December 15, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
For patients who need IV antihypertensive therapy, labetalol and nicardipine have emerged as the agents of choice because they maintain adequate cerebral perfusion while producing generalized reductions in vascular resistance.

December 14, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Aortic dissection has an immediate goal to reduce intimal shear forces by driving down the pressure that results from LV ejection with each cardiac cycle. This is best accomplished by decreasing heart rate and stroke volume.

December 13, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
With aortic dissection, unlike for other hypertensive emergencies, BP control to a specific target (systolic BP < 110 mm Hg) is essential because it decreases ongoing injury and reduces the likelihood of perioperative adverse events.

December 12, 2018

Nursing School | Read The Required Text

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Based on recommendations in JNC 7, the long-standing approach to acute antihypertensive therapy has been to target a maximal reduction in MAP of 20% to 25% within the first hour and a goal BP of 160/100 mm Hg by 2 to 6 hours.

December 11, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Most hypertensive emergencies occur in patients with chronic hypertension. Organ system involvement is dominated by injury to the heart, brain or kidneys. True hypertensive emergencies are defined by the target organ acutely involved.

December 10, 2018

Nursing School | Support System & Class Dynamics

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Unlike the pattern of target-organ damage that occurs with poorly controlled chronic hypertension, a hypertensive emergency results from endothelial injury triggered by an abrupt rise in vascular pressure that overwhelms autoregulatory mechanisms.

December 9, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Uninterrupted by treatment, vasoconstriction in chronic hypertension leads to a number of consequences that cause target-organ damage. On a macrocirculatory level, the central components of the cardiovascular system are most affected.

December 8, 2018

Book Review | The Informed Patient

Disclaimer: I received a free copy of the book for review purposes

As a person who is a nurse and who has an extensive medical history, I know how it feels to be in a hospital bed stressed. To be a patient in the hospital, wondering if everything is going well and hoping all your needs are being met in a timely fashion. Luckily, I have my medical background and work experience to guide my thoughts. Sadly, not every individual has this luxury. Often, people are in the dark about their medical team, common hospital practices, and methods. Practical guidance in this setting could help individuals in being their own healthcare advocate, while also allowing for an understanding of hospital-setting dynamics and environmental factors. I recently had the opportunity to read a book that could provide this very resource to patients and their support system. The book is titled, The Informed Patient: A Complete Guide to a Hospital Stay. The book was written by Karen A. Friedman, MD, Sara L. Merwin, MPH. The book is divided into sections and includes what patients and their support system can expect to see and experience during a hospital stay. The book's goal is to enhance and optimize the hospital stay, while answering common questions and concerns.

My husband was recently admitted to the hospital with chest pain. He has an extensive cardiovascular history, and his symptoms were a concern to everyone involved. As expected, he had a small moment of fear regarding the unknown process of observation. What did it mean? Why was it necessary? What would be happening? Who would be monitoring and assessing him? As a nurse blogger, I have the opportunity to review books from time to time and I gave him this book while he was on his 24-hour cardiovascular observation. I had already read the book but felt perhaps my opinion of biased, as I already knew about hospital processes and what they involved. I wanted to see if this book would help individuals who weren't already apart of the hospital environment. I gave him the book and said nothing about its content. I wanted him to read the book and see if he found value in it.

The following day, I walked into his room, and he was calm. He was resting comfortably, watching television. I asked him if he had any questions and he said, "No, the book helped me understand things. I asked my nurse a few questions, but I don't have any questions for you. I'm good, dear. Sit down, how was your night?" Now, you don't know my husband, but I am his hospital-person. He always had a thousand questions for me. Every time he has admitted for something, I knew I was going to be talking and answering all his questions. So this new development was a bit off-putting. He didn't need me, haha. As the day went on, he was even answering questions I had. I was very impressed! The book served its purpose and made my husband his own advocate. It's worth its weight in gold. Nothing beats knowledge. It was amazing to see him so calm and relaxed, knowing he knew exactly what was happening next. This book has many tips and covers various hospital topics. I'd recommend this book to anyone who is unfamiliar with the hospital setting and medical relationships. It's an easy read and presents complex concepts in a simplistic manner.

As a caregiver myself, I found this book to be accurate in the representation of the hospital stay. Every vignette and piece of advice was honest and authentic. The authors took their time to explain each component of the hospital stay, with each chapter building upon the previous one. By the end of the book, the reader has a full picture of every aspect of their healthcare team and medical system. I wish this book could be distributed to each newly admitted patient. It would be an excellent prelude to the hospital admission process. Self-education is empowering and this book will empower its readers.

Topics in the book include:
1. Why You Need This Book / How to Use This Book
2. The Changing Landscape of Medicine
3. The Emergency Department Experience **
4. Getting Settled and Finding Your Way **
5. Figuring Out the Care Team **
6. Physicians of All Kinds **
7. Lines, Ports, Drains, Tubes & Catheters **
8. Tests and Procedures in the Hospital **
9. Nutrition in the Hospital
10. Protocols and Precautions **
11. Intensive Care Units (ICUs) **
12. Special Patient Populations
13. Elective Surgery
14. Unplanned Surgery
15. Discharge
16. Some Final Thoughts
** Denotes my favorite chapters!

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Continued vascular stimulation by the SNS and renin-angiotensin-aldosterone system, coupled with an increase in wall tension caused by hypertension itself, leads to ongoing remodeling throughout the arterial tree.

December 7, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Angiotensin II exerts systemic and renal effects by binding to angiotensin II type I (AT1) receptors, which results in arterial vasoconstriction, sodium reabsorption and modulation of the glomerular filtration rate (GFR).

December 6, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Renin cleaves angiotensin I from its plasma globulin precursor, angiotensinogen. Angiotensin I is then converted to angiotensin II by circulating and tissue-bound (especially in the lung), angiotensin-converting enzyme (ACE).

December 5, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
In addition to activation by the SNS, the renin-angiotensin-aldosterone system exerts critical independent effects on BP. Renin is an enzyme produced by juxtaglomerular cells in the kidney in response to several factors.

December 4, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
The sympathetic nervous system (SNS) has a pivotal role in the development of hypertension. Norepinephrine, the principal sympathetic neurotransmitter, is a potent stimulator of vasoconstriction.

From Bedside Nurse ➡️ NP Student: Credentialing Process

I got a job, oh my god! Someone believed in me and is willing to train me, AND it's a well-renowned hospital in Tampa, Florida.

My new job is an ARNP of Cardiovascular Surgery at a Cardiothoracic ICU!

I am beyond excited to start. I wanted to explain the credentialing process because I was unaware of what was involved and I grossly underestimated the time frame needed to verify my information. Now, each state is different, but all government agencies require this type of professional verification. The credentialing process involves the confirmation of an applicant's education, eligibility, licensure, certifications, risk potential, and professional references. Credentialing is the practice hospitals use to evaluate and verify the qualifications of their healthcare providers to ensure that each individual practitioner possesses the necessary qualifications to provide medical services to their respective patients. Once a practitioner is credentialed, the hospital will take further steps to assess the practitioner’s competence in a specific area of patient care, through a process known as privileging.

The time frame of credentialing can range from 30 - 200 days, depending on the institutional processes and how prompt you are at providing the required documentation. It's a long process and will involve you speaking to multiple people and being on top of things. I recommend anyone who is starting this process to check your inbox often and check with your medical office contact frequently to make sure you are on your way to heading to orientation in a reasonable timeframe. Because often, hospital committees meet only certain times per month. So if your paperwork isn't completed and in before the meeting documentation deadline, you will have to wait until the next meeting for consideration and approval.

Oh, and oftentimes you have to come out of pocket money-wise for the verification process, but you will be reimbursed after you're approved. Weird, I know. But do you expect a company to do all this legwork, pay multiple companies to verify your information, to then find out you're under house arrest after investing $250 in getting you credentialed? I know, it's annoying but make sure you ask this upfront. Some places cover this upfront cost for you, but just make sure you ask.

Your employer's medical office will usually manage all the verifications and document processing for you. Don't do any of this on your own. I broke down my verification process for information purposes only. Your employer will have procedures for obtaining this information. The only thing you have to independently obtain is your NPI Number. The rest will be done for you, usually.

What did my credentialing process include?

1. Copy of Master's of Science degree in Nursing (MSN)

2. Copy of college transcript for Master's of Science degree in Nursing (MSN)

3. Apply (it's free) and obtain CMS National Provider Identification (NPI) Number

  • The NPI is a Health Insurance Portability & Accountability Act (HIPAA) standard. It is a 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services

4. Verification: National Practitioner Data Bank (NPDB) Screening

  • Information on medical malpractice payments and certain adverse actions related to health care practitioners and providers

5. Verification: Office of the Inspector General (OIG) Background Check

  • Individuals on the List of Excluded Individuals and Entities are barred from participating in federal health care plans. Hiring these individuals may result in civil monetary penalties as well as loss of reimbursement

6. Verification: System for Award Management (SAM) Screening

  • Screening against SAM Exclusions is essential for companies that hold Federal contracts and need to screen subcontractors that will work on the federal contract, as well as any company associated with federal assistance

7. Verification & Audit: Malpractice Insurance Records

  • During your nurse practitioner program (college insurance coverage information - for all years of attendance) 

8. Verification: ARNP Certification  - AANP / ANCC

9. Verification: Other Certifications - CCRN / CMC / CVRN / FCCS

10. Verification: Course Provider Cards - BLS / ACLS / PALS / NRP

11. Professional References - ARNPs / MDs /DOs only (at least three, active in roles)

12. Verification: Department of Health - State Nursing Licensure

13. DEA Registration (if applicable to position) -

14. Collaborative Practice Agreement (required) - 

A mutual agreement between the physician(s) and the ARNP

Collaborative Practice Agreement, must include...

     A. A description of the duties of the ARNP
     B. A description of the duties of the physician
     C. The management areas for which the ARNP is responsible, including:
          1. The conditions for which therapies may be initiated
          2. The treatments that may be initiated by the ARNP
          3. The drug therapies that the ARNP may prescribe, initiate, monitor, alter or order
     D. A provision for annual review by the parties
     E. Conditions and a procedure for identifying conditions that require direct evaluation

Disclaimer: I work in Florida, this is my experience. Your process could be slightly different.

December 3, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Hypertension is a major modifiable risk factor for the development of cardiovascular, cerebrovascular and renovascular disease. Uncontrolled BP is strongly associated with stroke, vascular dementia and kidney disease.

December 2, 2018

News Assessment | Vecuronium, Versed & Culpability


You are probably going to dislike my opinion regarding this issue. My opinion is based solely on national news reports regarding the events. I wasn't there, I have no personal ties to the parties involved nor am I aware of their institutional practices. I'm merely a registered nurse in Florida with knowledge regarding the nursing process. This post is about the medication error only. There is more to the story but my focus is on the medication events that took place and the social media comments I've read. My opinion is based on national news accounts of the event and Vanderbilt's response.

Is the nurse to blame for the medication error?

In my professional opinion, yes. By blame, I'm implying that the nurse is responsible for the error, responsible for the incorrect medication being administered. I read the reports regarding the nurse needing to override to the drug, as it wasn't profiled to the patient due to time constraints. I'm aware that the nurse attempted to locate the drug (on the patient's medication record) in the medication dispensing system before overriding said drug. I'm aware of this, I've experienced this, and still, my opinion is unchanged.

Many people online were complaining about the override option being the problem. Do you know how many people have almost died on my floor waiting for medications to be profiled in the medication dispensing system? Many! Too many to count. Various times on my floor, we are running a code and we run out of medications on the code cart. I'm talking 40-minute codes here. We've used up all the drugs on the code cart and we MUST have the override option to save the patient's life (or attempt to anyway). The override option is crucial and necessary in the critical care setting. I don't think all floors need this option but in my opinion, this option isn't an error and it did not contribute to the nurse's actions. Apparently, the nurse typed in V-E, and instead of selecting Versed, the nurse selected Vecuronium. The nurse accepted the medication name, pulled the drug, and administered it. The order was for Versed, yet the nurse administered Vecuronium. Computers only dispense what you accept. Computers only support what you approve. Computers don't make judgment calls, they depend on you to make selections. Have I made medication errors? Yes, but I wasn't blaming a machine for my mistake. I didn't take the time to read the label and it was on me. It was my fault, I'm okay with carrying that burden every day of my life and it's a professional reminder for me to slow down each and every time I dispense a drug. I've been there. I've done that. My patient luckily had no severe complications due to my error. And even then, I'm still saying the nurse messed up. This discussion isn't about good versus evil nurses, it is about a medication error. Folks need to stop trying to extrapolate this into an assault on the entire nursing profession. It's one terrible error that a nurse made. Doctors and pharmacists make mistakes also, but this one was a nurse.

Overrides are for time-critical situations. Where I work, for a newly profiled drug to enter the medication dispensing system, it takes about 10-15 minutes. That is an enormous amount of time for a blood pressure that is 60/15 and dropping fast. The body can only compensate for so long. The patient can only wait for so long. Overrides are life-saving options for patients. Now, one could argue, is Versed an appropriate drug to be on an override list? Yes, rapid sequence intubations occur often and again, respiratory distress doesn't have 10-15 minutes to wait. It's hard to see these scenarios from the outside. But minutes matter, seconds matter. Versed is a commonly overridden drug on my floor as well. Now, should Versed be given to someone who doesn't have a definitive airway? That's is up for debate, but I've seen and administered this drug for the same reason the provider in the event ordered it (anxiety, I believe) and no one died and no harm was caused. But this patient didn't die from Versed. They died from being given a paralytic, their diaphragm stopped working, and they died a slow, agonizing death. That is the problem here. The deflection, the distractions, ignore those. Versed can be given in this situation, it was an appropriate order. Focus less on dodging and more on what resulted, who died, and whose family is forever changed. That is the tragedy here, dear God it is horrible.

I have a very long medical history, so does my husband and my son. We are forever in this hospital dealing with this, that and the other. Nursing, like all professions, has passionate, professional individuals but it also has individuals who don't care, who don't bother following protocols or proper procedures. My father was given 25 pills (his entire day's worth of medications) in one-sitting by a nurse because "they needed to catch his home medications up." He was unresponsive for two days. My father also received an inappropriate amount of insulin because "the computer told a nurse to administer this amount, so she had to do it." I can go on and on about all the subpar nursing experiences I've endured. No one EVER accepted blame. Every nurse explained why they skipped critical steps. Why they didn't do this and why this fail-safe should have stopped them because of blah-blah. It's as if they really didn't need to do the safety steps because they were told something or someone else would catch all the errors. Yeah, scary! You almost killed my family member, and I'm supposed to care about "you being super busy" or you depending on fail-safes to catch your errors without any critical thinking on your part? Do you know how much power nurses have, how easy it is for us to kill people? What was that one spiderman movie saying, with great power, comes great responsibility. I'm so over everyone giving excuses why something isn't their fault. Each and every day I'm surprised with what people can reconcile in their mind, what they can live with and what they will actively compartmentalize and block out. I've been that patient afraid because my nurse isn't focusing or listening to me. I've been that family member who comes in when their loved one is about to die because a nurse was "too busy" and an error took place. The point I'm trying to make is that there will always be distractions but certain steps must be followed. I don't know what the nurse in this story did exactly but clearly, at least one step was missed. That doesn't make him or her a terrible person, they just had a lapse in judgment. We have all been there, no one is perfect. But that doesn't mean accountability goes out the window. I have great sympathy for all parties involved. Clearly, this is a complex issue that requires a root-cause analysis. I'm well aware that I don't have every, single detail. Nor do I know every party's intentions and circumstances. But accountability isn't a zero-sum game either.

We can talk in circles about processes (drugs, pharmacy, radiology). The nurse is the point-person regarding medication administration. The nurse is physically delivering this drug. You are the final piece in the patient and medication connection. Nursing is the role you decided to take, the job you decided you wanted. Don't then back step when the shit hits the fan and tell me, "shit happens, we're only human." Great, well when your loved one is in the hospital, I hope you have that same attitude. Because usually, nurses are the BIGGEST advocates for their family members. They are often seen by the bedside making sure everything is going as expected. I know, it's hard to see the faults within ourselves and to see we can make mistakes. It's scary, but the sooner we understand this the sooner we can find out what our profession needs. We need to slow down, we need more support. We need to see that we are humans caring for humans. We make mistakes, and there is only so much technology can do. Stop dodging the errors and lean into how we can improve this process. The mediation error I had as a new nurse opened my eyes to slowing my actions down. Once that medication is in, it's in there. No amount of apologies will soothe a person who has lost a loved one. Whether I'm giving Pepcid or Propofol, my mindset of the same. Five rights and safety, take a deep breath and do it one more time for good measure. Slow things down. My job is chaotic, I live in chaos for 13 hours each shift by choice. We are professionals, getting flustered isn't an excuse for rushing a process such as this. Rushing will always end badly. I'm in code blue situations often and frequently, and my actions remain deliberate and measured. If this is what you do for a living, you should learn to work successfully and safely within the environment.

Medication errors caused by nurses don't discredit the nursing profession nor do they negate how hard we work and how we care for our communities. Don't internalize this event or get defensive. Learn something from this experience. Understand someone's life was taken and that must mean something, something must change! Understand someone died and THAT is a tragedy, and the manner was uniquely horrific. That's it. Let this event touch your heart and not simply your mind.

** Again, this is my opinion. I'm a random nurse, no one special. If you feel differently, that's cool. Please don't blow my inbox up. I'm not one for arguing online, my life is too busy for that. Oh, and don't waste your time sending rude, long messages either. I won't read them. I'm entitled to my opinion and so are you. We can be adults and disagree **

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Cardiac tamponade is the result of compression of the myocardium by the contents of the pericardium. This compression is usually caused by fluid. It may be caused by gas, pus, blood or a combination of substances.