Your first year as a registered nurse is challenging.
This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills,
BSN RN CCRN and features experienced nurses from FreshRN.com, who
discuss the basics of that first year. From nursing orientation, code
blues, tricks of the trade, and personal experiences, to time
management, delegation, patient deaths, and more.
Welcome to Season 3 of the FreshRN Podcast. Ever wonder about how the bedside nurses work with nursing leadership? We interview Megan Brunson, a current practicing nursing supervisor and discuss how the bedside nurse can leverage leadership in various patient situations.
Please note, in this episode we talk about the AACN a lot – this stands for the American Association of Critical Care Nurses.
Introduction to Megan Brunson
On the board of directors of AACN
Treasurer of the AACN
Night Shift Supervisor in the Cardiovascular ICU at Medical City Dallas Hospital – a position she has held since 2007.
Has 15 years of nursing experience in the ICU environment
Started out in PCU step down for 3 years
Transferred to cardiovascular ICU dealing with open heart surgeries and valves in Atlanta.
Married a Texan and moved to Texas.
Took on a position as a supervisor in 2007.
She was hired for her clinical experience, the supervisor role was new to her.
The Role of A Supervisor
This can be different at different facilities. This is generally what this role means:
Some hospitals call them assistant managers
Many facilities have an assistant manager for the day shift and another for the night shift
Then there is a manager over the entire unit
A supervisor or assistant manager helps manage the nurses by:
Scheduling
Helping with clinical needs
Primary responsibilities:
Offer clinical support by answering questions
Offer support to help pull up or reposition a patient
Offer support listening to nurses that need someone to talk to about job-related questions and problems
In the night shift, leadership presence isn’t always there for nurses.
Works a 12-hour shift
Paid hourly, not salary
Having a supervisor that understands both the clinical side and management side is critical to providing excellent support to both the nurses and the upper management.
The hardest job in health care is a nurse manager.
Best way to be a nursing supervisor is to remember details about the nurses in your care
Create an intimate rapport with them
This increases their trust in you as a leader
It helps the leader build the team so they know how to use their talents best
Chain of Command
Next we discuss exactly what chain of command means to a new nurse, and how to enact it in the most politically correct way possible.
There is a reality in hospitals that you have to follow the process of the chain of command.
Chain of command essentially means that you’re hitting a roadblock with someone and you need to escalate the concern
For example, you have a concern about a patient and the resident does not agree. Escalating that would mean speaking directly with the chief resident or the attending.
Another example is that you have a conflict with your colleague and attempt to discuss it with them and they are non-responsive, then you go to your supervisor, then your manager, etc.
Following the chain of command process protects you as a nurse and it protects the managers and administration
On the night shift, the night shift supervisor or charge nurse is a nurse’s first step
Communication is key. Sometimes the person a nurse is having a conflict with doesn’t even know.
It is important and part of a nurse’s role to give them a shot and be honest about the things that bother or upset them.
If they are not receptive or they lash out, then they are accountable for their behavior and you can go to the next level.
The direct method for handling conflict is always the best way.
It leaves your vulnerable and it is scary.
It avoids a triangular situation where you don’t know if the person was told about your conflict or if it was ever resolved.
Another option is to pull someone in and go together to resolve the conflict.
Other experienced nurses have experience with these crucial conversations and can be a huge support system.
Sometimes a nurse has to go around the chain of command because the direct supervisor is physically not there.
It is a good idea to pause, write down what bothered you, and think it through before going up to the next supervisor.
This helps you sort through your thoughts and put them together professionally.
Do not have an emotionally-driven conversation
When looking for support, be selective with whom you let into your circle of trust
Don’t foster drama or encourage gossip
It can create a very unhealthy environment within which to work
Advice for New Nurses
Advice from a night shift supervisor to new nurses that might be facing issues with their manager or direct supervisor.
How to navigate issues with direct supervisors or managers:
AACN has valuable resources such as Healthy Work Environment Standards which covers:
Staffing
Communication
Creating a healthy culture within the unit
New nurses should read these standards
If you have a problem with a new nurse manager or a preceptor, try this:
Set the expectation correctly –
Take a moment to say to the preceptor, “This is where I am coming from. This is the kind of patient care I’m looking for. This is the experience that I need. I’m concerned because I’m really having trouble with ______.”
Set expectations with how you like to learn, too.
“I’m a very visual person.”
If you set the expectations clearly, there won’t be any surprises when you have a dialog later on.
It helps foster trust at the start of your shift.
It’s ok to say “we are not clicking.” It doesn’t necessarily offend the preceptor.
It does take courage to come forward and ask to change preceptors.
Advice for Nurse who Has Conflict with Physicians about Patient Care
If you have a new nurse that has a concern about a patient, calls the physician and doesn’t receive an appropriate response for the issue, this is what they should do:
Always go with your gut, but don’t do it in a silo.
The senior staff knows the physicians really well – walk through the situation with them
As a new nurse, you have a responsibility to build trust with that physician too.
Bring in your charge nurse or an experienced nurse.
Before you call the physician, write down on a piece of paper what you want to say.
Sometimes with a physician, it isn’t what you said it is how you said it.
Unless it is something like a completely inappropriate medication, do what the doctor says, but then call them right back.
There is a chain of command with physicians.
It doesn’t happen very often where you have to go to that physician’s chain of command.
In that instance, you would pull in the overall house supervisor.
Be assertive and clearly communicate details when you discuss patient care with physicians.
If you need to call back, as the charge nurse to listen on the other line.
It wakes up the situation
Charge nurse can help clear up miscommunications
Encouragement for Nurses With Barriers to Leadership Support
Helpful tips for new nurses that have actual or perceived barriers to leadership support.
As a nurse, recognize that you are a leader.
Even as a day-1 nurse, you are a leader in that unit because you are setting the tone for that unit.
When you say you have perceived barriers with leadership some of it might just be not knowing that person.
You might not have any personal connection to them.
You might not know their clinical background experience
Don’t be so task-oriented that you overlook getting to know your team.
Come in 10 minutes early and stay 10 minutes late. When you are getting your assignment, have a discussion with the buddy you will be working with all night, such as:
Learn basic personal details (“what did you do this weekend?”)
Build rapport
When you are in critical situations with patients, you have the rapport and established relationship that will help you navigate it easier.
It makes escalated conversations more comfortable.
Night Shift Supervisor Soapbox
A few last words from Megan Brunson to brand new nurses.
For night shift nurses – don’t mess around with your sleep.
Map it out
When new nurses come to the night shift, they don’t take into account their sleep and they make appointments during the day when they should be sleeping.
How much sleep you get affects the health of the patients and your entire mindset at work.
From a leadership perspective, build trust with the people around you.
This includes day shift too.
They will have your back as well as you have theirs.
Get to know the leadership in your unit.
Whether that is the charge nurse or the experienced nurse
Find out who has the listening ear. You will get frustrated. These are normal feelings and you need someone with whom you can talk about it.
Never use night shift as an excuse to not get involved.
I ask people to speak up for the shift
A meeting in the afternoon won’t work, but I want to be involved in that committee, can we meet at 4:30 p.m. or 7 a.m.?
Your professional development ultimately feeds back into the patient care you are giving.
Your first year as a registered nurse is challenging.
This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills,
BSN RN CCRN and features experienced nurses from FreshRN.com, who
discuss the basics of that first year. From nursing orientation, code
blues, tricks of the trade, and personal experiences, to time
management, delegation, patient deaths, and more.
Grab your nasal cannula and crank it up to 4L/min because in this episode, we interview Sean Dent who is an NP in acute care and discuss all things respiratory!
Introduction to Sean Dent
13+ years nursing experience
Spent almost entire career inside the ICU
Worked for 3 months in orthopedics at the beginning of his career
Has worked in every type of ICU in the adult world
6-7 years ago decided to go to NP School
Currently working on his 5th year as an Acute Care Nurse Practitioner for a Level 2 Trauma Service that provides critical care services to all of the ICUs inside of the walls of the hospital
Basic Things Points About A Gas Exchange A New Nurse Needs to Be Aware of
What most nurses forget about the airway is what happens between the outside and the back of your throat.
The most important part of all that is what can the patient do to assist themselves in their pulmonary toileting
Definition of pulmonary toileting: coughing and deep breathing. At its most basic level, can they take a deep breath, can they cough, and for those of us in the ICU world, can they protect their airway? Can they stop anything besides air from going down their trachea? Can they do that on purpose?
There are diseases that affect the epiglottis and the ability for your epiglottis to function properly. Things like “microaspiration” and vocal cord partial paralysis.
If you have someone that has a neurological disease process like a stroke or is weak from debilitation, their pulmonary toileting is going to be affected.
It is your job as a nurse – no matter the level – to master what goes from the outside to the back of the throat.
Oxygen Delivery Methods & Common Mistakes With Them
These are common mistakes with supplemental oxygen. Oxygen is a medication. It is toxic. Too much, too fast, or not enough, will kill the patient. Take it seriously.
Nasal Cannula – Delivers up to 6 liters of oxygen. It is affective at up to 6 liters of oxygen. Anything beyond that you are talking about flow rates and whether or not the amount of oxygen that you are blowing into their nose is getting into their airways.
If patients don’t need oxygen, don’t put them on it. Oxygen can be toxic.
If a patient has it and doesn’t need it anymore, take it off.
Common mistake – Putting it on too high and not humidified. Only put it on if you need to, and always put it on correctly.
Make sure to add humidification!
High Flow Nasal Cannula – 6 liters up to 15 liters of oxygen.
Keep in mind the comfort level. You are blowing 16 liters of oxygen through their nares
Before you put it in their nose, put it on your hand. Feel how much is blowing on your hand. That amount of oxygen will blow on your face as if you are in a car.
The idea behind high flow is you are still using the nares to deliver oxygen and 6 liters wasn’t enough.
Anyone that really needs that much oxygen better have a chronic respiratory problem that needs addressing in an aggressive manner.
Some patients need it because they are on an oxygen mask but can’t use the mask when they are eating so they are put on high flow while they eat.
Putting on high flow without humidifying will cause patient’s lips to crack, it will dry out their airways, and cause nose bleeds. It can also mask a true assessment of your patient because it dries out the mucus membranes.
Add humidification!
Simple Face Mask
Has no titration to it. It is basically a nasal cannula but as a face mask. This is for the mouth-breathers.
Can deliver the same amount of oxygen as nasal cannula.
Think about the delivery method and how your patient is accepting it.
If I am blowing 15 liters of oxygen into their nose but their mouth is open, am I really giving them 15 liters of oxygen?
A face mask gives them a pseudo-seal.
It looks like a BiPap Mask
It does not have an titration to it.
There is no advantage to it, other than if the nasal cannula isn’t effective
Mouth breathers
Patients who have had facial surgeries
Jaw removed from cancer
It is not a sealed mask.
Venti-Mask
A simple face mask with a dial that you can dial the titration of the oxygen
Some venti masks are titrated by liters
Some are titrated by percent of oxygen
Some can seal, most you cannot
A seal meals no oxygen can escape the borders of the mask and the patient’s skin.
New Grads, how to know what percent to set the dial at:
Start low and go slow.
If you are upping your game in any way, make a call to respiratory therapy. They are the experts and specialists that are going to augment your therapy.
Venti mask isn’t something that is easily accessible, you have to get it from respiratory.
Face Tent
Used post-operatively and on post-surgery patients.
A simple face mask that sits underneath their chin. It straps to the back of their head to hold it against their face.
It is something to augment a patient with supplemental oxygen while they wake up from anesthesia.
It isn’t something you are going to see unless you are in a specialty area.
For example, after a transphenoidal tumor resection
Humidified Face Mask
If you have someone that has a lot of secretions and you give them continued dry oxygen, they are going to wind up developing mucus plugs.
Anytime you can give humidified, you should. Even on 2 liters nasal cannula.
You are bypassing your body’s natural ability to humidify air.
Nasal Trumpet
This is for someone who has sleep apnea, or a history of obstruction or a deviated septum or getting frequent NT suctioning.
It stops the tongue from dropping in the back of the throat and creates a clear path.
My be used for someone who is not protecting their airway entirely, but is somewhat and they don’t necessarily require intubation
Non-Rebreather (NRB)
This will deliver the most amount of oxygen you can before you put them on a BiPAP / CPAP, or a ventilator.
Anything above a non-rebreather is called a non-invasive positive pressure ventilation – some form of pushing air into the lungs, not just throwing oxygen into the nose or mouth.
It delivers 100% pure oxygen at anything above 15 liters
It creates a pseudo-seal between the skin and the device.
If you don’t deliver the proper amount of oxygen, it will starve your patient of oxygen.
You need to deliver the proper amount of oxygen.
There is a bladder that is supposed to be full of oxygen. If that bladder or balloon is not full, you have not turned the oxygen up high enough.
Check the oxygen level in the balloon and make sure it is full before putting it on the patient’s face.
Crank it up until the dial can’t turn anymore, you will hear a deafening sound from the wall.
Leverage the knowledge of the respiratory therapist about how to use the devices. You can’t afford to use them wrong.
If you use either of these 2 therapies, they better have a chronic problem or you better have involved your providers. This is advanced.
Beards can cause sealing issues.
Putting the mask on too tight can cause pressure sores.
The alarm is really annoying if air is escaping.
They both create a seal between the patient and the mask. Air should not be escaping between the edges of the mask.
CPAP vs BiPAP
CPAP is continuous – Continuous Positive Airway Pressure. Same amount of pressure no matter what the patient is doing or not doing.
BiPAP – There are bilevels to it. Bi-level Positive Airway Pressure. You can titrate what goes in and what goes out.
Invasive Positive Pressure Ventilation
Also known as mechanical ventilation
Last resort
Direct line of communication between the patient and the oxygen delivery system.
A plastic tube in the trachea.
You have complete control of how much oxygen they are receiving.
Common mistakes new grads make:
If the monitor is alarming, look at the machine, is something not right? If you don’t know, grab a respiratory therapist.
Tubing could be touching the screen, Is there a kink in the tube? Did it pop off? Is the patient coughing?
Don’t just hit silence on the alarm, ask someone else. Investigate the cause of the alarm. Oxygen is a medication, treat it like that.
The Oxygen Saturation Monitor
It is not the end-all or do-all for respiratory status.
How to know that number is accurate:
View everything in respiratory the same way you view other things. Check the patient first, monitors second. There is always a malfunction or problem with monitors.
Rely on your assessment skills.
Look at the patient and their work of breathing.
How does the patient look? Are they in distress or completely comatose?
Pull the covers down and see how hard they are working to breathe.
Count respiratory rate, don’t just rely on the number on the screen.
Oxyhemoglobin Curve
Learned this in nursing school – may need to brush up!
PAO2 vs SPO2
Work of breathing
Oxygen sats are the last thing to go
If you are treating sat you are treating the last thing to go.
Respiratory Advice for New Grads
What all new grads should know about treating respiratory issues.
Rely on your physical assessment skills and basic nursing knowledge.
There isn’t one piece of equipment out there that will trump your gut and assessment skills.
If you feel in your gut like something is wrong, act on it.
Something as simple as sitting them up in bed could improve their sats by 10%.
Deep breathing and coughing (pulmonary toileting) – matters.
Do pulmonary toileting instead of spirometry
Don’t just leave the order for spirometry on your notes, it is actually exercise for the lungs. If they’re not doing it, it can’t be beneficial.
Educate patients on it and make sure they’re doing it
Your first year as a registered nurse is challenging.
This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills,
BSN RN CCRN and features experienced nurses from FreshRN.com, who
discuss the basics of that first year. From nursing orientation, code
blues, tricks of the trade, and personal experiences, to time
management, delegation, patient deaths, and more.
In this episode, we interview Michael Ackerman DNS RN APRN-BC and Tom Ahrens, PhD RN FAAN on sepsis, priorities for the new nurse, and current sepsis treatment trends and recommendations.
Basic Definition of Sepsis
Sepsis is the body’s response to an infection.
There has been no cure for sepsis. We have nothing for it, just supportive care.
The definition is very misleading, but we know it starts with an infection.
People don’t die from infection, they die from the body’s response to infection.
Once sepsis starts, we don’t know how to stop it.
We use the surge criteria to determine if sepsis has occurred and there is controversy if that is enough.
Cut on the leg from gym class, sent home with GI symptoms, died 4 days later
Trust your intuition. If you think it’s wrong, follow it up.
Use assessment skills of vital signs. If you suspect infection and vital signs are messed up, push it to the next level.
Draw cultures and labs before you start antibiotics.
If you are drawing cultures, draw a lactate and a procalcitonin level.
Listen to the patient or family member – are they acting differently?
You can’t afford to miss sepsis.
Look for things that could kill someone first. After you rule that out, then look for other hypotheses.
Sepsis Tips for Med Surge Nurses
The leading cause of death should be taught in nursing school
Sepsis is the leading cause of death
Graduating as a nurse and not knowing much about sepsis is scary
Do doctor’s know much about it? Family members bring up concerns and doctors explain it away.
Pay attention to low temperatures
It’s a sign their immune system isn’t working properly
It goes along with low white blood cell count too
“Anergy” – if they can’t illicit their own immune response, that’s troublesome.
First response to sepsis should be “does the patient have an advanced directive?”
This can get bad quickly, but is that what the patient wants?
What a Med Surge Nurse Should Look For Before Hypotension
Hypotension is late.
By the time we get hypotension, we are in the shock stage
A lot of clinicians recognize sepsis at this stage
The surge criteria can tell you a lot
Draw a lactate, see if it is healthy. It is simple, cheap, you usually can’t be fooled by a high one.
Ask for blood cultures
A Procalcitonin can be helpful with bacterial infections.
The evidence is increasing that it should be used more often.
It should be in the screening repertoire
If Patient is Already on Antibiotics
What if they are already on antibiotics?
If procalcitonin levels are drop by 80%, the antibiotics are working.
Get the procalcitonin levels regularly to check the efficacy of antibiotics.
Rapid Response Teams and Sepsis Rates
Do facilities that have rapid response teams of nurses that help evaluate patients increase the recognition of sepsis?
The data on that is unclear
Anecdotally, when sepsis became one of the rapid response calls, we did see more recognition of sepsis and more patients admitted to ICU.
The floor nurse needs help.
A rapid response nurse is typically someone that is a critical care nurse that has a pretty good grasp of most disease progressions that may be able to help you recognize or think through what is going on with your patient.
They are a wonderful resource to have and all nurses should use them if they have them.
Rapid Response Teams have their own protocols too to recognize and evaluate possible sepsis.
New ICU Nurse Tips for Sepsis
Brand new ICU nurse tips, for the times when a patient is in ICU with known sepsis.
CVP is not good as a measure for fluid resuscitation.
In heart surgery, you have to have a CVP to see pressure in the right side of the heart.
But to use it as an indicator of preload is just not right.
In the new guidelines, they eliminated CVP.
What Changed in the ICU with Sepsis
What has changed in ICU – back in 90s, didn’t have any real protocol. Then they moved to protocolized care with 6 hour and 9 hour bundle, and now they moved away from that again.
Criticism of the protocolized care was it doesn’t give the skilled clinician, intensivists, typically, the ability to modify the care based on the patient.
The new guidelines use the qSOFA score.
Derived from SOFA score
A European model used to assess the severity of illness and risk of mortality
It is 3 things: Change of mental status, respiratory rate greater than 22, drop in blood pressure.
The data says that this is a high predictor of mortality.
The problem is: it isn’t a screening tool.
They are still using fluid
It gives more discretion to the provider of how much fluid
They use blood cultures, cultures in general and antibiotics
Use more dynamic measures of fluid resuscitation
Echo
Ultrasound
Passive leg raise
Dr. Merrick’s New Study Causes Turmoil
Families see it on the news and they ask why you aren’t using vitamin C
It’s difficult to have an evidence-based conversation with a family desperate for using anything that could help.
That’s the family’s response – “but what’s the harm?”
It puts providers in a very difficult spot, when they have to defend why they aren’t going to use vitamin C.
There is no real benefit to deny it to a family member that is asking for it, the risk is low, but chances are it won’t work.
More Specific Studies About Sepsis Need to Happen
Precision Medicine Initiative – We treat everyone as if they have the same genotype and they don’t.
There is neonatal literature that is very clear out of Cincinnati Children’s Hospital
They draw blood on kids for years and try to genotypically identify which kids get septic, which ones survive sepsis, and which kids die
There is a difference in them genetically.
We know so little about sepsis. We throw everything we can at it, does anything work?
ICU Nurse with septic patient that won’t make it, how do you know when they won’t survive this?
It’s very difficult to tell
You have to take the patient’s history into consideration
90 year old from nursing home is different than 40 year old otherwise healthy man
If procalcitonin isn’t coming down by a lot, something is wrong.
If mixed venous oxyhemoglobin levels are going up, that’s a horrible sign.
It shows the cells aren’t using oxygen.
Tell family early on. Never surprise them.
Show them numbers. Show them the Fi02 numbers.
This number should be better in a couple days. If it still isn’t, they know it’s not getting better.
Talking to the family is a skill for nurses and providers that not everyone has.
Every ICU should have a nurse that is paid just to interface with the families.
Job title is ICU advocate
Let the family know they may hear different opinions from different specialized doctors (like the ICU doctor and the neurosurgeon).
90-Second Soapbox on Sepsis to the Brand New Nurse
You are going to see this almost every day, watch out for it.
You will find people develop sepsis that you don’t expect to have it.
The key is, it always starts with an infection, real or suspected.
Watch that person, make sure they are not getting worse.
Use advanced technologies like lactates and procalcitonins and doplars to assess the patient.
If the patient isn’t acting the way they normally are, something is wrong.
Trust your gut. Trust your assessment skills and use them.
Find your voice. You are the patient advocate. If you work at a place that doesn’t allow you to speak up, go someplace else.
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
Key Focus: As a new nurse, when do you know when it is it okay to trust your nursing judgment?
There comes a point at end of orientation, or right after, you have to trust your training, expertise, experience, clinical decision-making. This episode is based on Kati’s blog post; here we discuss our personal experiences related to the examples given by other nurses.
It’s normal to be nervous about trusting yourself.
Responsible for patients, by yourself, for the first time.
It’s just you; no one checking behind you at your charting or your patient care
Quote, #1: “When I was forced to rely on it.” – Micki P
Sometimes you may not be able to go to anyone else; you just have to do it.
Examples:
Patient with a poor neuro exam, and a non-functional ventriculostomy drain.
I was the only neuro nurse ijudgmentn the house.
Doctors knew the drain wasn’t functional; we were “just watching”
Only neuro change was one pupil getting larger.
Do I call? No one else for me to ask.
I did; I couldn’t live with myself if something happened.
Uh oh. “Mean” neurosurgeon on call.
A drain was replaced. I was complimented on making the right call!
Exciting! Good outcome!
Post-op patieant with a known history of Diabetes Insipidus (DI).
DI causes high levels of sodium in the blood.
Levels were already high, AM lab revealed it was somewhat higher.
Do I call? The surgeon is someone who notoriously doesn’t like to be called at night.
I did not call. I’ve been cursed at by him before, and the level was already high. He knew about it.
Bad Decision!
The surgeon was ANGRY when he came in.
Sodium was high enough, it could be life-threatening.
Fortunately, the patient received the necessary treatment and had no adverse outcome.
When trusting your judgment, you may be right, but you could also be wrong. Recognize that, and always err on the side of caution. It’s better to be safe than sorry.
When you think something is wrong, have some objective data.
Report what you see
Objective data is harder to discount.
Some things nurses think about when calling a provider:
Am I going to communicate the message the right way?
Am I gonna use the right words?
Is what I’m seeing really what’s wrong or going on?
With experience, you learn the words/verbiage to use.
It’s okay to say, “I’m concerned, I just can’t quite explain what’s going on, but this is what I see.”
You have knowledge! You passed your boards. You made it through nursing school. You know if something is not going the way it should.
If you’re wrong, you’re wrong.. at least you’ve taken the time to alert someone.
Quote, #2: “When my observations were confirmed with increasing frequency.” -Anastasia M
When noticing ‘x’… ‘x’ is right. I’m expecting ‘y’… and ‘y’ is right.
When you get this self-validation (the things you’re predicting come to fruition), it’s easier to trust yourself and your judgement.
Sometimes it doesn’t happen right away.
For example, You notice signs of early sepsis… You alert powers that be. Basic tests okay. But then later on… they are getting sicker and then full blown sepsis is identified. You were right!
Delayed validation will help you identify better questions to ask.
Was something done on day 2 or day 3 differently that, if we would have done on day 1, we would have caught it sooner?
Quote 3: “When co-workers started asking my thoughts and opinions (more experienced nurses). I felt like if they thought I was good enough, that what I thought mattered, I must be then.” -Jackie T
Experienced nurses should value the new nurse & their clinical judgement
When this occurs, it can have a powerful impact on the new nurse
This does not show weakness on the part of the experienced nurse, rather it helps to empower the newer nurse.
Helpful Hint: Always share positive feedback that you hear, regardless of the source, with other staff.
Both new and experienced nurses benefit from positive reinforcement.
Quote 4: “[Trusting your own judgement kicks in] when you can confidently teach others.” -Stephanie B
Validation occurs when you can educate a new nurse, or a patient, about a particular topic or disease process and have a good response.
For example: being able to teach about the difference between Type I and Type II Diabetes, and recognizing that you do have knowledge of the subject.
Solidifies trusting yourself.
You can experience this as a new grad, as well as an experienced nurse transitioning to a new specialty.
Precepting helps both the preceptor and preceptee keep up to date with the latest practice standards
Quote 5: “Time. As it went on and my gut continues to be right about patients, I trust it more and more. I value being able to ask more experienced nurses their opinion. But I’ve loved the strengthening feeling of “I got this!” With each shift and with each health issue I’ve caught that could’ve been missed (or had already been by others). I’m not perfect, but I do my best to also learn from my mistakes, which I also feel makes me a stronger nurse.” -Stephanie D
No magic switch that flips when you’re done with orientation, that tells you to trust yourself.
Time and consistency with:
Being able to teach others
Being ‘right’ more frequently
Others coming for you for advice.
Other thoughts:
What about asking others?
When asking questions, think about this: Are you seeking answers or validation? It’s a thin line.
This is a time when you are applying your textbook knowledge, and what things look like “in the real world”. They don’t always match perfectly.
What about experienced nurses?
They trust their judgment, but still, seek out others for counsel
Sometimes they are wrong too!
Keep up with continuing education!
Read research articles, especially as they apply to your specialty.
Validates your existing knowledge, but will also add more
This is a personal responsibility; no one will tell you that you have to
Things change in medicine and will impact your practice
Not all research will change your practice, but being aware of the topics of study will enable you to answer more thoughtful questions in your everyday practice.
Seeing that you are keeping up to date will also build your credibility with your co-workers and the providers with whom you work!
Here’s the takeaway!
The power of trusting your judgment can make a huge impact on a patient. The power of a nurse’s voice, and a group of nurses voices’, can save a patient’s life!
Speak Up! Do not be afraid. Even if you’re wrong, it would be worse if you didn’t speak up and the patient had a negative outcome.
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
Key Focus: Effective communication skills for interacting with the unconscious patient and their family.
Think about these:
How does caring for a patient who can communicate differ from one who cannot?
How do you talk to the patient?
How do you talk to the patient’s family?
How do you encourage the family interact with the patient?
What about consents? Healthcare power of attorney vs. next of kin
Patient Care
Assessments:
Recognize how your routine assessment differs between conscious and unconscious patient
Be Aware that eyes closed does NOT always mean the patient is unconscious
Always check to see if patient can follow commands
Commands may involve extremity movement (like showing thumbs up or wiggling toes), but also check for voluntary eye movement (like blinking eyes, or extra-occular movements).
Neuro Nugget: Locked-In Syndrome – A rare neurological syndrome involving complete paralysis of all voluntary muscle movement except for the muscles of the eyes. Occurs most often in patients with brain injury involving the pons.
Medications:
Remember pain medicine and sedatives can increase length of stay and risk of complications, such as delirium
Be Mindful of medication dosage; use the smallest effective dosage
Consider weaning sedating drugs, if possible (follow your hospital protocols or physician orders)
Professional Behavior:
We cannot predict and unconscious patient’s level of awareness, nor what they will remember following their illness.
Humanize their experience; do not simply perform a series of tasks.
ALWAYS talk directly to the patient during all interactions.
Interact with the patient like you would anyone else
Explain what you are going to do, before you do it (examples: turning, blood draws, mouth care)
Talking to the patients may reduce traumatic experiences/memories
DO NOT say anything or do anything around an unconscious patient that you would not do if they were awake.
For example, do not enter their room to complain about their family members or other staff.
Memories/Delirium:
Patients have reported various memories following a significant illness
Memories may be full, partial, or distorted. (For example, IV pump alarm may have been heard as a fire alarm they needed to escape).
Some report hearing conversations of people wanting to “give up”.
Some report remembering staff voices, but do not recognize faces.
May only remember traumatic experiences; have trouble reconciling their experiences vs. reality.
Patients who develop delirium have a higher long-term mortality rate.
Post-ICU Syndrome is actively being studied.
ICU Delirium can have prolonged and profound impacts on patients and their families.
Assure them that the patient may be able hear them, despite no clear indication from the patient.
Engage in regular conversation. Talk about the weather, what’s happening with other members of the family, special occasions coming up, etc. Anything the patient would normally participate prior to the illness.
Model this behavior, as the nurse.
Discourage family assessments.
Examinations should be done by medical personnel. Persistent attempts by the family to get patients to “follow commands” between nurse assessments can lead to patient fatigue, frustration, and possible refusal to participate in future exams.
Neuro Nugget: Prepare family for when, why, and how we apply noxious stimuli during the assessment of the unconscious patient. Watching us cause pain can cause distress for the family.
Offer guidance on establishing periods of rest.
Families have the best of intentions when trying to help care for the patient. Give suggestions on when/how much time to allow for periods of rest between assessments and during the night.
Engage their involvement, where possible.
Families want to participate. Give them a “job,” when appropriate. For example, teach them how to perform passive range of motion. Be sure to explain when, and for how long, it should be done.
Consents
Establishing who will provide consent for the incapacitated patient is essential.
Ideally, this will be done at admission, or as soon as possible.
Identifying this person(s) before there is an emergent need is ideal.
Case Management may be a resource, if assistance needed
Informed Consent Policy
Refer to your institutions policy for guidance
Be aware that the healthcare power of attorney (HCPOA) may override the Next-of-Kin.
HCPOA/Next-of-Kin does not override first person consent, if the patient is of sound mind.
HCPOA (Healthcare Power of Attorney)
Do not confuse with Durable Power of Attorney
Request copy of the legal document. Verbal confirmation is inadequate in court of law.
Electronic medical record may already contain a scanned image of the document.
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!
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
Hospitals don’t get reimbursed for infections that they give infections
Small minority of patients are at higher risk for CAUTI.
Be aware of patient’s factors.
Most CAUTI are preventable
Best prevention is not to have them
Changing mentality of why/when patients need catheters
Not using as frequently
More specific rationale for use
Not to be used for nurse convenience
Non-Invasive Urinary Output Methods
Males
Urinal – Be aware of challenges
Enlarged prostate
Positioning – some men need to sit or stand
Anatomical – consider use of female urinal (larger opening)
Condom Catheter – A condom that is applied externally, connected to a catheter bag
Use proper size
Needs a good seal for best prevention against leaks
Consider use of skin prep or benzoin to help with placement
Easy to pull off unintentionally.
Urostomy bags or fecal bag may be an alternative for some male genitalia
Females
Bedpan – Can be difficult to avoid spills
Bedside commode – Place next to bed for easier transfers for patients with limited mobility
Speci-Hats – Placed in toilet to capture urine, but sometimes difficult to put in perfect spot to avoid
misses
Female Urinals – Shaped differently, with larger opening, to fit against female genitalia
External Catheter for females – Purewick (https://youtu.be/xSOuvcShikw) catheter, lays against
the perineum and is connected to continuous suction
Need to use proper suction to assure that urine is pulled away from perineum, but not high
enough to cause tissue damage
Use for appropriate patients (not those who are constant wiggle worms)
Cannot be used during menses, nor for patients having frequent stools.
Universal Considerations
Diapers – Many facilities now avoid them
Can lead to skin breakdown, as moisture is captured against skin
Disposable Pads
Some weigh disposable pads (the pads patient’s lay on for repositioning) to calculate output
(like diapers in NICU)
Does your patient need to have accurate I/O?
Some patients can simply be assisted to the bathroom with no need for measurement
Although non-invasive methods may create more work for the nurse/nursing assistant, we must weigh
the risks associated with an indwelling catheter.
An indwelling urinary catheter, just by being there, is a risk of infection.
Urinary system is sterile. You are inserting a foreign device (which can easily be contaminated),
inside the body and all the way up into the bladder.
This is a direct line from the outside world to a sterile part of the body.
Normal flora found on skin can (or body excretions) can adhere to the catheter and find a route
into the bladder, even if insertion was perfectly sterile.
Diarrhea is particularly concerning with catheters, especially in females, because urethra is close to
the rectum.
Excellent peri-care is essential, use your hospital policy for guidance
Tips for Catheter Insertion
Universal Tips
Explain the procedure, using simple, plain language, before starting the insertion process.
What is a catheter?
Why is it needed?
What is involved for insertion?
Especially important for:
Young
Disabled
Language Barriers
Hx of sexual trauma
Remember: What is routine for us, is NOT to other people.
Start with excellent Hand Hygiene
Good peri-care prior to insertion
Use hospital approved cleanser
Be thorough
No fecal matter should be present
New sterile catheter following each unsuccessful insertion
Be mindful of how much urine is drained at once. Too much can lead to bladder spasms or
hemodynamic instability.
Know when it is appropriate to remove catheter. (MD order vs standing order)
Female Tips
Can be more difficult than males, because the urethral opening is so close to vaginal opening
Be sure that vaginal discharge, if present, is cleaned thoroughly prior to insertion
Use 2 person insertion technique
One person on each side, holding leg and helping to spread labia
Uretheral opening is not always clearly visible
Be generous with the betadine; a large quantity can “highlight” the urethral opening
Some women have the uretheral opening inside the vaginal opening; look closely
Women won’t know that about themselves
Explain to women that if you don’t get it on the first try, nothing is wrong with them.
Aim high
If you don’t get urine, leave the catheter in place
Marks the vaginal opening, and gives you a landmark on where to aim next time
Get a new sterile catheter for the next insertion attempt
Lay flat (maybe even a little trendelenburg), if not concerned about ICP issues.
Exam lights are helpful
Take your time in getting the patient and the catheter in ideal positions for insertion
Males
If meeting resistance during insertion, elevate the penis and point the tip toward the patient’s head
Do not be overly aggressive during insertion, as this may cause trauma
Leads to bleeding which can occlude urethra
Enlarged prostate
Consider coude catheter.
Has curved tip and is more rigid, curves past enlarged prostate easier
May require specific MD order
Hypospadias
Uretheral opening may appear to be in normal position, but there is no open pathway.
Actual uretheral opening is on the under side of the penis, and may appear as a slit.
Urology consult may be required, as they can use tools to dilate the urethral opening and assist with
insertion
Care of the Non-Circumcised Male
Peri care is important, regardless if applying an external or an indwelling urinary catheter
Retract foreskin and clean thoroughly. There can be a collection of discharge under the foreskin.
If applying an external catheter, condom cath should be placed over the penis with the foreskin in the
original position.
Return foreskin back into the original position after foley insertion.
If foreskin stays retracted, the penis will swell.
Can lead to the patient needing circumcision as an adult.
You may need to clarify with the patient (or family) if there is question whether patient has been
circumcised
Excellent hand hygiene & peri care prior to insertion
Regular and thorough peri-care (follow your hospital policy).
Use your hospital approved cleanser
Clean Stool immediately and thoroughly
Clean all the way from the foley insertion site to the rectum
For women, be sure to inspect vaginal canal for feces
Consider fecal management device for patients with indwelling catheters.
Can be internal or external
Be aware that internal FMS can have their own complications
There are contra-indications for using internal FMS
Use a catheter securing device. Excessive movement can lead to bladder spasms, and also
exposure to more skin tissue.
Secure devices should be placed in proper position
Urine should not flow uphill before draining into the bag
Leads to retrograde flow
No dependent loops, whether the close to the patient or closer to the bag.
Do not put foley bag into the bed with the patient
Foley should remain below bladder level at all times
Empty foley bag before traveling.
At a minimum of clamp foley during transport.
Remove catheter as soon as possible.
CBI – Continuous Bladder Irrigation
Uses 3 way foley
Larger catheter, to accommodate flow into and out of bladder, usually place by provider
Sterile fluid flows into the bladder and drains out catheter (mixed with urine).
Essential to track all fluid entering bladder
Subtract irrigant from total fluid output to calculate actual urine output.
Flow of irrigant can be adjusted based on how much blood (or blood clots) need to be cleared.
Can be needed following urinary trauma or surgery (anything that causes bleeding)
Usually requires an MD order to remove
In/Out Catheter (straight cath)
Catheter is inserted into bladder, urine is drained, and catheter is removed
Sterile procedure same as indwelling catheter
Be mindful of how much urine is drained at once.
Risk of infection is lower because catheter does not stay in place
Bladder Scan
Non-invasive ultrasound which calculates urine in the bladder
If a patient is not urinating bladder scan helps determine cause.
Does the patient need more fluids or are they retaining urine?
If a patient urinates frequently but in small amounts, the patient may not be fully emptying their
bladder. They may be retaining a large amount of urine
Urinary retention can be caused by many reasons, such as:
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
In this episode, we interview Karen Kesten, DNP APRN CCRN-K CCNS CNE who is currently the chair of the certification board of directors for the American Association of Critical Care Nurses (AACN). We talk about nursing certifications and why they are important to our profession, plus how to become certified.
Certification
A way to meet national standards in a specialty area
OB, mental health, med-surg, critical care, progressive care, dialysis, cardiac, etc. are just some examples
Essentially, you demonstrate that you meet this standard by practicing for a certain amount of hours (typically around 2 years full time at the bedside) and passing a rigorous exam
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
Top Tips for Cardiac Nurses. An Interview with Nurse Nacole
In this interview, we interviewed Nurse Nacole about tips for cardiac nurses. Nacole is a certified critical care nurse who is currently pursuing her Doctorate of Nursing Practice. Check out her website here.
A few important points
If you are a new grad that is not taking accountability for his or her learning and mistakes, it is a huge red flag.
If you want to learn more about something, you’ll have to do that at home – many times there isn’t enough time to do that while providing care at the same time
First things a new nurse should understand about cardiac
First focus on understanding the the anatomy of the heart
If something changed, it’s not your job to interpret the EKG perfectly on an instant – but know when something changes and get a 12-lead if you’ve got an order to do so
Many times there’s a standing order to get an 12-lead with telemetry changes
When to freak out/intervene?
When they’re symptomatic, even if the vitals are okay
Persistent issues like increasing runs PVC’s
Lung vs. cardiac
Use an ABG to differentiate
More Tips for Cardiac Nurses:
NRSNG also has quite a few great resources for nursing students and new nurses. There are various courses, or the entire academy. You can get access to Academy for 7 days for only $1! The specific courses that would give valuable tips for cardiac nurses include:
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
Elizabeth, Melissa, and Kati discuss some tips for nurses new to night shift. All three have worked night shift, and Elizabeth was working nights when this episode was recorded. This episode discusses very practical tips for learning how to live a night shiftnurse life from the perspective of current and former night shift nurses. We discuss eating and sleeping tips, to how to manage your nursing care on the night shift, communicating with the healthcare team at night, and more.
Pros to night shift
Make more money
Can get away with drinks at the nurse’s station – WATER 😉
Generally busiest part of the shift is the beginning
Time to read notes and look up things, figure out the plan of care
Not waking up at 0500
More time to process information as a new nurse
Food / staying awake at work during night shift
Kati’s “meal times” for night shift
2230 or 2300 – snack
0100 – lunch + coffee
0500 – second snack
May want smaller more frequent meals throughout the shift if one large meal will make you sleepier
Take a 15-minute break to eat lunch, and then nap for your 30-minute break
Exercise every hour for a few minutes (5 minute wall sits, 20 jumping jacks, lunges)
Sleep planning on night shift
Must be intentional; you can’t just sleep when you’re tired
The healthiest way to go about nights is to go to bed late (2-3 am) and get up around 10-11am, so they are still getting the necessarily total, but are awake during a good portion of each of the day and night
Flipping means going back to resting during the night, awake during the day
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
Code STEMI, Code Stroke, and Code Sepsis – Show Notes
In this episode, Elizabeth (former code-team nurse) takes the lead in discussing what’s important for new nurses to know about STEMI, stroke, and sepsis. We discuss nursing care and the big three – Code STEMI, Code Stroke, and Code Sepsis. Please note, this episode was recorded in January 2017, and the latest evidence at that time. The best practices surrounding treatment of these evolve continually and we encourage you to ensure you’re referring to the latest evidence and facility policy while providing patient care.
Various scales to measure signs/symptoms at different points of contact
NIHSS, FAST, Cincinnati Stroke Scale
Symptoms – a non-exhaustive list
Arm drift
Slurred speech
Facial droop
Blood sugar and vitals first – hypoglycemia can mimic stroke
Get nursing help! Rapid response, charge nurse, notify MD
Last known normal time is critical if you’re getting a history from the family/loved ones
Patient will need a CT – transport them yourself, do not wait for transport
Patient should be on a monitor with frequent vital
Neurologist/MD should be evaluating if the patient is a candidate for tPA and/or intervention (like a thrombectomy)
This is a really great resource from the American Stroke Association and American Heart Association, containing stroke treatment standard of care, tPA criteria, and information on mechanical thrombectomies
Very important to know blood pressure! May need to decrease it to qualify for tPA
If you’re not sure – get another set of experienced eyes on the patient, STAT!
More neuro resources
FreshRN Podcast episodes specifically related to neuro:
Overwhelming immune system response to a pathogen; unable to turn down the immune system and organs are not appropriately perfused and therefore you have end-organ damage
Recognition, timing, essential
Easily overlooked
Communicate concerns to MD, bring another set of eyes in if you’re not sure
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!
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
Dealing With a Negative Nursing Unit Culture, Nurse Bullies, and Confrontation – Show Notes
Working on nursing units can be amazingly rewarding with great teamwork, but can also be really challenging if you don’t fit right in or if you encounter a Negative Unit Culture, Nurse Bullies or more. This episode discusses how to deal with a negative unit culture, the importance of emotional intelligence, self-inventory, how to respond to nurse bullies, and confrontation. We talk empathy, sympathy, and more.
Observe the culture of the unit
Try to feel out the people who are negative
Observe what they’re passionate about and care about a lot (both negative and not)
Pay attention to the informal leaders – what are they like as a person?
Mental self-inventory
How do you communicate when things may not be right?
Mental self-inventory
How do you receive correction?
Identify the feelings you may be experiencing, give the feelings a name (hurt, insecure, frustrated, scared, whatever), and try to step outside of them and observe the situation. Don’t make decisions or act out of emotions
Emotional intelligence – takes time (link to emotional intelligence book)
You can’t control the behaviors of others, but you can control yourself and how you respond to their emotions and your own
Empathize
Empathize with one another, not just your patients
Dr. Brene Brown’s 2:53 minute explanation of empathy vs. sympathy
Be silent when people are being negative/gossip – soon it’s not going to be fun to talk to you about negative stuff
If you’re truly concerned about a new grad or another employee, bring it straight to the person directly or to the higher up (for example, a manager) rather than talking about them with others
Counteracting negative points with positive ones
Casually say, “Man, I wonder what people say about me when I’m not here…”
Get to know negative people, and learn things about them that are not negative and engage in those topics with them
This takes time, but is worth it
Negative people / bullies may not realize that is how they are perceived
Be unapologetic about being positive – don’t feel like you need to be a rain cloud to fit in
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
Tips for New Grad Nurses on Resumes, Applications, and Interviews
Show Notes
This episode covers the essential aspects of landing a job and gives practical tips for new grad nurse on resumes, applications, and interviews. All three of the hosts have experience interviewing new graduates and we give you our insider tips on the process.
Resumes
Perfect, no typographical errors
Don’t put all of your clinical experience
Put things that are relevant to this job
Put people other than your clinical instructors; nurses on the unit, MD’s, manager
Get a team of cheerleaders – people who will vouch for you
Networking begins in nursing school
Make a good impression EVERYWHERE
Don’t think only clinical people can write resumes
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
Contrary to popular belief, nurses as not perfect. Nurses make mistakes. In this episode, we discuss the mistakes we’ll never forget, as well as a few others. We also discuss some tips on how to deal with mistakes as a new nurse.
“The potential for harm in the absence of diligence is profound” – Kati Kleber
Respect the fact that you can make an error at any turn – do not take this lightly
Stay up to date on policy – be familiar with them for yourself
Policies change and it is your responsibility to be aware of these
Know your tasks
It’s your responsibility to know the safest way to do the tasks you need to complete
Be assertive when you need to focus
This may need to be done when passing meds, adjusting IV pumps, adjusting monitors, or assessing patients
Talking point: “I would love to finish this convo – if you could give me just a few minutes to focus on (blank; these medications/programming this pump/programming this monitor) then let’s chat.”
Safety is always the priority
Be unapologetic about patient to safety to everyone
From physicians to fellow nurses to patients and families
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
CORRECTION – in the episode we refer to something called substance abuse disorder. The appropriate term is substance use disorder.
This episode covers the important difference between pain management and pain elimination, patient education, appropriate assessment, a proactive approach to pain management versus reactive, and some essential definitions.
Striking the balance between too much pain medicine and not enough can be tough for any nurse, let alone a brand new nurse. What throws a big wrench in everything is the fact that we, as a nation, are experiencing a very real and very devastating epidemic of opioid use and abuse. Bedside nurses feel the brunt of this due to many patients requesting sometimes very concerning amounts of intravenous pain medications at alarming intervals. Here are some tips from bedside nurses about pain management.
A few helpful links diving deeper into the opioid epidemic
Always tell patients that a 10 on the 1-10 scale is burning alive/mauled by a bear/so engrossed with pain that you cannot communicate
Some think the pain management that occurs in the PACU continues on the floor (frequent assessments and IV pain med administration), but it does not and many are not aware
Special scenarios – like neuro, where we can’t overmedicate due to its impact on the patient assessment
Always think about transitions – IV to PO, weaning off PO
Ensure the patient knows what “pain meds” means and that it
Many don’t know which specific pain meds to request if multiple kinds are ordered (for example, when IV morphine and PO norco are both ordered and the patient requests “pain meds,” don’t just give whatever the last nurse gave – have a conversation about the specific medication to be given)
Balance between comfort and overmedicate and unable to participate in care
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
In this episode we discuss characteristics of the intensive care nurse, normal expectations, critical thinking, advocacy, communication, and more. We dive into 8 tips for new grads in the ICU! This episode is hosted by 3 CCRN nurses, which is a critical care specialty certification granted by the American Association of Critical Care Nurses.
8 Tips for New Grads in the ICU
#1 Come in with an open and actively engaged mind
Expect to be overwhelmed for awhile (at least 6 months)
Fight the “I want to be perfect” mentality; while it’s admirable, it’s not possible – setting yourself for more stress and disappointment with that expectation
Nursing is a practice – you’re never going to be at a point where you don’t make mistakes or be perfect. There is an art to this. The skills in nursing school aren’t the only ones you’ll need.
#2 Be aware of typical ICU nurse characteristics
Assertive, direct, business-like attitudes, detailed-oriented, anticipating things ahead of time, know protocols inside and out, intense, autonomous (very familiar with protocols, able to enact orders/protocols independently and then discuss with MD).
You are still bringing something to the table, it’s just different than what the others who bring to the table who are already there.
#3 Show initiative
You’ll have to be assertive yourself – go home to learn and understand more
Invest time into making yourself better in the off time
Round with MDs, seeking out learning opportunities
Introduce yourself to others
#4 – Know yourself and be your own advocate
Know your learning style and communicate this to your preceptor
Know your limits / what you don’t know so you can fill in the gaps
Please don’t be the new grad know-it-all
Find the balance between not knowing anything and being so obvious about that people question your ability to be a safe care provider, and being the know it all who continually acts like they do not need to be educated
Find a mentor!
# 5 – Own your orientation
Orientation is truly an extension of nursing school without formal grading
Ask for help when you need it – sometimes your preceptor cannot always pick up on times when things aren’t clicking
Advocate for yourself!
Work through the process of orientation; it’s a marathon and not a sprint
#6 – Keep an organized routine throughout your shift
Have a systematic routine way of assessments, your day, meds, etc. otherwise you will miss somethings
This helps get through the shift and not miss things.
Stop and get organized first before starting your shift so you start on a good note.
NRSNG also has quite a few great resources for nursing students and new nurses. There are various courses, or the entire academy. You can even get a 7 day trial of academy for only $1! The specific courses that would be valuable to the new ICU RN in particular include:
Learn both hard and soft skills about ICU nursing care. From vasopressors to emotional support, this comprehensive ICU skills workshop covers topics applicable to every nurse working in critical care, as well as those sending patients to, or receiving patients from, intensive care.
Neuro ICU Nurse Tips for Newbies, Part 3: Meds, Diagnostics, Monitoring, and Surgeries
Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, documentation for nurses, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
We continue our journey through neurocritical care nursing with more neuro nurse tips for newbies!
This episode discusses some important meds (mannitol, hypertonic saline), different kinds of monitoring (ICP), diagnostics (CTA, MRI), and surgeries (craniotomies) that are pertinent to the neuro nurse. This episode is hosted by three neurocritical care nurses.
Mannitol – osmotic diuretic, given to decrease ICP
Increasing the plasma osmolality to pull fluid off of the brain, into the intravascular space, and out of the bed
The cells actually shrinks because they were “swollen” – this “shrinks” them back down to their normal size
You’re increasing cardiac output; increasing urine output
If the serum osmo is too high, you can have cellular death because they’re shrinking too much which can ultimately cause more edema… there’s an inflammatory process that occurs when cells die
Normal serum osmo 275-285 (may differ between, typically holding if it gets to 320
Watch for kidney issues – intrarenal vasoconstriction can occur
Know sodium and how quickly it trends up; we expect it to rise but we don’t want a sudden drastic increase – you may have a holding parameter for the sodium as well
Give it through a filter set or draw it up with a filter needle – hurts like hell if you don’t
I would draw up with a blunt needle and give with a filter set because it’s faster
Whatever you do – FILTER it
Mannitol crystallizes and can get cloudy; don’t give it if it’s cloudy/crystallized
Places now give 23% hypertonic saline; physician must administer
Monitor labs and hemodynamics closely
If you’re drawing labs on a patient receiving a continuous infusing – PAUSE THE DRIP before drawing labs and draw them from a different lumen if possible.
This can significantly impact the lab result and is easily overlooked
Vasoactive drips
Nicardipine, Norepinephrine, Neosynephrine are some examples
KNOW THESE if you’re working in a neurocritical care unit
Consider the disease process when giving PRN BP meds
For example, if the patient has a hemorrhagic stroke and needs consistently blood pressure control, a Nicardipine drip at a low dose would offer more consistent/level blood pressure than intermittent dosing of a PRN IV push med (like 20 mg Hydralazine) when the BP spikes again
If a patient is hemodynamically unstable and requiring vasoactive med, get a central line sooner than later
If your patient is on a drip to keep their blood pressure UP, do not give their scheduled antihypertensive medications (if any). Clarify holding parameters or temporarily hold them (after clarifying with the physician) while the patient is on the medication to increase the blood pressure.
Double check drips, dosings, titrating, why, and wean
Consider other meds the patient is getting while vasoactive meds are getting and the impact they may have on the blood pressure medication
For example, many antiepileptics will lower blood pressure
Antiplatelets / anticoagulants
Typically many patients with a hemorrhagic stroke are on a blood thinner
Know if they’re on any; when it was last taken and the dose
Reversal agents
Examples: Fresh frozen plasma (FFP), Kcentra, vitamin K
Educate family on why it’s being reversed; this can be especially challenging when they’ve been told by their physician for years how important their blood thinner is and now they’re not getting it
If you have a mechanical valve who had a hemorrhagic stroke, they will be taken off their blood thinner – you must recognize the big risks with this
Cardiology and neurology will be working together to figure out what’s best because they’re stuck between a rock and a hard place (risk another hemorrhagic stroke, or risk a ischemic stroke or pulmonary embolism due to the mechanical valve)
Antiepileptics
Know your indications
If you have Lorazepam ordered for seizures, do not give it for agitation. Call and get another order
Families think that an EEG will tell you very detailed aspects of brain function (what they can/cannot understand, if they can hear and understand what’s going on around them, etc.)
It shows the electrical activity, not structure
Think of it like an ECG shows the electrical activity of the heart and an echocardiogram shows the structural components while an EEG shows the electrical activity of the brain and a CT/MRI shows the structures
Continuous versus spot EEG
Just because you
Don’t document if you see the patient having a seizure; you can’t say definitively say someone is having a seizure without the EEG to confirm it
Chart “rhythmic twitching” or whatever it is that you see
The children’s book we talked about, written by a nurse, to explain to his kid what he does working as a nurse: Daddy, the Amazing Nurse! By Donald Jacobsen, RN
Brain death testing
EEG, apnea testing, cold caloric testing
Surgeries/Procedures
Thrombectomy
Neurovascular procedure; similar to a heart cath but in the brain
Catheter placed through femoral artery up to the brain, administer contrast, so they can identify the clot and remove it to open up a blocked artery in the brain
Only done for large vessels – so think any artery in the Circle of Willis
This is done when there is clear indication for it because it is an invasive procedure with very real risks; most patients have had a CTA first
Please note, this shows only 1 device and was published in 2013. He states that they use tPA or this procedure. Now, both can be done to the same patient to perfuse the brain.
Remember your post-procedure care; similar to a patient who just had a cardiac cath with a femoral approach (lay flat for 6 hours, pressure and monitoring insertion site, watch for a hematoma/retroperitoneal bleeds)
Craniotomy
Removing part of the skull to get to the brain to do something (remove a tumor, clip an aneurysm, remove a hematoma, and many more reasons)
Typically incision pain not necessarily all up in my brain pain – not as many pain receptors in the brain so it’s not as painful as other surgeries
Craniectomy
Removing part of the skull and leaving it off to allow room for edema
Can be stored in a freezer or in the patient’s abdominal cavity
Drains via gravity, so it must be leveled correctly
Similar to an arterial line
Anatomical landmark – foramen of Monro
Tragus or lateral canthus
MUST follow precisely – a change of head of bed can fatal
Educate families and other healthcare team members not to move the head of bed without checking with the nurse
Can be hooked up to ICP monitoring
Monitoring
ICP monitoring
7-15 mmHg = normal
20+ mmHg = uhhh… you need to do something
Can be done with an EVD or a bold
Cerebral perfusion pressure (CPP)
MAP-ICP = CPP
Basically, the blood pressure of the brain
You want to maintain CPP, even in the event of increased intracranial pressure because you want to ensure the brain is getting the blood flow it requires otherwise additional damage/compromise can occur
60-70 typically good
50 or less, you are going to have brain issue because the brain is not being adequately perfused with blood
Just because the CPP is high doesn’t mean it’s great either
May have other issues like ARDS
It’s a balancing act
Body temp
This is so important guys!
For every degree of increase in body temp, the increase in oxygen demand increases 10%
Aggressively treat fevers
Know your orders!
Neuro changes can occur with increased body temp
If you’ve got neuro changes, check a body temp to see if it’s increased. This could explain your neuro changes.
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!
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