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.
What Nursing Teamwork Practically Looks Like At the Bedside
Welcome to Season 4 of the FreshRN Podcast. Nursing Teamwork is one of those buzzwords, but what does it practically look like during elbow-to-elbow nursing care? In this episode, we chat tips, what good teamwork feels and looks like, and how to be a good team member, and more.
Nursing Teamwork
This is what good teamwork looks like for the in-patient nurse:
Teamwork can be challenging for new nurses
You are nervous, trying to do all your tasks right, so you kind of get a “silo mentality”
Teamwork is looking at the unit as a whole instead of your role individually.
If you have a light assignment you should take a proactive approach and help your fellow nurses who don’t
The best teamwork is someone that knows what a fellow nurse needs without them having to say it.
Think about what kind of picture cohesive teamwork paints for the patient and their family.
Teamwork in admissions
Admissions are a standard process
The team can come in and delegate to each other
One does blood sugar, one does blood pressure, etc
The challenge occurs when one nurse is very busy and attempting to predict their needs
Look on that patient’s chart and see if there are tasks that you can help with.
Use the Red-Yellow-Green Method to distinguish who needs help most and who can give help.
Red – super busy, I need help the most
Yellow – moderately busy
Green – not very busy, available to help others
Personalities in Teamwork
Everyone on a team has different strengths and weaknesses. Being aware of that can help everyone work better together.
Leverage people’s strengths
If there are things some people aren’t as strong at, ask someone that is better at it to help you.
Manage expectations. Don’t expect someone that is super relaxed to be acutely aware of the unexpressed needs of those around them
Use direct communication with them.
Be direct and ask.
Some people don’t know how to delegate, so suggest ways you can help them.
“Can I grab a blood sugar for you?”
“Do you need me to draw some labs?”
“What meds can I pass for you so that you can catch up on charting?”
Learn non-verbal behaviors that nurses exhibit so you can know when to help them.
Fast-paced walk
Shorter sentences
Facial Cues
Learn how to ask for help
Don’t get your feelings hurt thinking “why isn’t anyone helping me?” if you haven’t asked anyone for help yet.
Sometimes some people don’t look like they need help, so it’s tough to read their mind.
Reach out and verbalize your need for help when you have it.
How to Learn Personalities
Learning more about the personalities of your fellow nurses will help you all work better together as a team.
How to learn about personalities:
Watch your mentor – how did they do it?
Have conversations with people that aren’t about work.
Ask about their kids or what they are doing next weekend.
Make an effort on your own part to look around.
Is there an alarm going off? If so, how can you help with it?
The Problem With Delegating
Even experienced nurses have trouble delegating tasks to other nurses around them.
Reasons delegating isn’t easy:
The nurse might be a control freak.
Has a certain way he/she likes things done
Trouble trusting new nurses
Not sure if the new nurse has the experience to do the task correctly.
How to Help The Most
When you are working as a team, there are things you can do to help everyone out when they need it.
Anticipate upcoming tasks and offer to help and do them.
When you are helping, do your tasks correctly and thoroughly.
Don’t make the person you are helping have to redo your work, this will stress them out and hurt their trust in you.
Don’t just do the tasks, but document that they were done.
Earn that person’s trust.
Demonstrate that you are going to follow through on things and do them appropriately.
Experienced nurses have a responsibility to:
Demonstrate what teamwork looks like
Check in with new nurses and see what help they need.
Ask new nurses questions you know the answer to. This will build confidence in the new nurse and help foster communication.
Check in with fellow nurses throughout the shift
How to Work With People That Aren’t Team Players
How do you work with people that aren’t team players, and maintain a positive attitude for the rest of the group?
Keep nagging them, ask them direct questions
If they refuse to work as a team, take it up the chain of command.
Notify leadership about this unhelpful trend.
Talk to them directly. Let them know how their behavior is affecting the team.
Support them and let them know how they can grow.
Colleagues have to hold them accountable. Keep asking for help.
Ask for reinforcement – not discipline – from leadership
How to Succeed at Teamwork
This is what excellent teamwork looks like on the nursing floor.
Be proactive. Think about everyone around you and how you can help the entire unit.
Know your limits. Don’t agree to watch more patients if you are already way too busy.
Don’t be a silo. It isn’t only about you getting your tasks done. All the nurses on the shift should help each other with all the patients together.
Help each other out. If a call light is on and you are available, answer it even if it isn’t your patient.
It takes time. Give yourself time to learn more about your team.
Get to know personalities. Learn how they think and how to work better with them.
If everyone is helping each other out, everyone will have a fantastic shift where no one feels alone.
More Resources on Nursing Teamwork:
You can download Show notes for this episode here.
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 4 of the FreshRN Podcast. Join us as we discuss some tips for floating to another unit. We cover how to start out your shift with success in a different environment, questions to ask, how to manage your nerves, and more.
Floating As A Nurse
What is floating?
You come to work on your unit, and there are not enough patients to justify that amount of nurses. Another unit might not have enough nurses, so they share the wealth.
How do they pick who floats?
Typically, you take turns.
PRN staff may be the first ones to float, depending on policy
Normally you will stay within your current service line.
So a labor and delivery nurse might not go to neuro ICU
If you are put somewhere that is totally foreign to you, you have the right to speak up and say “I don’t feel comfortable because I don’t understand this role very well.”
Communicate your anxieties: What about floating is making you nervous?
Patient population
Not knowing where things are
No knowledge about how to do tasks on this floor
Not knowing how to find a medication
How to treat people floating to your unit:
With a welcoming attitude
Be grateful
Say “thank you” to them
Check in on them and help them find things
Nurse Floating Tips
What to do when you are assigned as a floating nurse.
Go with a positive attitude
If you are a new nurse, you shouldn’t have to float until 6 months after orientation
If you feel uneasy or unsure, communicate it and try to help out as much as you can.
At the beginning of the shift, get a tour and find someone to be your support
After the tour find a friendly face and ask them, “hey can you be my go-to person?”
You will need the support of someone experienced to rely on when you feel overwhelmed and don’t know where things are.
Speak up and ask a lot of questions
Reiterate to your lead nurse any questions you have.
You can’t just have your head down and check the tasks off.
Example: what’s normal and good for a neuro patient isn’t always normal and good for a cardiac patient.
Ask what is normal for that unit, it might be different than what is normal in your unit.
Check your orders
You are working with patients you aren’t used to working with at a different part in their stay.
There should be “notify MD” parameters
Ask questions but always go to the chart and pay extra close attention.
Speak Up
If you aren’t getting help from the unit that you are floating to, notify your nursing supervisor.
You’ll have to give specific information, but let people know if you aren’t getting the right support.
Give yourself some credit
Have faith in yourself
You are a good nurse, or you wouldn’t be out of orientation
Always trust your gut.
Use it as a learning experience
Take this as a chance to learn something new
You never know when you are going to pick up something new that might help you with your home unit.
Be the Change You Want to See
Make floating a positive experience for yourself and others.
Have a positive attitude when you float.
When you have a floating nurse in your unit, be kind and supportive.
If you are making assignments to floating nurses, don’t give them bad assignments.
If you are floating and discover you have downtime, offer to help the other nurses that are feeling frantic or too busy.
More Resources on Floating to another Unit:
You can download Show notes for this episode here.
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.
When the patient is donating their organs, there are a lot of things that are now the responsibility of the nurse. In this episode, we discuss what it practically looks like to prepare a patient for organ procurement and some of the variations of the process, as well as our own experiences.
Organ Procurement
What is organ procurement?
Done in critical care
It is procuring organs from someone who has passed away and giving them to people who need them.
Don’t say harvesting – say procuring.
Organ Procurement Organizations
Organ Procurement Organizations are also called OPOs.
What the OPO’s job includes:
After they get a referral about a patient, they will delve into the patient’s chart.
They do not talk to the patient’s family
They look to see which organs could potentially be donated.
What affects the types of organs that can be donated:
Lab work
Past medical history
Age
Comorbidities
Trauma
More and more!
Reasons you don’t bring this up with telling the family
Bringing up organ donation is not the responsibility of the nurse! Do not do this! If the family asks you about it first, you can field questions. However, do not ask them ever. This is out of our scope.
The referral is made to the OPO to pre-screen the individual to see if the patient would even be eligible to donate IF they wanted to – many things can make it so someone can’t donate. This pre-screening prevents unnecessary emotional conversations. If the patient is not able to donate due to labs/other diseases/trauma/etc. then there’s no need to chat about this.
Remember, organ procurement is an ethically-sensitive situation
If you’re not sure if you can say something – exercise caution and don’t say it, chat with your OPO rep who you’ve talked to first
In many cases, tissue and eye donation can be done (at the funeral home) if organs cannot be donated. Again, this is out of the nurse’s scope to decide this.
Your job is to notify the OPO when triggers are met (which are listed below), and follow their instructions. That’s it. Don’t take it upon yourself to have conversations about donation with the family.
Legally you cannot deny a patient or their family the opportunity to donate their organs.
Know your facility’s policies in regards to how and when to notify OPOs.
When to call OPOs
GCS less than 5
Glasgow Coma Scale – the level of unresponsiveness
Made up of the eye, verbal and motor response
Imminent death
The family is wanting to withdraw life support
What Happens After Death is Imminent and OPOs are Notified
What happens after all tests prove the patient is declared brain dead and OPOs have been following?
First, gain consent.
Types of Consent
First Person Consent – varies by state. If you state on your driver’s license that you are an organ donor, you already gave your consent. You can also carry a donor card.
Next of Kin Consent – the health care power of attorney or next of kin
Donor Card
After death is declared, a nurse’s documentation changes.
No longer about saving the patient’s life.
Focus changes to maintain organ perfusion.
We have gone from life support to organ support.
The ventilator is supporting the organs, not the person.
Next, do lots and lots of lab work.
Central line placement
Arterial line placement
Why do the labs?
Tissue Markers
Blood Type
They all have to be sent out to see who may be a match
Anticipate issues
When patients are in the process of being declared brain dead they are in a state of hypotension.
Give them medications to throw them into a thyroid storm to get them off suppressors and raise their blood pressure.
There is a long list of medications we give from the beginning throughout the entire procurement process.
The moment the patient is declared brain dead care is dictated by the OPO.
This is typically listed on the death certificate
Types of tests that might be run:
Blood work
Echo
Cath lab
Bronchoscopy
Neurogenic pulmonary edema
What Happens If A Patient Codes
We know what happens if a patient is declared brain dead, but what happens if a person codes?
If the heart stops, do chest compressions on the way to the OR.
They go to the OR to do the organ procurement immediately.
Kinds of Tests They Do for Various Organs
What are some of the different tests they run for different organs?
Heart
Echo
Lungs
Cath Lab
O2 Challenge
ABGs
Bronchoscopy
Liver
Lab work
Ultrasounds of the liver
Ultrasound-guided biopsy
Kidneys
Lab Work
INO – fluid amount
Ultrasounds
Actual inspection of the organs by the transplant team is incredibly important.
Malignancy or other issues can hide and only be seen when the organs are inspected visually.
How to Prepare the Family if You Think the Patient is Brain Dead
If you think the patient is brain dead and there will be tests to verify, the family should be prepared.
Don’t use the term “brain dead.” Use the phrase “I think the brain is no longer functioning” a lot.
Brain death is scary.
Talk to them about the reflexes that aren’t happening.
Always say, “I’m really concerned about your loved one. I’d really like to see more movement when I’m doing these things.”
DCD – Donation After Cardiac Death
What is it and how is it managed differently?
Donation After Cardiac Death (DCD):
Persistent Vegetative State – Patient is not brain dead
There is an age limit – 55 years old or younger
You need to let them pass first
There are only certain organs that can be donated
Most organs aren’t being profused correctly in this case
Know the difference between cardiac death and brain death.
They have a time limit of one hour to pass before organs are no longer usable.
After the heart stopped, they have to be taken immediately to the OR (if they’re not already in the OR) and organs are procured.
More Resources on Organ Procurement:
You can download Show notes for this episode here.
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.
Nursing Considerations with Brain Death and Organ Procurement
Welcome to Season 4 of the FreshRN Podcast. We discuss the difference between coma and brain death, how brain death is determined, working with an organ procurement team, and general insights related to this sensitive topic.
Organ Procurement
What is brain death and how do you respond to it?
Look for these triggers that will suggest when to call the organ procurement team:
GCS Less Than 5
On a ventilator
Major neurological injury
Plans to withdraw life support
You cannot deny a patient or family member the chance to donate their organs.
It’s not up to you as a nurse to decide if their injuries make them a candidate for donation.
You have to go through the appropriate channels
If you don’t allow the family this chance, there could be lawsuits and major fines to your facility.
Brain Death
What is brain death?
Brain Death Definition: According to the National Institute of Health, brain death is “the irreversible loss of all functions of the brain including the brain stem.”
The term coma is vague and not useful anymore.
When someone dies there are 2 routes by which they can be pronounced dead:
Death by neurological criteria
Death by cardiac criteria
It can be tough for family members to see the blood pressure still working and the heart still beating and understand that they are technically dead – brain dead.
It may take a while, but if the brain is dead, eventually the heart will stop beating.
How to Determine That a Patient is Brain Dead
Now that we know what brain death is, how do we know a patient is brain dead?
Normalize everything else before doing brain death tests
MAP above 65
Systolic blood pressure above 90
Normothermic – core temperature above 97 degrees F
Must have a normal ADG
Neuro Exam Consists Of:
Check their pupils
Do a cold caloric – or oculovestibular reflex
Ice water injected into the ear canal
Inject about 50ccs of ice water into the ear and look for eye movement. It could take up to a minute
Check both sides, but wait 5 minutes to do both sides
A nurse cannot do this, it has to be done by a provider.
Corneal – touch the cornea to see if they react at all
Check gag reflex
Cough reflex
Put the suction all the way down with the ventilator and hold it and see if they cough.
See if they respond at all to pain.
Do appropriate painful stimuli, such as track pinch, supraorbital pressure, nail bed pressure.
Be careful with the extremities, you can have spinal reflexes and still have brain death.
Oculocephalic
Doll’s eyes test. You move their head (if they do not have a neck injury) and see if their eyes move.
Fairly briskly turn their head to the side.
You have to be able to see their eyes.
Be careful with the breathing tube.
Look at their eyes. Do their eyes stay forward? Like midline meaning, they don’t move. That’s a negative doll’s eyes.
If you turn their head to the left, their eyes should fall to the right.
You have to turn the head both ways in case there was a stroke or something preventing one side from moving.
There is absolutely no medication or sedation that can be happening during the brain death test.
What Happens Next
After verifying there are no reflexes at all and made sure there is nothing else contributing to that, what happens next?
Apnea Test
Can be done with family in the room. Prepare them for what they might see.
The patient is on a ventilator, so verify that they have good oxygen levels. Their CO2 levels should be normal as well.
During the test, you put oxygen down the tracheal tube.
Disconnect the ventilator and put a suction catheter down the tracheal tube that is connected to oxygen. They continue to get this oxygen throughout the exam.
What we are looking for is the patient to breathe within 6-8 minutes.
If they aren’t breathing, the carbon dioxide level will rise in the blood.
Look for a chest rise – put your hand on their test so you don’t miss a subtle movement.
If there wasn’t a breath in 8 minutes, the respiratory therapist will draw blood and check CO2 levels and they go back in the ventilator.
What you’re looking for:
A rise of at least 22 mg of CO2. So if my CO2 levels were 38 then my new CO2 (after the patient didn’t breath) levels should be 58.
If there is a rise of CO2 and they didn’t take a breath, that would be considered confirmation of brain death.
If the test is inconclusive, the physician has a few options:
Try again later
Start looking for other types of testing to do.
Other Supportive Tests for Brain Death
Not all facilities follow the apnea test. So what other tests are used?
Confirmatory Tests or Supportive Tests
These confirm blood flow to the brain.
MRA – blood flow to the brain as seen on an MRI
CTA – blood flow to the brain as seen in a CT Scan
Traditional Cerebral Angiography – where they go in through the groin like a heart cath
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.
How to Deal with Family Members (Who Are Not Mad At You)
So, how do you deal with the family members… like, normally? How do you meet their expectations and work together as a team? We discuss routine communication points with typical family members who are engaged and want to be part of a patient’s care, and how you as a fresh RN can speak to them with confidence.
How To Be A Leader
“You are a leader and you should not have to wait to be spoken to when you enter a room.”
What does this quote mean?
When you walk into the room and acknowledge the family, it gives you and them a sense of confidence.
A simple “good morning” can make a difference to the family. They feel included and they don’t have to fight to feel included.
Family members that don’t feel included are put on the defensive, and begin to judge everything negatively.
Try to avoid and prevent that “us vs them” mentality.
Don’t make appear like all you care about is the labs and medications.
Actively including them with confidence, includes them in the “team” of their family member’s care.
It might be difficult to sound confident when you are learning and in training, but be upfront with them and tell them you are learning.
A lot of people will give you grace under those circumstances.
Family members are a wealth of background knowledge about the patient, so we have to present ourselves and engage with them in a way that says “you are helping us out.”
Make them feel like a valued part of the health care team.
It’s up to us as nurses to pull them in and give them permission to be included.
Proactive Education
After greeting the family, now what do you say?
Take the initiative to say, “this is what is going to happen today and this is how.”
Proactively educating can pull down anxiety slightly.
There are lots of studies coming out about protocols with keeping families included and reducing stress.
Give them a recap of the past 12 hours
Then say “tentatively this is what we have going on for the day, things may change.”
Ask them “what kinds of questions do you have?” Avoid yes or no questions.
Proactively educate them about:
Alarms – a lot of them are non-actionable, but to the family members those alarms could be terrifying.
How to educate families about alarms:
Compare it to things in the house. Like hearing the dryer go off. Not every alarm means you have to come running.
Alarm fatigue – they have to be loud, we have to be able to hear them all over the unit.
Have confidence and reassurance.
How to React to Family Members That Are Current or Past Nurses
Family members that are current or past nurses might be more scrutinizing than non-medical family members.
Remember – just because they are a nurse in one field, does not make them an expert in your specialty.
Acknowledging their background is important.
Try to say, “I don’t mean to mean to sound insulting, but I want to make sure I’m coming across clearly, both to you and anyone else in the room that isn’t medical.”
Let them guide the conversation. Let them ask specific questions.
Just because they say they have a medical background, don’t assume they know what is going on in this exact situation. Ask questions.
If you don’t know something, don’t fake it. Ask someone that does know.
It’s ok to say confidently, “I’m not sure, I’m going to find out that answer for you.”
It’s not about your ego, it’s about the patient.
These family members feel like they have no sense of control in these vulnerable situations. Give them some sense of control.
Tell them how to comfort their family member.
Let them be involved by educating them about the upcoming plans for the patient.
Rubbing lotion on hands and feet, or even suctioning their mouths.
Let them participate in their care.
How to Explain Expected Situations with Family Members
Use Proactive Education to prepare family members for what you are expecting will happen, even if it appears like a health decline.
This establishes your authority. You are showing the family members that you know what is going to happen and how to handle it.
It takes away the fear of the unknown.
Explain what you are anticipating and the expected progression.
Establish Boundaries with the Family Members
Pulling family members in can quickly cross over into them dictating orders. What is the line?
Example: a family member kept silencing the alarms. The nurse didn’t realize it needed attention because she kept thinking another nurse was taking care of it, since it kept being silenced. Finally, a family member sought out the nurses and it turns out the IV was occluded.
Explain that when the equipment is silenced, it makes the nurse think another nurse handled it. Yes, it is annoying, but if you let it ring for a bit longer, someone will come in.
Be firm when family members silence alarms. It’s a safety issue.
Use proactive education – family members might think the IV pump is connected internally to the front desk. They think that if the alarm goes off that we get a push notification, but that’s not how that works.
Empathize with them, but you don’t always have to be happy happy joy joy.
“This isn’t personal, but there are too many people in the room, this is impeding my ability to care for the patient.” Be calm and firm.
Keeping Information Back From Family Members
What is the line of what not to share with family members?
There are certain things as a nurse that are outside of your scope to share
Imaging studies
Test Results
You can say, “I don’t have the exact report yet, if it was something drastically different or drastically worse, I would know right away and I’d get the Dr. in here to let you know.”
You can say “no news is good news.”
We are not experts in knowing what all test results mean.
You might not know what the results of the scans are, but you can look at the patient and if they are doing well, share that with the family.
One thing not to share – is when the doctor is going to by. Because I never know when the doctor will be by, and if you get a family member’s hopes up about when to expect the doctor, you risk disappointing them.
But you can let them know about when the rounds are. Say “rounds start at about 9:30, but we do the entire floor, so it could be an hour afterward before we reach you.” That helps them know an estimated time of the doctor arriving.
Journals and Logs
Encourage family members to keep a log or journal about the patient.
This is especially important in the ICU.
Write questions down as they think of them.
This gives them something to do.
There is a balance between writing down every blood pressure and taking quality notes.
Write down answers as you receive them.
Next of Kin
Know who you can talk to legally.
This is especially important for a neurologically compromised or unconscious patient.
One thing that is important to establish who everyone in the room is.
Ask in a business-like tone, “how do you know Mr. Smith?”
Don’t just assume who they are and how they are related.
It’s very common for patients to have loved ones in the room that they don’t want to have access to private medical information.
Don’t make the mistake and call someone’s wife their mother, you could look ridiculous.
If they have a health care power of attorney they take precedence over everyone else.
Social workers are a great resource for case management.
It’s not up to you to navigate by yourself what the family wants to do, especially when dealing with confusing family dynamics.
More Resources on Dealing with Family Members:
You can download Show notes for this episode here.
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.
This is the final episode for Season 3. Arterial lines, ventilators, central lines galore! Together with Acute Care Nurse Practitioner Sean Dent, Melissa and Kati discuss some tips and tricks for dealing with typical ICU devices.
Introduction to CRRT
CRRT stands for Continuous Renal Replacement Therapy
It is another form of dialysis treatment for a patient who is either in acute on chronic or acute renal failure.
It is gentler to the body than HD (hemodialysis)
HD is anywhere from 2-6 hours
But CRRT is over 24 hour period at a trickle rate
Best piece of advice Sean Dent can give with CRRT is to master the machinery that your facility utilizes.
Over the years, he experienced 3 different machines. Each machine comes with its own set of troubleshooting and issues.
The machine is dependent on the flow of the catheter.
It’s a central venous catheter
Treat it the same way you treat a central line.
Look for patency
Look for infection
Is it sutured into place?
Is it moving?
Is there pus coming out of the insertion site?
Is the dressing intact?
HD – Hemodialysis Catheters
Is the catheter the same for HD as it is for CRRT?
No, they are different.
You cannot do CRRT through an AV Fistula
There are different accesses for patients on chronic dialysis, which can be:
Fistula
Permacath – usually placed in the chest wall, but can also be in the femoral. You can’t do CRRT with permacath either because it has to do with the flow.
Blood flow goes in one direction, through one catheter, when a dialysis nurse accesses an AV fistula they use 2 catheters – one for venous, one for arterial. But when you use a CRRT catheter, it has 2 separate ports. One is inflow and the other is an outflow. There is no arterial and venous, the catheter sits in the vein.
If a patient was on CRRT can you use the same catheter for short term dialysis?
No. They will need either a temporary dialysis catheter or they will need a more permanent dialysis catheter.
The catheters used for chronic dialysis are not the catheters used for CRRT.
New Nurses – What You Need to Know Before Taking CRRT / HD Certification Classes
You have to work for a certain amount of time before you qualify to take the class.
You need to be comfortable with:
Stabilizing hemodynamics
Drips
Basal Pressures
Working with patients that are most of the time on the ventilator
Why CRRT Machines are Finicky
They are very flow, dependant
Any changes in the following things will sound an alarm:
Flow rate from outside to inside the patient
Is there a change in flow rate from the machine?
Is there something going on with the filter?
Is there something going on with the catheter itself?
The catheters are very positional.
You have a single catheter that has 2 lumens of equal size on both sides that have 2 separate ports.
One port is inflow, one is outflow, they are going at a high-pressure rate
Sometimes these flows – pushing fluids in and pulling fluids out – can cause the catheter to bump against the vessel.
Once that happens, you have to troubleshoot the machine until you’ve exhausted your efforts and then the staff nurses have to approach the provider to see if they can manipulate the catheter itself.
Impellas and Intra Aortic Balloon Pumps
What are they and are they the same thing?
Similarities
They are both catheters
They are both inserted into the groin
They are inserted on different sides of the groin
Usually, the balloon pump is on the left
The Impella is on the right
IABP – The Intra Aortic Balloon Pump
It is an augmentation device to offset afterload
Afterload has to do with the systemic vascular resistance of the body which equates to your systolic blood pressure.
Afterload is “what is the heart pumping against?”
The IABP is going to pump or inflate at the end of diastole – allowing the heart to work a little less.
It is a temporary device
The Impella Device
A ventricular assistive device.
A device to help with the strength of the EF – ejection fraction.
When someone has a cardiac event, and they have a cardiac stunning (like the heart got knocked out) it needs a little bit of time to wake up.
The Impella device helps the heart wake up without having to work overtime.
It does the same thing as an IABP, it just does it in a different part of the cardia cycle with a different part of the hemodynamic support.
Both are treated the same way from an external perspective
Look at infection
Look at the ports
Look at bleeding
Looking for irritation
Dressing changes
The devices themselves have troubleshooting things you will have to learn to address
Both work on timing mechanisms and how often they inflate and deflate in the cardiac cycle.
As a bedside nurse, pay attention to how your patient responds to the treatment. If they become less stable, discuss it with the health care provider.
Both of them are in the venous system
Don’t ever assume just because they have a pump in, that they will be anticoagulated in 24 or 48 hours as each surgeon or cardiologist treats it a little bit differently because of the patient’s comorbidities and their disease process.
Someone who has a coagulopathy who has an unstable bleeding pattern, you won’t anticoagulate them.
Are patients that have these awake?
They can be.
If the patient is awake, not vented, not sedated, what kind of considerations do you have to have?
They are going to have to lay flat
Most of the time, they can’t sit up, because of the location of the catheter in the groin.
Best practice is to allow them to sit up maybe 20 or 30 degrees.
Is there a complication related to the catheters, just by having them in place?
Catheters just being there can cause bleeding, hematomas, pseudoaneurysms
Are these removed at the bedside?
They can be.
It all depends on the patient profile
Surgeons and interventionalists remove them.
The biggest concern is that you can have post-removal hypotension and bradycardia.
Internal Pacing
These are the different types of devices that help with internal pacing.
Temporary Pacemakers
Internal pacing for someone who has an electrophysiology compromise
These are good for someone who is refractory bradycardic
Or someone who has sustained v-tac
You will need a temporary pacemaker to stabilize them until they can get a permanent pacemaker
These are also inserted into the groin
These are also very positional – the patient has to lay flat or maybe 10 degrees
These are monitored by the bedside nurses
This is a very specialized piece of equipment that requires additional training.
Even if you haven’t had the specific training, you can care for people who have pacemaker wires postoperatively if you have the correct support from other staff members. Always ask if you have any questions.
Proning Devices
What is proning? What are some devices? When will we run into this?
Proning is – instead of someone laying on their back (which is called supine), you are going to lay them on their stomach.
This is in extreme respiratory failure scenarios.
ARDS – Acute Respiratory Distress Syndrome
Significant and severe respiratory distress
Leaky lung syndrome
Capillary membrane leaking
When lungs can’t hold onto the water they need to and it leaks
Prone therapy came out 12-15 years ago
It has been proven that when you take a patient from laying on their back to laying on their stomach, it helps.
When you are laying on your back, the lung tissue that is closest to your nipples is receiving the most oxygen.
Fluid always travels down.
So if you are turned upside down, with your back toward the sky. Whatever is anterior will have oxygen now.
Someone that needs to be prone is very sick, they are usually on a ventilator – this can be very difficult dealing with the tubes.
They have created a specialty bed – a rotoprone bed – you clamshell them from top to bottom, then it spins on its axis so you can go from their back to their stomach without compromising the equipment.
Evidence doesn’t support the manner in which you leave them there.
How long? Do you lean them on the right side? Left side?
No evidence supports what’s better or worse.
If you don’t have a bed, you can “rig” a set of pillows to put on their chest and above their head and around their head and manually flip them – with a LOT of support of course.
It usually takes about 10 people
Some to watch and handle the machines
1-2 at each part of the patient – the head, the feet, the arms, etc
Watch out for pressure ulcers when laying on the stomach
The oscillator
Mostly used for babies
Can be used for adults with the flu who weren’t ventilating well with other ventilation
Not used very often on adults
Last ditch effort
Advanced Practice Provider – Favorite Device
What is your favorite device that you get to use?
Ventilators
As a bedside nurse, they were scary and it became his goal to master them.
He always asked questions of people more advanced than him and learned how to master devices that once scared him.
Advice to New Nurses
Stay uncomfortable – don’t avoid those things that challenge you, that is how you grow
Non-Invasive Cardiac Monitors
The final device of the show will be non-invasive cardiac monitors
You can monitor cardiac output from the outside in using an external device.
You have some that you can put monitor leads on their chest wall.
Some monitor calculations using an A-Line.
They monitor:
Fluid volume status
Cardiac output
Cardiac index
Cardiac performance
It’s great for the bedside nurse because you manage that entire machine.
More Resources on ICU Devices:
You can download Show notes for this episode here.
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.
Arterial lines, ventilators, central lines galore! Together with Acute Care Nurse Practitioner Sean Dent, Melissa and Kati discuss some tips and tricks for dealing with typical Intensive Care devices.
Introduction to Nurse Practitioner Sean Dent
An older “seasoned” nurse of 13+ years
Practiced in the ICU for his entire career except for about 3-6 months where he tried working in orthopedics
7 years ago he went back to school and got his bachelor’s and master’s
He is now on his 5th year as an acute care nurse practitioner
He provides services to all of the ICUs inside the hospital
Let’s Talk Art Lines
As a brand new nurse, never dealt with art lines before, what are some big “never do,” and “always do” tips?
Understand why the patient is needing it – This is important because it’s not a permanent device, it’s a temporary device.
The sooner you can get it out the better.
It’s usually because their hemodynamics are compromised in some way that they need invasive monitoring.
An art line gives you continuous monitoring of their arterial pressure vs a cuff pressure which is intermittent and not as accurate
What NOT to do with an art line
Don’t NOT check it on a daily basis or shift basis
What You Should Check on Art Lines
Check and make sure that it is doing the job it’s supposed to do. Looking at the patient, looking at the insertion site. Looking at where it is because you can have an art line that either one of these:
radial art line
brachial art line
axial art line
Femoral art line
Radial art lines are the most common.
Look at the circulation of the limb or the site
This is because you just put a catheter into someone’s artery. So you have compromised the circulation of that vessel in some way.
You could lacerate someone’s artery if you aren’t paying attention to what you are doing.
The most important thing is looking at the insertion site
Then going from the patient to the monitor – you need to assess the function of the equipment.
Is it working appropriately?
Are all the lines, circuits and systems doing what they are supposed to be doing?
Is the pressure bag pumped up?
Is the tubing not kinked?
Are the 3-way stop clocks opened and closed properly?
If you use a vamp – is that opened or closed?
If things don’t look appropriate, ask for help.
You are trickling 3cc’s of normal saline into the artery to maintain a specific pressure, so you want to make sure you have adequate fluid and adequate pressure.
Look at the monitor and the quality of the waveform.
Do you have a whip in your wave
Do you have a dampened wave
Is it over correcting or under correcting someone’s actual blood pressure?
Never just treat a number. The quality of the waveform is what matters most.
You have to assess from wall to patient to see if something is off.
Is the equipment working the way it is supposed to work?
The way to assess that is to do the square wave test – a basic skill learned in ICU – doing a quick pressure change utilizing the pigtail on your pressure bag to see if fluid goes in and goes out quickly
Efficacy of Blood Pressure Cuffs with Art Lines
You see a number on the screen. Should you be checking that with a regular blood pressure cuff? If so, where and how often?
It is very patient-specific
Some patients that will always return inaccurate blood pressure cuff results are:
Patients that are third-spacing
Patients that are severely obese
Someone who is very cachectic
Blood pressure cuffs can be inaccurate
They can be used to compare
If you are interested in getting rid of the A-Line, you definitely need to start checking cuff pressures because you need to have some sort of correlation.
A-line should correlate with the cuff pressure. They usually don’t, but there should be some variance.
Is your A-line higher or lower than your cuff pressure?
You need to have this in the back of your mind so that when you get rid of the A-line you know ahead of time that the cuffer is going to be falsely elevated or going to be falsely lower.
When to discontinue the A-line is completely up to you and your team.
It should come out as soon as possible.
The sooner it comes out the better because it is an opportunity for infection and injury.
A-Line Tips
Follow these tips to provide excellent care for patients with A-lines
Make sure all the connections are tight
You don’t want your patient to lose blood due to loose connections
The A-line has to be leveled appropriately to get an accurate blood pressure
If the transducers are too high you aren’t going to get a good pressure
If you have a patient on drips and are you titrating drips off that art line, it is imperative that you make sure it is accurate
Quick tip: A lot of families and patients know not to bother nurses when they are giving meds, but they don’t always connect that when you are working with equipment. They don’t realize that me messing with this arterial line impacts how I give this medication and how much of it.
How to Use Different Kinds of Fluid Monitoring Devices
Tips for how to use common monitoring devices such as CVP and NICOM.
Know the Why – why you are doing it and how it’s working
You need to have a good solid foundation of anatomy and physiology and where the catheter is and what it is measuring.
CVP is part of a central line that is measuring fluid volume status and it is measuring central venous pressure.
Traditionally it sits somewhere in the SVC – just above your right atrium.
CVP is up from interpretation.
There is no normal.
There are trends
You are looking for a response to therapy.
Understand why you are using a CVP.
It is just another tool in the toolbox.
When you are measuring fluid volume status with various tools, it gets complicated. This is advanced stuff, you won’t have to know it on the first day.
You can also measure CVPs through a Swan Ganz Catheter, or a PA Catheter
A PA Catheter sits in your Pulmonary Artery
A CVP is just a piece of a monitoring tool
Cooling Devices
How to use cooling devices correctly as you monitor patients.
Know how the equipment works
Know how to troubleshoot when alarms go off – a lot of times it has to do with connections and pressure and it depends on where the catheter is on the body.
Cooling devices are very specialized unless you are working in a unit where you are using it often like in a code-cool situation
TTP – Targeted temperature management
Hypothermia Protocol
There are different brands and types of devices
You can cool someone with an external device and an external device
More Resources on Intensive Care Devices:
You can download Show notes for this episode here.
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.
Nursing conferences are fun but can be pretty overwhelming. In this episode, Melissa and Kati discuss some practical tips to get the most out the experience and investment.
Introduction to NTI in Houston, Texas
NTI is a National Teaching Institute
An annual conference that the American Association of Critical Care Nurses puts on
Anywhere from 6,000-8,000 nurses attend
Kati attended conferences in Houston, Denver, and San Diego
Melissa attended conferences in Denver, New Orleans, and now Houston
How to Get the Most Out of Conferences
Conferences are expensive, but they are definitely worth it. Here are some tips for getting the most out of conferences.
Figure Out Your Purpose – Why are you going here?
Kati attended her first NTI to learn more about Neuro Critical Care. She was newer to it and attended neuro-specific classes.
When she attended a 2nd time, she was already familiar with neuro, so she went to learn about ARDS and respiratory things.
This time in 2017, Kati is looking more big picture. What kind of sessions can I go to for engagement with nurses and helping new grads?
Melissa has been doing neuro ICU for a long time but she appreciates staying up to date on up and coming research.
When she attends NTI, she focuses more on critical care in general.
It’s a way to expand your knowledge. You never know when something is going to benefit you.
You hear things at different stages of readiness. You might have heard something 5 times, but when you hear it at the conference the 6th time, you are ready to comprehend it and put it into action.
There are opportunities for networking opportunities. If you want to get involved in professional organizations like AACN, you can connect with those people at dinners they offer.
Conference Setup Overview
If you have never attended a conference, here is a general overview of what a conference is and what you can expect.
Usually held in a large city with a large conference center
There are “Super Sessions”
Everybody goes into one room
It’s a room large enough to hold 6,000 nurses
There are major keynote speakers
Emcee and performance type things – usually held once a day
There are also “Breakout Sessions”
They offer different specific sessions that cover a variety of topics
NTI has a massive schedule
Each session lasts anywhere from 45 minutes to 2.5 hours
The 2.5 hour long sessions are called “Mastery Sessions.”
You pick what you want to go to
After you attend, you will get your CE credits after you complete the evaluation (can be done on mobile).
They have an “Exhibit Hall”
A bunch of vendors and companies that want to market to nurses
Organizations also have booths – like the Daisy Foundation, nursing schools, medical equipment companies like Cheetah, Stryker, etc.
You find out more information, enter giveaways, and get free stuff
Everything is scheduled
There are specific times for the exhibit hall, specific times for the sessions, breakout session, and super sessions
It is up to you to make it what you want
You are not required to follow the schedule exactly. You can do as much or as little as you want.
If you invest a lot of money on travel and ticket cost, but only go to 2 sessions and get 2 CE credits, that is your prerogative. But you can get so much more out of it if you want.
You can get as much as 37 CE credits at once here at NTI.
For reference, many states require only approximately 20 every few years for relicensing
Practical Conference Tips
These are tips you will actually use to get the most out of the conference and be prepared for what really happens.
Wear practical and comfortable shoes
The conference center is 4 city blocks long, you will be walking a lot
Conference clothes – what to wear
Don’t wear scrubs
You can wear jeans, but nice jeans.
It’s like a casual/business casual environment
Presenters will wear dress suits or more business professional attire
Most attendees wear jeans with nice dress shirts or khakis/slacks with nicer shirts/blouses.
Dress in such a way that if you saw your boss or the CEO of your hospital, you’d be proud to stand in front of them professionally.
There isn’t a dress code, but there is a way to dress that represents yourself professionally.
Dress in Layers
Conference centers are large, so the temperature is difficult to regulate.
They tend to be very cold places, but the outside temps are hot.
If you want to eat lunch at lunchtime, you probably can’t
You might be in line for an hour if you show up right at lunchtime
The Starbucks lines are insanely long
Maybe sneak out of a session a little early
Plan an off time to get some food
Bathroom lines are typical
The men’s line is never a problem
Women’s bathroom is always super long
At one conference, they changed a men’s restroom into women’s restroom, taping over the sign
Try to pee in off times to avoid the long lines
What to keep in your bag
Protein Bar (or some other snacks)
Water bottle
Conference schedule
Phone charger
Plan your sessions ahead of time
If you know what your purpose is, look for sessions that achieve that purpose
You won’t get as much out of it if you show and just try to wing it
Read the descriptions of the sessions
There might be 5 sessions on sepsis, but what do you want to get out of the sepsis lecture?
Choose your partner carefully
If you choose someone that is really going to site-see all day and you want to go to classes, you will have a conflict
Go with someone that wants to learn if you want to learn
Make sure you are compatible with the person you are sharing a room with. (Night owls vs morning people)
If you get to a session and it isn’t what you thought it was going to be, leave immediately and attend a backup session.
Your time is valuable
Don’t waste your time sitting in a session that isn’t valuable to you.
Some sessions might be too advanced for you, change sessions.
Take advantage of what is most beneficial to you.
New Nurses: Attend a Conference
New nurses should definitely try to go to a conference, this is why:
There is so much out there and available beyond what your hospital offers
Early on in your career, they don’t reimburse for conferences, but the benefit outweighs the cost.
If you have a hospital that will reimburse you, take advantage of it.
Conferences start a dialogue, get people thinking, and shows your level of engagement.
More Resources on Nursing Conferences:
You can download Show notes for this episode here.
Brittney Wilson and I do an in-person 5-hour seminar during the NNBA Conference. Stay on the lookout for more information about this year’s conference.
I’m elated to work with the NNBA (National Nurses in Business Association) because they offer a huge network of support… support I could have used when I was going through this whole mess. It would have been helpful to already be in a network of people to bounce ideas or situations off of that just didn’t seem right, but I couldn’t really specify why.
The NNBA consists of over several thousand nurses, leaders, and mentors. Growing a successful business, balancing life, and making sure to consider our profession as a whole can be challenging. If you’re a nurse business owner or considering starting a membership, an NNBA membership is truly an investment in your success.
In addition to being a member of the American Nurses Association and the American Association of Critical Care Nurses, I’m also a member of the National Nurses in Business Association, and I highly recommend becoming a member. Join me.
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.
Season 3 Episode 6 – What Nurses Need to Know About Palliative Care Show Notes
In this episode, we interview Kathleen Puntillo, Ph.D. RN FAAN who has written about and researched palliative care extensively, about what the nurse needs to know about palliative care and considerations for their patients.
Introduction to Kathleen Puntillo, Ph.D. RN FAAN
Winner of the 2017 AACN Pioneering Spirit Award
Professor and Research Scientist in the School of Nursing at the University of California San Francisco
Since 1999 she has been involved in research related to the integration of palliative care with critical care
Difference between palliative care and hospice
Defining the difference between the two and when a patient might qualify for palliative care but not for hospice.
Palliative care – a philosophy of providing care to people with serious illnesses, and providing this care to their family as well.
3 key domains of palliative care:
Symptom Management
Communication
Family Engagement
We practice palliative care by looking at these domains and introducing into our practice what the patient and their family need.
Hospice – a structured approach to palliative care; like an institution.
Hospice patients always receive palliative care, frequently in their home.
Hospice is not the only palliative care
Palliative care can be provided wherever there are seriously ill patients who have needs for symptom management, or their families need clearer communication.
Palliative Care Examples
Simple examples of a patient for whom palliative care is perfect but they are not in hospice:
Congestive heart failure
Lung diseases
They have a disease that is going to be constant over a period of time
They might not be at the end of their lives
They might have a serious illness, but it isn’t the illness that will kill them tomorrow.
They have needs for symptom management
Thirst
Fatigue
Pain
They aren’t ready for hospice but they have needs for palliative care
Hospice care is for patients with 6 months to live or less.
You don’t have to be dying to receive palliative care.
Every patient in the ICU needs palliative care.
The word palliation means to relieve or support. That is what we provide patients and their families.
Benefits of Bringing Palliative Care on Earlier
There are many benefits to bringing on palliative care early, especially in the ICU.
When patients are in the ICU, their care is complex, and there are multiple physicians seeing them.
Palliative care helps put the pieces together for the family.
Please note that physicians don’t always agree with this.
There is a misunderstanding that palliative care is the same as the end of life care.
Advice for New Nurses About Verbalizing Need
Advice for new nurses who identify a need for palliative care but are having challenges expressing that effectively:
It happens very often.
Physicians misunderstand what palliative care is.
There are 2 kinds of palliative care:
Primary palliative care – The type of care that can be provided by the patient’s primary physicians.
Can we address symptoms like pain and shortness of breath?
Can we communicate with the family?
Yes, we can provide this care at the bedside.
Specialty or consultative palliative care – When you say “can we call palliative?” you mean “can we bring in the palliative care service,” that is specialty palliative care.
Particular ICU patients might not need specialty palliative care service if their needs can be met by their own clinicians in the ICU
Sometimes that means bumping up our knowledge about assessing symptoms and looking at the collective picture
When do you call in palliative care?
If the patient’s situation is very complex, their symptoms aren’t being managed the best, or if it is a family that is completely not handling the situation, it may be better to bring the specialist in.
Don’t think that starting palliative care means you are stopping curative care.
They can be addressed side by side.
Don’t think you have to make a choice.
Curative care might not be enough for some patients. If they approach the end of their life, the balance of care changes from more curative and palliative to more palliative care.
Nurse and Surgeon Communication
An example of when a nurse can offer education and use good communication.
What does the nurse mean by “can we call palliative”?
Know the difference between primary and consulting palliative care.
Example: a patient is having a lot of trouble with symptoms. The nurse could say to the surgeon, “I’m thinking that maybe this is a patient that is good for palliative care,” to bring the palliative care team in. The surgeon says, “my patient isn’t dying.”
Then the nurse would say, “Alright. But here is the situation. The pain is ___, and I know you don’t have all the time in the world to be addressing all these issues. I know the palliative care service does a great job with symptoms. Do you think we could call them in, to help manage the patient’s symptoms?”
Show respect to the surgeon with the NURSE process –
Naming – “I know that you are very busy.”
Understand – “You are in surgery now and can’t come down.”
Respect – “I really respect your expertise”
Support – “Can we get some support, not just for you but for the patient, through calling the palliative care service?”
Explore – “Can you tell me a little bit more about your thoughts now?”
How to let the family know about palliative care without making them think about hospice and dying.
These are tips for the brand new nurse that has to speak to the family about palliative care without making them worry about hospice and dying.
You might start out by just asking some questions:
Find out where they are what their understanding is of the situation.
Try and gauge where they are at and what their understanding of the patient’s condition is.
Listen to them describe it and notice the gaps in understanding or if they describe it incorrectly.
Another communication skill
Ask – what is your understanding of what is happening?
Tell – these are some of the things I am worried about and things the physician has said to you
Ask – does this make sense to you? How are you feeling now?
Communication is a procedure. You can learn and have a toolbox of communication skills you can use.
You are there to support the family.
Family meetings should always include a nurse. You don’t need an invitation. This is your patient. When you are there, you know what is being said, you can provide support to the family.
Explaining palliative care to the family could be tricky.
You may not need to use the word “palliative” in the beginning.
You might say, “it seems like we could use some help here. We have some people here that might be helpful to you.”
When you feel the time is right you can explain what the palliative care service does. They are really good at symptom management, etc.
The better your knowledge base is, the more you can advocate for your patients.
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
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