Manage Your Time in Critical Care for Nurses: Part II

This post contains affiliate links

One of the most important things to master in critical care is prioritization.. what do you do first?  It’s kind of like prioritization on the floor, except the stakes are higher.  Instead of doctors rounding, patients being hypertensive, patients in pain, families wanting you to discharge them 10 minutes ago, or facilitating a transfer to a nursing home.. you have patients with subarachnoid hemorrhages who are suddenly developing hydrocephalus, septic patients on four different drips to increase their blood pressure, active GI bleeds profusely bleeding from their rectum, patients with impellas that cannot move a muscle, and very emotional family surrounding everyone all the time.  Oh, and the guy next door has basically been coding for the last two hours.

How do I figure out who needs me most right now?

A lot of intensive care time management has to do with the “who needs me the most right now” mentality. Yes, they both always need you.. however, who needs you MORE.

If you don’t know which task to do next, ask yourself: which patient is the least stable right now?  That can help you quickly prioritize when there are many tasks that need to be completed.

Once you’re more familiar with the urgency of certain situations and disease processes, you’ll figure it out.  And also, once you’ve screwed it up a few times.. you’ll never forget!

3 examples of typical critical care situations

Both patients need you now, but who needs you right now?  (Sorry for all the neuro, but I love it so much!)

One patient has had a hemoglobin drop from 7.9 gm/dL yesterday to 6.9 gm/dL today and has two units of PRBC’s due now. He’s asymptomatic. Your other patient has a stable subarachnoid bleed (not in vasospasms) and their blood pressure limit is to keep their systolic pressure less than 160. Their last three pressures are 159, 168, and 174 over the last 45 minutes. He’s also asymptomatic. How do you handle this?

One of your patients had a devastating stroke in their brainstem yesterday. The family has all arrived and is at the bedside and wants to allow the patient to pass naturally. She was made a DNR last night and the MD ordered comfort care measures once everyone has arrived. Respiratory therapy just pulled out the endotracheal tube and her oxygen saturation is 71% and her heart rate is 39. Your other patient was admitted from the floor with septic shock. Antibiotics were initiated, cultures have been sent, and up until this point their vitals were stable. Now his pressure is 69/42 with a MAP of 51. You can only do one thing right now, what do you do?

One of your patients has an intercerebral hemorrhage and is on Cardene to keep their systolic pressure less than 160. Their pressure is now 185/90 and climbing.  Your other patient is in respiratory distress. He’s been on 4L NC all day and has an O2 saturation of 95% but all of a sudden he’s 84% on that 4L NC and clearly in distress. How do you handle this?

Here’s how I would handle all of those situations

Ok… which patient is the least stable?

Typically asymptomatic anemia is only treated if it’s less than 7.0 gm/dL and you’re barely below that. He hasn’t had a major drop, only 1 gm/dL overnight, so he’s not acutely bleeding. That guy can wait a second for you to start that blood; you need to deal with your hypertensive subarachnoid. Check your PRN medications to see what you have, if you don’t have anything, you need page the MD immediately, get a STAT order, and administer it NOW.

Now, which patient is the least stable that you’re going to treat?

The family of your patient receiving comfort care may need you more emotionally, but your septic patient is not perfusing blood to his organs with a MAP of 51. You need to get him on some Levophed and Vasopressin (or whatever is ordered) STAT. Do that first, then go emotionally support the family of your dying patient. It would be ideal if you could delegate starting your drips to someone
else and stay with the dying patient, but realistically that’s not always an option.

Ok… now, which patient is the least stable?

The guy in respiratory distress! Yes, that’s a scary high blood pressure for someone with a bleed in their brain, but Mr. Respiratory Distress needs you, like, NOW!  Get a non-re-breather on them and crank it up all the way and see if that works. If not, they may need to be emergently intubated.  If possible, delegate to someone to titrate your Cardene up.. again, that’ s not always going to be an option.  In the case that it’s not, you need to get Mr. Respiratory Distress stabilized and then titrate your Cardene.

These are a little neuro-y, does anyone who works in cardiac or SICU/MICU have a good scenario they’ve experienced?  One where both need you right now, but you had to figure out who needed you more?  The newbies to critical care will greatly appreciate it!

More resources for newbies to critical care

I have compiled a list of posts below, from this blog and others, of resources for newbies to critical care:

NRSNG also has quite a few great resources for nursing students and new nurses.  There are various courses, or the entire academy. The specific courses that would be valuable to the new ICU RN in particular include:

And finally, here are some books for newbies to critical care! Click on any of them to purchase.

    

How to Manage Your Time in Critical Care For Nurses:  Part I

How to Manage Your Time in Critical Care For Nurses: Part I

 

I’ve worked on both the floor and intensive care. In both units time management is absolutely essential. However, time management on the floor is very different from time management in critical care.   I’m going to go through some tips to help you appropriately managing your time in a critical care setting.  I know it can be scary at first, but it will get easier as you become more confident in yourself.

First of all, congratulations on landing a job in critical care! It’s amazing and terrifying all at the same time. You’re excited to care for patients who are critically ill, but once you step on the unit and see the lightening-fast pace and truly how sick these patients are and it’s now you’re responsibility to monitor, notify, and intervene…. you can start to feel like…

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I want to dive into some specific, actionable tips that you can take with you to work tomorrow so you feel a little less like Steve Harvey and a little more like…

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It’ll take some time and experience, but you’ll get there – I promise! And keep in mind, this is part one of a 2-part blog series on time management in critical care. Check out the links at the bottom for more resources and a link to part two.

The ideal critical care time management timeline

Here is my general timeline after I get report on my two patients. Typically, one is sicker than the other.

  • After report, I double-check my orders. I make sure my monitor matches my ordered parameters (for example, if my order is to keep their systolic blood pressure 120-150, I make sure the monitor is set appropriately). I see if there’s anything I have to do (meds, labs, scans, etc.) at 0800. I print and interpret my telemetry strips. If my patients are on drips, I insure I have a full bag and one on deck. If not, I order one.
  • I go see my sicker patient first. I get any 0800 meds/supplies, go in and do my assessment, turn, meds, oral care, and talk to them about the plan for the day. If time allows, I immediately chart my assessment at the bedside.
  • Then, I go grab any 0800 and 0900 meds/supplies for my second (less sick) patient. I complete everything I listed above with this patient and immediately chart what I’ve done. I usually end up administering medications last because it’s barely 0800 by this time and I have to wait until then to give my 0900 meds. So sometimes I even chart my entire assessment first and then go back to administer meds.
  • Then I head back into my first patient’s room with their 0900 meds. If they are a q2h neuro check then I complete it and chart it at this time.
  • If my second patient is a q2h neuro check, I then complete that and chart it.
  • Typically, if no one decompensates or needs to travel and if no doctors round.. I’m caught up by 0930.

However, it doesn’t happen too often like that. But it’s important to know your “this is what I do every day when time allows” routine.

Important general nurse time management tips

1. Have a consistent routine. If you do this, then you won’t miss things. Rarely do things work perfectly, but you need to have a consistent, efficient and comprehensive routine that you stick to.. otherwise you could miss something important. Also, you can get behind early which screws up your entire day.

time management

2. Stay ahead. Always have your charting done, even if you think you have nothing pressing going on. Things change QUICKLY and severely in intensive care. You could all of a sudden get a coding admission and be in that room for hours and if you didn’t have your stable patient’s assessment charted from 2 hours ago, you’ll never remember it now!  So if your meds are given at 0800 and your assessment isn’t charted, it is NOT time to go grab coffee.  Chart everything first, turn, make sure there is absolutely nothing left for you to do before you have a break.

3. Anticipate and prepare. Once you’re there for a little while, you’ll be able to predict how patients respond to certain things. For example, if I have a patient with a history of CHF that needs 4 units of fresh frozen plasma, I know we’re going to need some Lasix at some point.. otherwise Mr. Smith is going to turn into Mr. Respiratory Distress. If we’re about to do a bedside tracheostomy placement, I know I’ll need to have a bolus primed and ready to go and a bag of Levophed hanging and programed because typically they become hypotensive with the procedural meds we administer. If you anticipate and prepare you won’t have to frantically grab supplies while your patient is decompensating.

4. Be meticulous. Most nurses in intensive care have Type-A personalities and are meticulous and detailed. If you don’t care about the details, you can miss something BIG and it would be your fault.  Meticulous nurses save lives because they know everything about their patient.  And not only that, they care about the details.  Say goodbye to being task-oriented.. you are now big-picture oriented and you won’t be able to see and interpret the big picture if you don’t know the details off the top of your head.  Additional, when things go downhill (because they will, and quickly!) you will know the important stuff off the top of your head for quick problem solving in the midst of chaos.

5. Figure out what you think about death. I know this is odd to say, but I highly recommend soul searching to figure out what you personally believe happens after people die. Because you’re going to see it. A lot. It can be pretty gut-wrenching and it can hit close to home. Make sure you have a good emotional support system so when you do have a really sad day, you can go talk to someone you trust and love so that they can support you. Nurses that don’t become angry, sad, difficult to be around, and jaded. Moral distress is the #1 cause of caregiver burnout. If you can’t process that stuff, it’ll get to you eventually. PTSD in critical care nurses is real (check out this article about it); please take care of your heart and soul.

6. Develop rapport with your physicians. Things change very quickly in critical care. However, sometimes you just get a feeling about something.. and you need doctors that will listen to you and believe you. Take the time to get to know them and develop a trusting relationship with them.. it will pay off for the both of you.

7. When you come home, process your day with a loved one for no more than 10 minutes, then move on. It’s very easy to let your nurse life take over your entire life.  Don’t let it. Yes, you’re a nurse, but that is one aspect of your life. Invest and grow the other areas of your life so that work doesn’t take over. It will help in dealing with rough work situations when you find fulfillment and purpose in other things.  You will get burnt out if you don’t maintain a good work-life balance.  And that includes unnecessarily going over situations that happened at work that you cannot change over and over again at home.  Please save your sanity.. and your loved ones!

8. Take care of yourself on your days off. REST, work out, eat right and spend quality time with people that you love and that love you. Be intentional with your time. Our job is hard. It’s emotionally and physically draining. If you’re not taking care of yourself, it’ll make those days that you work that much harder. Your sanity and happiness won’t last long.

I know it seems like a lot but soon it will be second nature.  And when you feel like you’ve got your mind around things and can clock in with confidence, you’ll start to feel like

via GIPHY

(Please note: I have a similar response when one of the docs asks if we want him to buy us pizza)

More resources for newbies to critical care

I have compiled a list of posts below, from this blog and others, of resources for newbies to critical care:

NRSNG also has quite a few great resources for nursing students and new nurses.  There are various courses, or the entire academy. The specific courses that would be valuable to the new ICU RN in particular include:

And finally, here are some books for newbies to critical care! Click on any of them to purchase.