Season 3, Episode 5 Understanding Nursing Leadership Show Notes

Season 3, Episode 5 Understanding Nursing Leadership Show Notes


Click here to list to this FreshRN Podcast Episode

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.

Download the Season 3, Episode 005 show notes or view them below.

Season 3, Episode 5 Understanding Nursing Leadership Show Notes

Understanding Nursing Leadership

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.

Anatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyAnatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyAnatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyThe Heart of a Nurse Leader: Values-Based Leadership for  Healthcare OrganizationsThe Heart of a Nurse Leader: Values-Based Leadership for Healthcare OrganizationsThe Heart of a Nurse Leader: Values-Based Leadership for  Healthcare OrganizationsThe New Leadership Challenge: Creating the Future of NursingThe New Leadership Challenge: Creating the Future of NursingThe New Leadership Challenge: Creating the Future of NursingA Charge Nurse’s Guide: Navigating the Path of LeadershipA Charge Nurse’s Guide: Navigating the Path of LeadershipA Charge Nurse’s Guide: Navigating the Path of LeadershipEffective Leadership and Management in Nursing (8th Edition) (Effective Leadership & Management in Nursing (Sull)Effective Leadership and Management in Nursing (8th Edition) (Effective Leadership & Management in Nursing (Sull)Effective Leadership and Management in Nursing (8th Edition) (Effective Leadership & Management in Nursing (Sull)

 

Season 3 Episode 4 – All About Respiratory Show Notes

Season 3 Episode 4 – All About Respiratory Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 3, Episode 004 show notes or view them below

All Things Respiratory

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.
  • BiPAP/ CPAP
    • Non-Invasive Positive Pressure Ventilation  – NIPPV
    • 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

More Information on Respiratory:

West's Respiratory Physiology: The EssentialsWest’s Respiratory Physiology: The EssentialsWest's Respiratory Physiology: The EssentialsRespiratory SystemRespiratory SystemRespiratory SystemWhiteCoat Clipboard- Black - Respiratory EditionWhiteCoat Clipboard- Black – Respiratory EditionWhiteCoat Clipboard- Black - Respiratory EditionRespiratory & Circulatory SystemRespiratory & Circulatory SystemRespiratory & Circulatory SystemRespiratory Care Made Incredibly Easy (Incredibly Easy! Series®)Respiratory Care Made Incredibly Easy (Incredibly Easy! Series®)Respiratory Care Made Incredibly Easy (Incredibly Easy! Series®)

 


For more information, check out these podcasts on respiratory from NRSNG.
Season 3 Episode 3 – What Nurses Need to Know About Sepsis Show Notes

Season 3 Episode 3 – What Nurses Need to Know About Sepsis Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 3, Episode 003 show notes or view them below

what nurses need to know about sepsis

What Nurses Need to Know About Sepsis

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.
  • CARS and MARS are other indicators
    • CARS – compensatory anti-inflammatory response syndrome
    • MARS – Mixed Anti-inflammatory response syndrome
  • There will never be one treatment for sepsis it depends on the phase that it is in.

Dr. Marik’s Sepsis Study

Dr. Marik’s Study About Vitamin C and Lowered Sepsis Mortality

  • Theory – by giving vitamin C, anti-oxidants, thiamin, low dose steroids, retrospectively they saw lower mortality
    • Danger – if people abandon conventional therapy there is risk because this hasn’t been studied in depth.
    • News articles spin this as a cure. Family members ask if their loved ones are getting enough vitamin C.

Early Recognition of Sepsis

Good sepsis care from ED nurse to sepsis patient looks like:

  • Key is recognition. It’s not simple, it’s kind of vague.
  • Examples of recent sepsis cases
  • 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.

More Resources on Sepsis:

Handbook of SepsisHandbook of SepsisHandbook of SepsisWinning the Fight Against Sepsis: What Every Nurse Should KnowWinning the Fight Against Sepsis: What Every Nurse Should KnowWinning the Fight Against Sepsis: What Every Nurse Should KnowSepsis and Septic ShockSepsis and Septic ShockSepsis and Septic ShockMandell, Douglas, and Bennett's Principles and Practice of Infectious DiseasesMandell, Douglas, and Bennett’s Principles and Practice of Infectious DiseasesMandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases

 

Season 4, Episode 8: How to Trust Your Nursing Judgment Show Notes

Season 4, Episode 8: How to Trust Your Nursing Judgment Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 4, Episode 008 show notes or view them below

I’ve received a lot of questions from new nurses saying that one of their biggest struggles is when they’ve learned a lot but are having trouble learning how to trust your nursing judgement. You think you know what you’re doing, but you’re not sure...

How To Trust Your Nursing Judgement

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.

How to Trust Your Nursing Judgment

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:

  1. 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!
  2. 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.

I’ve received a lot of questions from new nurses saying that one of their biggest struggles is when they’ve learned a lot but are having trouble learning how to trust your nursing judgement. You think you know what you’re doing, but you’re not sure...

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.

More Resources:

 

Critical Thinking, Clinical Reasoning, and Clinical Judgment: A Practical Approach (Alfaro-Lefevre, Critical Thinking and Clinical Judgement)Critical Thinking, Clinical Reasoning, and Clinical Judgment: A Practical Approach (Alfaro-Lefevre, Critical Thinking and Clinical Judgement)Critical Thinking, Clinical Reasoning, and Clinical Judgment: A Practical Approach (Alfaro-Lefevre, Critical Thinking and Clinical Judgement)Clinical Judgement and Decision Making in Nursing (Transforming Nursing Practice Series)Clinical Judgement and Decision Making in Nursing (Transforming Nursing Practice Series)Clinical Judgement and Decision Making in Nursing (Transforming Nursing Practice Series)Fundamentals of Nursing -- Caring and Clinical JudgementFundamentals of Nursing — Caring and Clinical JudgementFundamentals of Nursing -- Caring and Clinical JudgementNursing Power and Social Judgement: An Interpretive Ethnography of a Hospital Ward (Developments in Nursing & Health Care)Nursing Power and Social Judgement: An Interpretive Ethnography of a Hospital Ward (Developments in Nursing & Health Care)Nursing Power and Social Judgement: An Interpretive Ethnography of a Hospital Ward (Developments in Nursing & Health Care)Fundamentals of Nursing: Caring and Clinical Judgment (Book with CD-ROM)Fundamentals of Nursing: Caring and Clinical Judgment (Book with CD-ROM)Fundamentals of Nursing: Caring and Clinical Judgment (Book with CD-ROM)

Season 4, Episode 7  Talking to Unconscious Patients Show Notes

Season 4, Episode 7 Talking to Unconscious Patients Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 4, Episode 007 show notes or view them below

how to talk to unconscious patients

Talking to Unconscious Patients

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.
    • References:

Family Support

  • Encourage families to talk to patient.
    • Familiar voices can be comforting to the patient
    • 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.

 

More Resources:

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

Enroll in Class
 

The First Year: Conversations with a New ICU NurseThe First Year: Conversations with a New ICU NurseThe First Year: Conversations with a New ICU NurseICU Nurse: 6x9 Notebook, Ruled, Intensive Care Unit Nurse Appreciation, Memory Journal, Diary To Write, Organizer, PlannerICU Nurse: 6×9 Notebook, Ruled, Intensive Care Unit Nurse Appreciation, Memory Journal, Diary To Write, Organizer, PlannerICU Nurse: 6x9 Notebook, Ruled, Intensive Care Unit Nurse Appreciation, Memory Journal, Diary To Write, Organizer, PlannerLives in the Balance: Nurses' Stories from the ICULives in the Balance: Nurses’ Stories from the ICULives in the Balance: Nurses' Stories from the ICU

Season 4, Episode 6 All Things Urinary Catheters Show Notes

Season 4, Episode 6 All Things Urinary Catheters Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 4, Episode 006 show notes or view them below

Season 4, Episode 6 All Things Urinary Catheters

All Things Urinary Catheters

In this episode we talk all things urinary catheters… CAUTIs, tips, tricks, internal and external devices, and nursing considerations.

Key Focus: Catheters can lead to infections, which can be fatal.

CAUTICatheter Associated Urinary Tract Infection

  • CAUTI is a type of HAI – Hospital Acquired Infection
    • NOT an infection the had at the time of admission
    • An infection we gave the patient because we placed a catheter
  • Impacts the hospital’s reimbursement (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
    Assessment-Instruments/Value-Based-Programs/HAC/Hospital-Acquired-Conditions.html)

    • 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

CAUTI prevention

  • Don’t have a catheter unless truly needed
  • Treatment of CAUTI is expensive.
  • Can be fatal – think urosepsis, amongst other complications
  • Risk of CAUTI increases each day the catheter remains in place
  • 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:
    • Enlarged prostate
    • Spinal injury
    • Brain injury
    • Medications

In Summary, always ask yourself:

  • Do they have a catheter?
  • Why do they have hit?
  • Do they still need it?
  • When can it come out?

Preventing Catheter-Associated Urinary Tract Infections: Build an Evidence-Based Program To Improve Patient OutcomesPreventing Catheter-Associated Urinary Tract Infections: Build an Evidence-Based Program To Improve Patient OutcomesPreventing Catheter-Associated Urinary Tract Infections: Build an Evidence-Based Program To Improve Patient OutcomesCatheter-Associated Urinary Tract Infections: Evidence-Based Best Practices for NursesCatheter-Associated Urinary Tract Infections: Evidence-Based Best Practices for NursesCatheter-Associated Urinary Tract Infections: Evidence-Based Best Practices for NursesThe 2019-2024 World Outlook for Urinary CathetersThe 2019-2024 World Outlook for Urinary CathetersThe 2019-2024 World Outlook for Urinary CathetersMinimize The Microbial Load On Urinary CathetersMinimize The Microbial Load On Urinary CathetersMinimize The Microbial Load On Urinary Catheters

Season 3, Episode 2: Nursing Certifications: The What, Why, and When Show Notes

Season 3, Episode 2: Nursing Certifications: The What, Why, and When Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 3, Episode 002 show notes or view them below

Nursing Certifications: The What, Why, and When Show Notes

Nursing Certifications: The What, Why, and When

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
  • Long-term goal
  • Example:  CCRN (certified critical care nurse)
  • The Why? The Benefits of Nursing Certification
  • It feels amazing to pass the exam
    • All three FreshRN Podcast hosts are certified, nurses
  • Whenever you pass, you get to add letters behind your name
    • Kati Kleber, BSN RN CCRN
    • Melissa Stafford, BSN RN CCRN SCRN
    • Elizabeth Mills, BSN RN CCRN
  • Take a prep course
    • Check with the organization who gives the exam
      • For example, checking if the AACN has a review course for the critical care certification (spoiler alert: they do)
    • Online resources like review books are typically available

      PASS CCRN®!, 5ePASS CCRN®! 5e

Certification exam vs. NCLEX®

  • It’s not computer adaptive (which means giving you a harder question based off of the answer to your previous question)
  • Experience really helps you answer the questions, while NCLEX® is very textbook
  • You typically find out if you pass immediately, versus going
  • You don’t have to go through your State Board of Nursing / Pearson Vue to take it, rather through the accrediting body (like AACN or ACCN)
  • Focuses a lot on the synergy model

Tips

  • See if your hospital/facility offers a review course or resources
  • See if your hospital/facility reimburses for the exam or will increase your pay for having a certification
  • Before you start to study…
    • Take a pre-test – tells you where to focus your time
    • Look at the blueprint for the exam so you know what’s on the exam
  • Question banks + a review course are really helpful

Maintaining your nursing certification

  • Every organization handles this differently, be aware of what’s expected of you before it’s time to renew
  • Typically, you must have a minimum amount of hours and many CEU’s OR you can take the test over again
  • Make sure you’re taking the CEU’s you need in the correct categories to maintain appropriately
  • Keep track of your paper trail of CEU’s

More Resources on Nursing Certifications

 

Certification Review for PeriAnesthesia Nursing, 4eCertification Review for PeriAnesthesia Nursing, 4eUpdates in Primary Nursing Care: Continuing Education Program for NursesUpdates in Primary Nursing Care: Continuing Education Program for NursesCertification and Core Review for Neonatal Intensive Care Nursing, 5eCertification and Core Review for Neonatal Intensive Care Nursing, 5eBasic Critical Care Guidebook: A Training Program for the Development of Critical Care Nurses with 75 Continuing Education Contact Credit HoursBasic Critical Care Guidebook: A Training Program for the Development of Critical Care Nurses with 75 Continuing Education Contact Credit HoursLippincott Certification Review: Medical-Surgical NursingLippincott Certification Review: Medical-Surgical Nursing

Season 3, Episode 001: Top Tips for Cardiac Nurses. An Interview with Nurse Nacole – Show Notes

Season 3, Episode 001: Top Tips for Cardiac Nurses. An Interview with Nurse Nacole – Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 3, Episode 001 show notes or view them below

Top Tips for Cardiac Nurses

Top Tips for Cardiac Nurses. An Interview with Nurse Nacole

In this interview, we interviewed Nurse Nacole about tips for cardiac nurses. Nacole is a certified critical care nurse who is currently pursuing her Doctorate of Nursing Practice. Check out her website here.

A few important points

If you are a new grad that is not taking accountability for his or her learning and mistakes, it is a huge red flag.

If you want to learn more about something, you’ll have to do that at home – many times there isn’t enough time to do that while providing care at the same time

First things a new nurse should understand about cardiac

Things to know

  • Cardiac history / procedures
      • Parameters can be different depending on the different surgeries, procedures, or history
      • Know parameters!
        • Look at nursing orders before calling / treating
  • Potassium lab is a big focus for cardiac surgeons and cardiologist
      • Very diligent and proactive to supplement potassium
      • Your body doesn’t hang on to potassium if your magnesium is low. If you have to replace both, replace magnesium first then do your potassium.
      • Magnesium doesn’t come on a BMP; you’ll have to add that on if the MD wants it or you’re concerned about ectopy.
  • Vitals / monitor changes first, then it’s evident in the assessment
      • Know your patient’s trends because even though they may be in technically “in range” it may be abnormally high or low for that unique person
      • Some people will not be concerned by alarms that stop or don’t continue; it is essential to see what caused the alarm
        • Was it a run of PVC’s?  How many runs have they been having?
        • Was it a pause? How long was the pause?
  • EKG Dance Video
      • If something changed, it’s not your job to interpret the EKG perfectly on an instant – but know when something changes and get a 12-lead if you’ve got an order to do so
      • Many times there’s a standing order to get an 12-lead with telemetry changes
  • When to freak out/intervene?
      • When they’re symptomatic, even if the vitals are okay
      • Persistent issues like increasing runs PVC’s
  • Lung vs. cardiac
    • Use an ABG to differentiate

More Tips for Cardiac Nurses:

NRSNG also has quite a few great resources for nursing students and new nurses.  There are various courses, or the entire academy. You can get access to Academy for 7 days for only $1! The specific courses that would give valuable tips for cardiac nurses include:

 

12 Lead EKG for Nurses: Simple Steps to Interpret Rhythms, Arrhythmias, Blocks, Hypertrophy, Infarcts, & Cardiac Drugs12 Lead EKG for Nurses: Simple Steps to Interpret Rhythms, Arrhythmias, Blocks, Hypertrophy, Infarcts, & Cardiac DrugsMens Nurse Heartbeat Shirt Nursing Passionate Jobs Heart Beat Tee Large Heather BlueMens Nurse Heartbeat Shirt Nursing Passionate Jobs Heart Beat Tee Large Heather BlueHeart Attack, Cardiac Cath, & Bypass: A Nurse's Guide to Caring for the PatientHeart Attack, Cardiac Cath, & Bypass: A Nurse’s Guide to Caring for the PatientCardiac Rhythm Compression Socks 20-30mmHg (Small/Medium)Cardiac Rhythm Compression Socks 20-30mmHg (Small/Medium)Cardiac/Vascular Nurse Exam Secrets Study Guide: Cardiac/Vascular Nurse Test Review for the Cardiac/Vascular Nurse ExamCardiac/Vascular Nurse Exam Secrets Study Guide: Cardiac/Vascular Nurse Test Review for the Cardiac/Vascular Nurse Exam

Season 2, Episode 10: Tips for Working as a Night Shift Nurse – Show Notes

Season 2, Episode 10: Tips for Working as a Night Shift Nurse – Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 2, Episode 010 show notes or view them below

Night Shift nurse

Tips for Working Night Shift – Show Notes

Elizabeth, Melissa, and Kati discuss some tips for nurses new to night shift. All three have worked night shift, and Elizabeth was working nights when this episode was recorded. This episode discusses very practical tips for learning how to live a night shift nurse life from the perspective of current and former night shift nurses. We discuss eating and sleeping tips, to how to manage your nursing care on the night shift, communicating with the healthcare team at night, and more.

Pros to night shift

  • Make more money
  • Can get away with drinks at the nurse’s station – WATER 😉
  • Generally busiest part of the shift is the beginning
  • Time to read notes and look up things, figure out the plan of care
  • Not waking up at 0500
  • More time to process information as a new nurse

Food / staying awake at work during night shift

  • Kati’s “meal times” for night shift
    • 2230 or 2300 – snack
    • 0100 – lunch + coffee
    • 0500 – second snack
  • May want smaller more frequent meals throughout the shift if one large meal will make you sleepier
  • Take a 15-minute break to eat lunch, and then nap for your 30-minute break
  • Exercise every hour for a few minutes (5 minute wall sits, 20 jumping jacks, lunges)

Sleep planning on night shift

  • Must be intentional; you can’t just sleep when you’re tired
  • The healthiest way to go about nights is to go to bed late (2-3 am) and get up around 10-11am, so they are still getting the necessarily total, but are awake during a good portion of each of the day and night
  • Flipping means going back to resting during the night, awake during the day
  • Three ways to go about this
    • 1. Awake every night, asleep every day
    • 2. Flip for when there are 2+ nights off in a row
    • 3. Flip every night
  • Pay your dues on nights, then apply for days

More night shift nurse resources

Anatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyAnatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyWomens Night Shift Nurse Funny Keeping Em Alive Nursing Shirt Large NavyWomens Night Shift Nurse Funny Keeping Em Alive Nursing Shirt Large NavyCoffee Mug Tea Cup BlackCoffee Mug Tea Cup BlackDon Not Disturb Night Shift Nurse Sleeping e Sign / Nurse Door SignDon Not Disturb Night Shift Nurse Sleeping e Sign / Nurse Door SignADULT NURSE T-SHIRT AM BAT NURSE I WORK THE NIGHT SHift ShirADULT NURSE T-SHIRT AM BAT NURSE I WORK THE NIGHT SHift ShirBecoming Nursey: From Code Blues to Code Browns, How to Care for Your Patients and YourselfBecoming Nursey: From Code Blues to Code Browns, How to Care for Your Patients and Yourself

Season 2, Episode 9: Code STEMI, Code Stroke, and Code Sepsis Show Notes

Season 2, Episode 9: Code STEMI, Code Stroke, and Code Sepsis Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 2, Episode 009 show notes or view them below

Code STEMI, Code Stroke, and Code Sepsis

Code STEMI, Code Stroke, and Code Sepsis – Show Notes

In this episode, Elizabeth (former code-team nurse) takes the lead in discussing what’s important for new nurses to know about STEMI, stroke, and sepsis. We discuss nursing care and the big three – Code STEMI, Code Stroke, and Code Sepsis.  Please note, this episode was recorded in January 2017, and the latest evidence at that time. The best practices surrounding treatment of these evolve continually and we encourage you to ensure you’re referring to the latest evidence and facility policy while providing patient care.

Code STEMI

  • ST-elevated Myocardial Infarction
  • American Heart Association – Recommendation for Criteria for STEMI Systems of Care
  • Symptoms – a non-exhaustive list
    • Chest pain
    • SOB
    • Diaphoresis
    • Atypical symptoms (back or epigastric pain)
  • STAT 12-lead will confirm and is required
  • Time to diagnosis to intervention is critical
  • Notify MD immediately for them or cardiology to review ECG; notify cath team/rapid response
  • Need a working IV, preferably 2 and get them on a monitor and full vitals
  • MONA is mentioned (morphine – oxygen – nitroglycerin – aspirin) but is not a hard and fast rule
  • May give a beta blocker and/or heparin
  • Goal to get to cath lab as fast as possible to stent/restore myocardial blood flow
  • Time is of the essence!

Code Stroke

  • Ischemic and hemorrhagic
  • American Stroke Association Guidelines and Statements
  • Time is brain, people!
  • Various scales to measure signs/symptoms    at different points of contact
    • NIHSS, FAST, Cincinnati Stroke Scale
  • Symptoms – a non-exhaustive list
    • Arm drift
    • Slurred speech
    • Facial droop
  • Blood sugar and vitals first – hypoglycemia can mimic stroke
  • Get nursing help! Rapid response, charge nurse, notify MD
  • Last known normal time is critical if you’re getting a history from the family/loved ones
  • Patient will need a CT – transport them yourself, do not wait for transport
  • Patient should be on a monitor with frequent vital
  • Neurologist/MD should be evaluating if the patient is a candidate for tPA and/or intervention (like a thrombectomy)
    • This is a really great resource from the American Stroke Association and American Heart Association, containing stroke treatment standard of care, tPA criteria, and information on mechanical thrombectomies
  • Very important to know blood pressure! May need to decrease it to qualify for tPA
  • If you’re not sure – get another set of experienced eyes on the patient, STAT!

More neuro resources

FreshRN Podcast episodes specifically related to neuro:

NRSNG Podcast Episodes specifically related to neuro:

Neuro-specific blog posts:

Code Sepsis

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

Enroll in Class

STEMI 12 Lead Tool Vertical Reference Badge ID Card (1 Card)STEMI 12 Lead Tool Vertical Reference Badge ID Card (1 Card)Healing Hearts: One Stemi Cardiovascular ShirtHealing Hearts: One Stemi Cardiovascular ShirtMy Stroke of Insight: A Brain Scientist's Personal JourneyMy Stroke of Insight: A Brain Scientist’s Personal JourneyAnatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyAnatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyNo Sepsis Pinback ButtonNo Sepsis Pinback ButtonJust Beat It Sepsis Shirts Love Hope Faith Support FightJust Beat It Sepsis Shirts Love Hope Faith Support FightHandbook of SepsisHandbook of Sepsis

Season 2, Episode 8: Dealing with a Negative Unit Culture, Nurse Bullies, and Confrontation Show Notes

Season 2, Episode 8: Dealing with a Negative Unit Culture, Nurse Bullies, and Confrontation Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 2, Episode 008 show notes or view them below

Working on nursing units can be amazingly rewarding with great teamwork, but can also be really challenging if you don’t fit right in or if you encounter a Negative Unit Culture, Nurse Bullies or more. In this podcast episode, we discuss some tips on how to deal with this.

Dealing With a Negative Nursing Unit Culture, Nurse Bullies, and Confrontation – Show Notes

Working on nursing units can be amazingly rewarding with great teamwork, but can also be really challenging if you don’t fit right in or if you encounter a Negative Unit Culture, Nurse Bullies or more. This episode discusses how to deal with a negative unit culture, the importance of emotional intelligence, self-inventory, how to respond to nurse bullies, and confrontation. We talk empathy, sympathy, and more.

Observe the culture of the unit

  • Try to feel out the people who are negative
  • Observe what they’re passionate about and care about a lot (both negative and not)
  • Pay attention to the informal leaders – what are they like as a person?

Mental self-inventory

  • How do you communicate when things may not be right?
  • Mental self-inventory
  • How do you receive correction?
  • Identify the feelings you may be experiencing, give the feelings a name (hurt, insecure, frustrated, scared, whatever), and try to step outside of them and observe the situation. Don’t make decisions or act out of emotions
  • Emotional intelligence – takes time (link to emotional intelligence book)
  • You can’t control the behaviors of others, but you can control yourself and how you respond to their emotions and your own

Empathize

  • Empathize with one another, not just your patients
  • Dr. Brene Brown’s 2:53 minute explanation of empathy vs. sympathy

Tips to deal with negativity

  • Be outside of the negativity, not within it
  • Be silent when people are being negative/gossip – soon it’s not going to be fun to talk to you about negative stuff
  • If you’re truly concerned about a new grad or another employee, bring it straight to the person directly or to the higher up (for example, a manager) rather than talking about them with others
  • Counteracting negative points with positive ones
  • Casually say, “Man, I wonder what people say about me when I’m not here…”
  • Get to know negative people, and learn things about them that are not negative and engage in those topics with them
  • This takes time, but is worth it
  • Negative people / bullies may not realize that is how they are perceived
  • Be unapologetic about being positive – don’t feel like you need to be a rain cloud to fit in

More reading on dealing with negative people

Do No Harm Applies To Nurses Too!: Strategies to Protect and Bully-proof Yourself at Work.Do No Harm Applies To Nurses Too!: Strategies to Protect and Bully-proof Yourself at Work.The Positive Solution to a Negative Workplace: You can survive, thrive, and take back your soulThe Positive Solution to a Negative Workplace: You can survive, thrive, and take back your soulWhat's Next: The Smart Nurse's Guide to Your Dream JobWhat’s Next: The Smart Nurse’s Guide to Your Dream JobAnatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyAnatomy of a Super Nurse: The Ultimate Guide to Becoming Nursey

Season 2, Episode 7, Tips for New Grad Nurses on Resumes, Applications, and Interviews Show Notes

Season 2, Episode 7, Tips for New Grad Nurses on Resumes, Applications, and Interviews Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 2, Episode 007 show notes or view them below

Tips for New Grad Nurses on Resumes, Applications, and Interviews Show Notes

Tips for New Grad Nurses on Resumes, Applications, and Interviews

Show Notes

This episode covers the essential aspects of landing a job and gives practical tips for new grad nurse on resumes, applications, and interviews. All three of the hosts have experience interviewing new graduates and we give you our insider tips on the process.

Resumes

  • Perfect, no typographical errors
  • Don’t put all of your clinical experience
    • Put things that are relevant to this job
  • Put people other than your clinical instructors; nurses on the unit, MD’s, manager
    • Get a team of cheerleaders – people who will vouch for you
  • Networking begins in nursing school
    • Make a good impression EVERYWHERE
  • Don’t think only clinical people can write resumes
    • Volunteers, administrators, administrative assistants, leadership

Applications

  • Don’t wait until graduation to apply
    • Do this way before graduation
    • Look at the websites of prospective facilities
  • HR departments are slow
    • Give it a few weeks before calling about the status of an application
    • Many won’t even let you call them; they just update online portals
  • Video interview tips
    • Don’t look at the floor
    • Look at what’s behind you – remember they are seeing that!
    • Don’t wait until the last day

Interviews

  • First impression begins with scheduling the interview
    • Don’t be difficult to schedule because it looks bad
  • Look up information on the facility, work into the conversation
  • Questions beforehand
    • Go over them at home, with others – even if it looks silly!
  • Strike the balance between confident and cocky
  • Handwritten thank you note post interview – looks awesome
  • Make sure you’re speaking positively about yourself and not negatively about others to make yourself to look good

More resources

Get Hired Every Time: Job Interview Tips for the New or Seasoned Nurse: A quick guide to nursing job interview success!Get Hired Every Time: Job Interview Tips for the New or Seasoned Nurse: A quick guide to nursing job interview success!Cracking the Nursing InterviewCracking the Nursing InterviewAnatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyAnatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyYou're Hired! A Nurse's Guide to Success in Today's Job MarketYou’re Hired! A Nurse’s Guide to Success in Today’s Job Market

Season 2, Episode 6: Nurses Make Mistakes – Show Notes

Season 2, Episode 6: Nurses Make Mistakes – Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 2, Episode 006 show notes or view them below

Nurses make mistakes

Nurses Make Mistakes – Show Notes

Contrary to popular belief, nurses as not perfect. Nurses make mistakes. In this episode, we discuss the mistakes we’ll never forget, as well as a few others. We also discuss some tips on how to deal with mistakes as a new nurse.

“The potential for harm in the absence of diligence is profound” – Kati Kleber

  • Respect the fact that you can make an error at any turn – do not take this lightly
  • Stay up to date on policy – be familiar with them for yourself
    • Policies change and it is your responsibility to be aware of these
  • Know your tasks

    • It’s your responsibility to know the safest way to do the tasks you need to complete
  • Be assertive when you need to focus

    • This may need to be done when passing meds, adjusting IV pumps, adjusting monitors, or assessing patients
    • Talking point: “I would love to finish this convo – if you could give me just a few minutes to focus on (blank; these medications/programming this pump/programming this monitor) then let’s chat.”
  • Safety is always the priority

    • Be unapologetic about patient to safety to everyone
      • From physicians to fellow nurses to patients and families
  • Subjective vs. Objective Data – helpful resources

  • Incident reports

    • The process for each place is different – know how to do this
    • Fill these out whenever necessary – they are not a way to penalize you
      • Maybe there is a process that needs to be changed – this documentation enables this change
      • We have all filled these out multiple times… for ourselves, for larger situations, and other times
  • More resources on nurses making mistakes

Nurse Appreciation Gift Mistake Your Internet Search for Degree Gift Coffee Mug Tea Cup BlackNurse Appreciation Gift Mistake Your Internet Search for Degree Gift Coffee Mug Tea Cup BlackMedicine, Mistakes and the Reptilian Brain: The NewMind Response(TM) to better decisionsMedicine, Mistakes and the Reptilian Brain: The NewMind Response(TM) to better decisionsMens Autocorrect Has Become My Worst Enema T-Shirt Large BlackMens Autocorrect Has Become My Worst Enema T-Shirt Large BlackAnatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyAnatomy of a Super Nurse: The Ultimate Guide to Becoming Nursey

Season 2, Episode 5, Pain Management Tips Show Notes

Season 2, Episode 5, Pain Management Tips Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 2, Episode 005 show notes or view them below

Pain Management Tips Show Notes

Nursing Pain Management Tips – Show Notes

CORRECTION – in the episode we refer to something called substance abuse disorder. The appropriate term is substance use disorder.

This episode covers the important difference between pain management and pain elimination, patient education, appropriate assessment, a proactive approach to pain management versus reactive, and some essential definitions.

Striking the balance between too much pain medicine and not enough can be tough for any nurse, let alone a brand new nurse. What throws a big wrench in everything is the fact that we, as a nation, are experiencing a very real and very devastating epidemic of opioid use and abuse. Bedside nurses feel the brunt of this due to many patients requesting sometimes very concerning amounts of intravenous pain medications at alarming intervals. Here are some tips from bedside nurses about pain management.

A few helpful links diving deeper into the opioid epidemic

Set realistic expectations

  • What does “treat pain” means to this specific patient?
    • Do they think you’re going to eliminate all pain, or bring it down to a manageable level?
  • Pain management versus pain elimination – know the difference
  • If possible, educate before a surgery or procedure so they know what to expect and if they’ll have any movement limitations
    • For example, lying flat for 6 hours post femoral sheath placement

Proactive education

  • Ideally provided before planned surgeries by the MD
    • What kind of pain is to be expected with various issues
  • Educate about pain medications, how long they last, when to let you know that they need another dose
  • Identify what level of comfort is tolerable
  • Explain pain scales BEFORE if possible
  • Some think the pain management that occurs in the PACU continues on the floor (frequent assessments and IV pain med administration), but it does not and many are not aware
  • Special scenarios – like neuro, where we can’t overmedicate due to its impact on the patient assessment
  • Always think about transitions – IV to PO, weaning off PO
  • Ensure the patient knows what “pain meds” means and that it
    • Many don’t know which specific pain meds to request if multiple kinds are ordered (for example, when IV morphine and PO norco are both ordered and the patient requests “pain meds,” don’t just give whatever the last nurse gave – have a conversation about the specific medication to be given)
  • Balance between comfort and overmedicate and unable to participate in care

When you think you’re being manipulated

Please read Nurse Beth’s 6 steps in this article – Nurse Beth’s 6 steps are below, they are incredibly helpful and realistic:

  1. Check your judgemental attitude
  2. Be realistic
  3. Understand your job
  4. Take control
  5. Do not engage in a power struggle
  6. Be professional

More Resources

Fundamentals of Pain Medicine: How to Diagnose and Treat your PatientsFundamentals of Pain Medicine: How to Diagnose and Treat your PatientsCore Curriculum for Pain Management Nursing - E-BookCore Curriculum for Pain Management Nursing – E-BookPain Management Pocketcard SetPain Management Pocketcard SetPain Management Nursing Exam Study Guide: Test Prep and Practice Test Questions for the Pain Management Nursing ExamPain Management Nursing Exam Study Guide: Test Prep and Practice Test Questions for the Pain Management Nursing Exam

Tips for New Grads in the ICU Show Notes

Tips for New Grads in the ICU Show Notes

Click here to list to this FreshRN Podcast Episode

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.

Download the Season 2, Episode 004 show notes or view them below

Tips for New Grads in the ICU

 

In this episode we discuss characteristics of the intensive care nurse, normal expectations, critical thinking, advocacy, communication, and more. We dive into 8 tips for new grads in the ICU! This episode is hosted by 3 CCRN nurses, which is a critical care specialty certification granted by the American Association of Critical Care Nurses.

8 Tips for New Grads in the ICU

#1 Come in with an open and actively engaged mind

  • Expect to be overwhelmed for awhile (at least 6 months)
  • Fight the “I want to be perfect” mentality; while it’s admirable, it’s not possible – setting yourself for more stress and disappointment with that expectation
  • Nursing is a practice – you’re never going to be at a point where you don’t make mistakes or be perfect. There is an art to this.  The skills in nursing school aren’t the only ones you’ll need.

#2 Be aware of typical ICU nurse characteristics

  • Assertive, direct, business-like attitudes, detailed-oriented, anticipating things ahead of time, know protocols inside and out, intense, autonomous (very familiar with protocols, able to enact orders/protocols independently and then discuss with MD).
  • You are still bringing something to the table, it’s just different than what the others who bring to the table who are already there.

#3 Show initiative

  • You’ll have to be assertive yourself – go home to learn and understand more
  • Invest time into making yourself better in the off time
  • Round with MDs, seeking out learning opportunities
  • Introduce yourself to others

#4 – Know yourself and be your own advocate

  • Know your learning style and communicate this to your preceptor
  • Know your limits / what you don’t know so you can fill in the gaps
    • Please don’t be the new grad know-it-all
    • Find the balance between not knowing anything and being so obvious about that people question your ability to be a safe care provider, and being the know it all who continually acts like they do not need to be educated
  • Find a mentor!

# 5 – Own your orientation

  • Orientation is truly an extension of nursing school without formal grading
  • Ask for help when you need it – sometimes your preceptor cannot always pick up on times when things aren’t clicking
  • Advocate for yourself!
  • Work through the process of orientation; it’s a marathon and not a sprint

#6 – Keep an organized routine throughout your shift

  • Have a systematic routine way of assessments, your day, meds, etc. otherwise you will miss somethings
    • This helps get through the shift and not miss things.
  • Stop and get organized first before starting your shift so you start on a good note.
  • Resource: Anatomy of a Super Nurse, The Ultimate Guide to Becoming Nursey, chapter 7

Anatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyAnatomy of a Super Nurse: The Ultimate Guide to Becoming Nursey

#7 – Learn your alarms and use them to your advantage

#8 – You need downtime

  • Becoming a critical care nurse straight out of school tough and exhausting, take care of yourself
  • Again, advocate for yourself
  • Take time off for yourself, make time for yourself – no one will do this for you

Resources for newbies to critical care

NRSNG also has quite a few great resources for nursing students and new nurses.  There are various courses, or the entire academy. You can even get a 7 day trial of academy for only $1! The specific courses that would be valuable to the new ICU RN in particular include:

ICU Skills Conference

Learn both hard and soft skills about ICU nursing care. From vasopressors to emotional support, this comprehensive ICU skills workshop covers topics applicable to every nurse working in critical care, as well as those sending patients to, or receiving patients from, intensive care.

Use code ICUskills for $20 off!

Womens Intensive Care Unit ICU Nurse T-Shirt Small BlackWomens Intensive Care Unit ICU Nurse T-Shirt Small BlackCritical Care Notes: Clinical Pocket GuideCritical Care Notes: Clinical Pocket GuideOpoway Pen Light with Pupil Gauge LED Penlight Medical for Doctor Nurse Diagnostic Batteries Free 2ct. Pink and WhiteOpoway Pen Light with Pupil Gauge LED Penlight Medical for Doctor Nurse Diagnostic Batteries Free 2ct. Pink and White

Season 2, Episode 003 Neuro Nurse Tips for Newbies Part III: Meds, Diagnostics, Monitoring, and Surgeries

Season 2, Episode 003 Neuro Nurse Tips for Newbies Part III: Meds, Diagnostics, Monitoring, and Surgeries

neuro nurse tips for newbies

You can listen to Season 2, Episode 3 here.

Neuro ICU Nurse Tips for Newbies, Part 3: Meds, Diagnostics, Monitoring, and Surgeries

Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, documentation for nurses, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.

Download the Season 2, Episode 003 Neuro Nurse Tips for Newbies Part III: Meds, Diagnostics, Monitoring, and Surgeries or view them below.

We continue our journey through neurocritical care nursing with more neuro nurse tips for newbies!

This episode discusses some important meds (mannitol, hypertonic saline), different kinds of monitoring (ICP), diagnostics (CTA, MRI), and surgeries (craniotomies) that are pertinent to the neuro nurse. This episode is hosted by three neurocritical care nurses.

Medications

tPA – discussed in Part I

Mannitol – osmotic diuretic, given to decrease ICP

  • Increasing the plasma osmolality to pull fluid off of the brain, into the intravascular space, and out of the bed
  • The cells actually shrinks because they were “swollen” – this “shrinks” them back down to their normal size
    You’re increasing cardiac output; increasing urine output

    • You’re putting more fluid into the vessels
    • Watch patients with existing fluid overload issues (like congestive heart failure)
  • Watch electrolytes
  • Basic metabolic panel (BMP), serum osmolality
  • Know holding parameters
  • If the serum osmo is too high, you can have cellular death because they’re shrinking too much which can ultimately cause more edema… there’s an inflammatory process that occurs when cells die
    • Normal serum osmo 275-285 (may differ between, typically holding if it gets to 320
  • Watch for kidney issues – intrarenal vasoconstriction can occur
  • Know sodium and how quickly it trends up; we expect it to rise but we don’t want a sudden drastic increase – you may have a holding parameter for the sodium as well
  • Give it through a filter set or draw it up with a filter needle – hurts like hell if you don’t
    • I would draw up with a blunt needle and give with a filter set because it’s faster
    • Whatever you do – FILTER it
  • Mannitol crystallizes and can get cloudy; don’t give it if it’s cloudy/crystallized

Hypertonic saline (3%) – treat hyponatremia and/or cerebral edema

Vasoactive drips

  • Nicardipine, Norepinephrine, Neosynephrine are some examples
    • KNOW THESE if you’re working in a neurocritical care unit
  • Consider the disease process when giving PRN BP meds
  • For example, if the patient has a hemorrhagic stroke and needs consistently blood pressure control, a Nicardipine drip at a low dose would offer more consistent/level blood pressure than intermittent dosing of a PRN IV push med (like 20 mg Hydralazine) when the BP spikes again
  • If a patient is hemodynamically unstable and requiring vasoactive med, get a central line sooner than later
  • If your patient is on a drip to keep their blood pressure UP, do not give their scheduled antihypertensive medications (if any).  Clarify holding parameters or temporarily hold them (after clarifying with the physician) while the patient is on the medication to increase the blood pressure.
  • Double check drips, dosings, titrating, why, and wean
  • Consider other meds the patient is getting while vasoactive meds are getting and the impact they may have on the blood pressure medication
    • For example, many antiepileptics will lower blood pressure

Antiplatelets / anticoagulants

    • Typically many patients with a hemorrhagic stroke are on a blood thinner
    • Know if they’re on any; when it was last taken and the dose
    • Reversal agents
  • Examples: Fresh frozen plasma (FFP), Kcentra, vitamin K
  • Educate family on why it’s being reversed; this can be especially challenging when they’ve been told by their physician for years how important their blood thinner is and now they’re not getting it
  • If you have a mechanical valve who had a hemorrhagic stroke, they will be taken off their blood thinner – you must recognize the big risks with this
    • Cardiology and neurology will be working together to figure out what’s best because they’re stuck between a rock and a hard place (risk another hemorrhagic stroke, or risk a ischemic stroke or pulmonary embolism due to the mechanical valve)

Antiepileptics

Know your indications

If you have Lorazepam ordered for seizures, do not give it for agitation. Call and get another order

Diagnostics

  • MRI vs. CT
  • EEG – electroencephalogram
    • Most likely due to seizure activity
    • Educating family/patient is critical
      • Families think that an EEG will tell you very detailed aspects of brain function (what they can/cannot understand, if they can hear and understand what’s going on around them, etc.)
      • It shows the electrical activity, not structure
      • Think of it like an ECG shows the electrical activity of the heart and an echocardiogram shows the structural components while an EEG shows the electrical activity of the brain and a CT/MRI shows the structures
    • Continuous versus spot EEG
      • Just because you
    • Don’t document if you see the patient having a seizure; you can’t say definitively say someone is having a seizure without the EEG to confirm it
      • Chart “rhythmic twitching” or whatever it is that you see
    • The children’s book we talked about, written by a nurse, to explain to his kid what he does working as a nurse:  Daddy, the Amazing Nurse! By Donald Jacobsen, RN
  • Brain death testing
    • EEG, apnea testing, cold caloric testing

Surgeries/Procedures

Thrombectomy

  • Neurovascular procedure; similar to a heart cath but in the brain
  • Catheter placed through femoral artery up to the brain, administer contrast, so they can identify the clot and remove it to open up a blocked artery in the brain
  • Only done for large vessels – so think any artery in the Circle of Willis
  • This is done when there is clear indication for it because it is an invasive procedure with very real risks; most patients have had a CTA first
  • Video animation of a of thrombectomy: https://www.youtube.com/watch?v=7TcUoBQqkac
    • Please note, this shows only 1 device and was published in 2013. He states that they use tPA or this procedure. Now, both can be done to the same patient to perfuse the brain.
  • Remember your post-procedure care; similar to a patient who just had a cardiac cath with a femoral approach (lay flat for 6 hours, pressure and monitoring insertion site, watch for a hematoma/retroperitoneal bleeds)

Craniotomy

  • Removing part of the skull to get to the brain to do something (remove a tumor, clip an aneurysm, remove a hematoma, and many more reasons)
  • Typically incision pain not necessarily all up in my brain pain – not as many pain receptors in the brain so it’s not as painful as other surgeries

Craniectomy

  • Removing part of the skull and leaving it off to allow room for edema
  • Can be stored in a freezer or in the patient’s abdominal cavity

New articles we discussed

External ventricular drains

  • Draining CSF and/or blood to relieve pressure
  • Drains via gravity, so it must be leveled correctly
    • Similar to an arterial line
    • Anatomical landmark – foramen of Monro
    • Tragus or lateral canthus
    • MUST follow precisely – a change of head of bed can fatal
      • Educate families and other healthcare team members not to move the head of bed without checking with the nurse
    • Can be hooked up to ICP monitoring

Monitoring

ICP monitoring

  • 7-15 mmHg = normal
  • 20+ mmHg = uhhh… you need to do something
  • Can be done with an EVD or a bold

Cerebral perfusion pressure (CPP)

  • MAP-ICP = CPP
  • Basically, the blood pressure of the brain
  • You want to maintain CPP, even in the event of increased intracranial pressure because you want to ensure the brain is getting the blood flow it requires otherwise additional damage/compromise can occur
  • 60-70 typically good
  • 50 or less, you are going to have brain issue because the brain is not being adequately perfused with blood
  • Just because the CPP is high doesn’t mean it’s great either
    • May have other issues like ARDS
  • It’s a balancing act

Body temp

  • This is so important guys!
  • For every degree of increase in body temp, the increase in oxygen demand increases 10%
  • Aggressively treat fevers
    • Know your orders!
  • Neuro changes can occur with increased body temp
  • If you’ve got neuro changes, check a body temp to see if it’s increased. This could explain your neuro changes.
  • Combination of Fever, Neurological Injury Strongly Linked to Poorer Outcomes

Encouragement

More neuro resources

FreshRN Podcast episodes specifically related to neuro:

NRSNG Podcast Episodes specifically related to neuro:

Neuro-specific blog posts:

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

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