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Who You’ll Hear
Kati Kleber, MSN RN CCRN-K – Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, speaker
Melissa Stafford, BSN RN CCRN SCRN – Highly experienced and currently practicing nationally certified neurocritical care nurse
Elizabeth Mills, BSN RN CCRN – Highly experienced neurocritical care nurse, current Stroke Navigator for a Primary Stroke Center
What You’ll Learn
- Incentive spirometry
- Intake and Output (I&O)
- Oral Care
- Consider the Environment
The skin is the largest organ in the human body!
- Not repositioning at least every two hours can cause life-altering injury.
- Just because a patient can turn themself doesn’t mean they do turn themself.
- Incorporate repositioning as part of your rounding, as part of your routine for each major time you are in the patient room.
Pillow-ify the patient!
- 30-45 degree turn to get patient off their sacrum and spine (wedges or many pillows to support)
- Pillow between knees
- Pillow under arms
- Reposition devices or tubing that can be moved
- One flat pillow under a hip isn’t enough!
- Only changing head-of-bed up or down doesn’t count!
Maximize what you do each time you go in the room by weaving multiple assessments into the turning process.
- Neuro assessment: level of consciousness, ability to follow commands, pain response
- Skin assessment: look at their skin! Any new redness under devices? Need any protective dressings on bony prominences?
- Respiratory: listen to posterior lung sounds while turned
Why do we do it?
- It’s important for all patients, but especially post-operative patients to maintain their respiratory function.
- It helps the patient to take a very big breath, bringing air down into the deepest parts of the lungs to open up the alveoli.
- When those alveoli collapse, atelectasis develops, which can turn into full-blown pneumonia.
Teaching your patient
- The device has two chambers: one measures the volume, the other how fast the breath is being taken.
- Goal is to take in as large of volume as they can, at a slow and steady speed— this helps the air to really circulate through all the airways and open up the alveoli– and then hold that deep breath in as long as they can.
- If they’re doing it right, they’ll likely become short of breath– it is exercise for your lungs.
- The patient can splint their surgical site (abdomen, chest, ribs) with a pillow or folded blanket to offset the pain associated with taking a deep breath after those surgeries.
Nurse tips and tricks
- In addition to teaching the patient how to do it, teach them and their families the importance of it— give them the motivation to do it even when you aren’t standing there asking them to do it.
- Make a game out of it by setting goals, or if the patient is watching TV tell them to do 3-4 reps every commercial break– then involve the family member by asking them to keep track of their progress on the white board.
- Again, this is all to prevent respiratory issues from developing, making sure the patient can move on to the next phase of care as quickly as possible
Intake and Output (I&O)
Every single mL of fluid that goes into your patient and every single mL of fluid that comes out of your patient should be documented.
- If your IV pumps can communicate with your EMR, verify those fluid volumes at least every shift. Otherwise it may look like a patient had days of zero IV fluids, and then 10,000mL all in one shift– that isn’t accurate!
- Consider tube feedings, including scheduled water flushes and fluid with medication administration.
- Make sure there is a hat in the toilet or a urinal available in the bathroom so that every void can be measured (if your CNA isn’t doing this, it is your responsibility to have that discussion and correct it).
- If incontinent, weigh incontinence briefs or pads to capture urine output.
- All drains including chest tubes, EVDs, NGs, JPs, ostomies, wound vacs, etc.
Involve family members
- Put them in charge of writing on the white board every juice box that was finished and every cup that was taken away.
- Many family members appreciate the involvement and take pride in contributing to the care of the patient.
The patient’s weight is also a factor in tracking I&Os
- Do daily weights if ordered, or ensure your CNA is doing it.
- If using bed scale first remove SCD pumps, excessive blankets, and additional devices, empty drains and foley catheters– all things that would make the reading inaccurate
Very important aspect of clinical decision making
- Documented intake and output determine
- what medications and fluids are prescribed
- when drains are ready to be discontinued
- if enough nutrition is being provided
- Providers only look at the hard numbers in the chart and they rely on your documentation to be accurate.
- Document as often as ordered (Q shift, Q4, Q2, Q1), because the providers are monitoring it that often
- For ventilated patients
- Oral suction (deep in the back where secretions pool)
- Chlorhexidine rinse with suction swabs
- Prevents ventilator associated pneumonia (VAP)
- Not just for ventilated patients!
- Brush teeth
- Oral swabs
- Denture care
- For conscious patients, reduces the risk of pneumonia if a patient is silently aspirating
- If a patient refuses oral care, educate and encourage. Patients do not realize the impact that oral health can have on overall health.
Consider the Environment
A stimulating environment can agitate patients, while a familiar environment can calm them.
- Noise level
- Alarms going unaddressed
- Roommates or family talking
- Noise from the nurse’s station
- During the day, lights on, blinds pulled up
- At night lights dimmed, blinds drawn
- Create a comforting environment– ask the family members!
- Use preferred name
- Put on favorite music
- Put on a favorite TV show
- Place pictures of family and pets in view
- Talk about their interests or hobbies while doing patient care
- Check your bases to save your faces. When troubleshooting an issue, go back to the basics and work your way up to the more complicated possibilities.
- As nurses, we are the patients’ guide along their hospital pathway. We can either be a passive and disengaged guide or we can be a motivator and a coach, teaching and encouraging them throughout their admission.
- Many of these tasks are part of a person’s ADLs so if patients can do it themselves, we need to encourage that independence (while ensuring that it is actually done) and not enable them by just doing it for them.
- We can get so focused on other important nursing things, that we forget the value of the basics. We need to include all of it in our nursing care.
- What makes the very best nursing care is being able to fit those most basic elements of care into our already very busy day.