May 25, 2018

Check Your Pumps | Nursing Hacks # 1


This is a new series of quick little reads on things I've learned throughout the years.

Check Your Pumps

When I receive bedside report, I write down the information I'm given, and I immediately confirm the drip rates and make sure the concentrations match from bag to pump. I scan the infusion pumps quickly so the outgoing nurse can leave. But, I make sure I've laid eyes on the drips BEFORE he or she leaves. Too often, I'm told one thing, and see another when I assess the pump configurations. Mistakes happen, numbers could be inverted, and wrong medications programmed. It is too easy to input the false information. Once I accept the responsibility of a patient, I make sure the infusing drugs are accurate, and the order in the chart matches the drug infusing. Yes, it sounds crazy but I've had many instances where a drug was hanging without an order. If a provider walks by your patient's room and sees this on your shift, you will definitely have problems.

Here is an example:
The patient weighs 135 lbs.
Information given during report: Neosynephrine concentration of 50mg/250mL is infusing at 1 mcg/kg/min
Infusion found at bedside: Neosynephrine concentration of 100mg/250mL is ACTUALLY infusing at 1 mcg/kg/min
The drug concentration programmed into the infusion pump: 50mg/250mL

Problem: Double concentrated medication infusing at the wrong rate

The patient should receive 18.41 mL/hr (1 mcg/kg/min) if receiving 50mg/250mL bag
The patient should receive 9.20 mL/hr (1 mcg/kg/min) if receiving 100mg/250mL bag
(Need math help? I always do, check this out... https://bit.ly/2IPSvGY)

See the difference there? You are infusing double the dose. And what does your pressure look like? Is it 290/150? Oh, I wonder why. This is why I say always inspect, it takes a second but can save you from inheriting a problem or being accused of something.

Now, this isn't your fault, but if you find the discrepancy at 1 PM (and you started work at 7 AM), that's six hours the drug was infusing on your shift. That is your fault, 100% for sure. I love my co-workers and value them, but I always confirm drips because mistakes are easy and interruptions are plentiful. Computers are great, but they require accurate information.

Don't even get me started on wrong drugs being hung! You told me insulin, why do I see a heparin bag hanging?! Yeah, check your drips, it can get confusing but label and confirm everything. It's your license. Once you accept responsibility, it's on you, and you will be at fault if you accept a problem and find it later. I've seen it. I surely wouldn't believe you if it's been five hours and you start blaming the previous shift... sounds shady. You might be telling the truth, but it doesn't look right.

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Unconjugated bilirubin that is not bound to albumin can cross the blood-brain barrier, causing adverse neurologic effects ranging from subtle developmental abnormalities to encephalopathy. Conjugated bilirubins are not neurotoxic.

May 24, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Bile metabolism may be altered in three areas: (1) overproduction of heme products (hemolysis); (2) failure of the hepatocyte to take up, conjugate, and excrete bilirubin (hepatocellular dysfunction) or (3) obstruction of biliary excretion into the intestine.

May 23, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Clinical jaundice is usually not evident until the total serum bilirubin concentration rises above 2.5  mg/dL. It is observed in tissues with high albumin concentrations, for example, the skin and eyes.

May 22, 2018

Nursing Honesty | Nursing Images & Perceptions


I love nursing, it is a passion of mine. I couldn't do it otherwise, because every shift I'm challenged emotionally and physically. Nursing isn't a profession you can work in auto-pilot mode. When you are at work, you must be present and cognizant. Things change too often for you to be spacing out. I created my blog to help new nurses. Why new nurses? Because, in my opinion, students aren't exposed to what real nursing involves. In nursing school, we learn about diseases and treatment plans. We learn what will be expected of us after graduation. We watch television shows and see advertisements of nurses wearing full faces of evening makeup, doing exclusively what they are told, having only positive interactions, and kissing infants. Nursing can be all those things, but I feel it's much more. With that said, I think the profession of nursing isn't adequately represented in society.

Now, let me give you my bedside nursing background. I work in the adult, inpatient, critical care setting. I've been a nurse for over six years and have been working in multiple hospitals throughout the Central Florida area. My lane is adult, multisystem critical care and I love it. It's filled with crashing patients, dynamic family members, emotional moments, and collaborative efforts with medical professionals. No one wants to be admitted to an intensive care unit, and no family member expects to visit their loved ones there. The intensive care setting itself brings about episodes of outbursts and mixed emotions. Are some days tough? Of course. People aren't admitted to the critical care environment because they "might" be sick. They are sick, probably facing demise. It's not a good place to be, in general. Nurses are the warriors who thrive in this world and manage all these various moving parts. They manage the emotional, physical and spiritual dynamics of everyone involved with a patient. It's a big responsibility and can be overwhelming.

When I post about my work experiences, I get messages from other nurses who are experiencing the same situations. Across the nation, nurses have tough nights and long days at work. I want to hear those stories. I want to learn from those people. I want to see more nurses sharing their experiences and discussing what nursing really entails. Let's educate ourselves on how to manage a crashing patient or what medical-surgical nurses experience nowadays. I want to know what is happening in the nursing field across the world. I don't want fake smiles and stock images photos, and this is why I created my little world here. I wanted to create a place for nurses to get the true picture of bedside nursing. Reality shouldn't be a bummer. You shouldn't get out of training and be utterly devastated by what is really going on. Upon graduation, a certain level of shell-shock is expected. But over the years, I've noticed more and more graduate nurses are overwhelmed by the interplays and level of responsibility nurses face at the bedside. Cute scrubs and colorful stethoscopes are fantastic things, but I didn't get into nursing to merely look "attractive." I became a nurse to help my community. I want others to fall in love with the profession and honestly plays an important role.

When I turn on the news, I often see nurses being attacked or injured at work. It's sad but common. I, myself, have been assaulted at work and even suffered injuries due to my bedside responsibilities. When events like these involve nurses, society demonstrates outrage and genuine concern. They have no idea what nurses experience. I feel that lack of knowledge is related to the nursing community not sharing their experiences more. We work in healthcare, I'm aware of the limitation in sharing what we do. By sharing, I'm referring to education and advice. We can learn from each other and assist our communities is understanding the conditions we work within. I received messages that stated, "Just show cute scrubs and cool nursing tools. I don't need the rest, it's a downer." And this is why changes in nursing conditions are slow. Because most people in the world only see the aesthetics of nursing. They lack a real understanding of what nurses experience and deal with shift after shift. Sharing a bad experience doesn't make you a negative person, you're just being honest. As nurses, we interact with our communities. These encounters are a reflection of our society and social norms. If we don't talk about these events, the veil of nursing aesthetics will continue to be the primary focus. If you're a nurse, please share and educate as often as you can. We are reading, we are listening. Continue to use your voices, and never lose your passion for nursing.

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Dyspnea is the term applied to the sensation of breathlessness and the patient’s reaction to that sensation. It is an uncomfortable awareness of breathing difficulties that in the extreme manifests as “air hunger.” 

May 21, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Minor hemoptysis typically originates from tracheobronchial capillaries that are disrupted by vigorous coughing or minor bronchial infections. Conversely, massive hemoptysis nearly always involves disruption of bronchial or pulmonary arteries.

May 20, 2018

Confused Patient Nursing Assessment


You walk into the room and notice your patient is restless and confused. During beside report, you were told the patient was alert and oriented and did not have fluctuations in mentation. You complete your assessment but are concerned regarding the mentation change, what do you do? Here is a quick breakdown of recommendations on how to approach situations involving confused patients.

#1. ASSESSMENT
Well first, let's make the patient's room as safe as we can. Can you hear your professor rambling the list in your head?

Bed is in the LOWEST position, side rails x two are UP, bed alarm is ON, call light is WITHIN reach, side table is PRESENT, room lights are ON, and non-skid socks are ON.

I know this sounds self-explanatory but you have no idea how many are flagged as confused (or require assistance) and yet, I walk into a room and NO safety measures are in place. Run down the list, chart the list has been initiated, and then you can go onto more important things. If a confused patient falls, the first question you will be asked is, "what safety measures were in place before the fall occurred?" Trust me, one minute of work will save you hours of charting and transports to XR/CT/MRI.

Now, let's get into it. We need to confirm our ABCs are in under control (airway, breathing, circulation), and perform focused neurological, respiratory, and cardiovascular physical assessments. Afterward, get yourself a set of full vital signs. The goal is to physically assess your patient before you start placing calls or notifying the rapid response team. You shouldn't be calling anyone or initiating any treatments until you ASSESS your patient. The assessment might look like this...

Neurologically: Patient agitated, eyes open spontaneously, best verbal response: confused, best motor response: obey commands, LOC alert, speech clear, L/R eye position midline, size 2mm, round, brisk, no facial droop or ptosis present. Gag and cough reflexes present. L/R limbs strength normal, purposeful. Denies trauma, HA, changes in eyesight, and N/V. Respiratory: Patient on BIPAP 5/5/65% (good seal), O2 is 100%, unlabored, symmetrical, diminished breath sounds. Denies SOB and dyspnea. Cardiovascular: Atrial fibrillation, controlled. Heart rate 80-90s, pulses palpable +2, capillary refill < 2. Denies chest pain and heart palpitations.

The physical examination could suggest congestive heart failure, pneumonia, or signs of illicit drug use. Fever indicates an infection as the cause of altered mental status and should prompt a search for the source, particularly urinary tract infection in the older patient. New focal neurologic findings suggest a possible mass lesion or stroke.

#2. BACKGROUND
After the full physical assessment is completed, get a detailed history. The primary goal of obtaining history is to determine when the patient last exhibited normal thinking and behavior and what normal is for the particular patient. History can be obtained from the chart, family members at the bedside, or nursing staff. Here is an example:

Patient 65 y/o male. Admitted 5/19 with shortness of breath. PMH: HTN, DM2, COPD, CAD, AICD, CHF, EF 20-25% (October 2017), CKD (stage 5) with HD MWF. Upon initial assessment (19:00), patient confused and agitated. Last reported oriented time is 17:00 per AM RN. No history of neurological, impairment, dysfunction, or deficits. New onset, the exact time of event initiation is unknown.

Providers can't create quality differential diagnoses and workups without adequate background information (current clinical picture, past medical history, diagnostics, and laboratory results). You must have the background information to paint the proper clinical presentation. Could this be ICU delirium? Did you perform a CAM-ICU delirium assessment? Is there a history of dementia? Does your patient have a history of stroke or cardiovascular dysfunction? The process is, "to assess your patient and then go research your patient." You are the patient's advocate. You can't truly advocate without knowing the full clinical picture and contributing factors. New-onset neurological changes mean nothing, without identifying background components. What looks like a change in mentation could be Parkinson's disease. You don't know what acute-onset signifies until you know your patient's history.

#3. DIFFERENTIALS
Common differential diagnoses for confusion include:

▪  Infection
▪  Hypoglycemia
▪  Failure to oxygenate
▪  Failure to ventilate
▪  Dementia/sundowning
▪  Cardiovascular injury or dysfunction
▪  Neurological injury or dysfunction
▪  Electrolyte and fluid disturbance
▪  Endocrine disease (thyroid, adrenal)
▪  AIDS-related complex
▪  Exogenous toxins
▪  Drug withdrawal
▪  Psychiatric origin

Your assessment/research will assist providers is pinpointing a diagnosis and appropriate workup.

#4. PLAN
Here are routine diagnostics/tests ordered for confused patients. This list isn't all-inclusive, just a list of common items.

▪  Blood cultures
▪  Urinalysis (UA)
▪  Chest x-ray (CXR)
▪  Hematology testing (CBC)
▪  Chemistry testing (CMP)
▪  Liver function testing (LFT)
▪  Thyroid function testing (TFT)
▪  12-lead electrocardiography (EKG)
▪  Cranial computed tomography (CT)
▪  Magnetic resonance imaging (MRI)
▪  Arterial blood gas (ABG)
▪  Lumbar puncture (LP)
▪  Toxicology testing

#5. GOALS
Confusion has many causes, and various tests can be ordered to find the culprit. As a nurse, make sure you perform quality physical assessments, obtain patient background information, and complete the ordered diagnostic and laboratory tasks. Your priorities are safety and care management. Don't let the signs and symptoms overwhelm you, take it one body system at a time. Confusion is a symptom, not a diagnosis. Getting to the diagnosis might take some time.

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Hemoptysis is defined as the expectoration of blood from the respiratory tract below the vocal cords. Many definitions exist, but massive hemoptysis is generally accepted as 100 to 600 mL of blood loss in any 24-hour period.

May 19, 2018

You Do Not Know Anything | #FlexPath MBA Journey

Disclaimer: I’m an actual Capella student compensated for posting about my experience at Capella. All thoughts and opinions are my own.
So, my first course is LEADERSHIP. Here is a breakdown of my academic program...
Three courses from my MSN courses transferred over. So, I'm seven courses away from my MBA!


I hope I don't sound like a fool, but I honestly thought I knew what business involved. No, I do not have a background in business, but I thought I knew a little something. And within just a week of my leadership course, I was proven wrong. Our first assignment was evidence-based management. Sounds simple enough, but it was like a gut punch after eating a large meal. I have a new found respect for people in management positions after starting this course. It's not about the financial terms or operational aspects of a business. It's all about balancing multiple elements from people to products. You are balancing various decisions based on a thorough, multi-leveled analysis. The hard part is locating and sifting through quality research. Making decisions based on evidence, rather than personal strengths and business history is an uncommon practice.


Do you know how many times I've heard nursing managers say, "I made this choice because it has worked in the past" or "This is a strength of mine and will work?" Often, very often. This course is helping me to examine my decision-making process not only as a business student but as a bedside nurse as well. Now, remember, I already have a Master's degree in Nursing. I knew these concepts would be new to me, but I thought they would be somewhat known to me. Not at all! From VUCA to benchmarking to critical thinking processes, it all consists of layers of information. When I started reading the course material, my ears got warm, haha. I've never had to think using this many layers of data before, then consolidating the data into a plan, and making an educated decision. It's an odd feeling. I'm getting used to it now (luckily), but it's new, and I'm stumbling along. I know nursing, I do not know anything about business. I could see how a medical provider could be overwhelmed with managing a business, it's a complicated process.

"We've suggested six substitutes that managers, like doctors, often use for the best evidence - obsolete knowledge, personal experience, specialist skills, hype, dogma, and mindless mimicry of top performers - so perhaps it's apparent why evidence-based decision making is so rare."Pfeffer & Sutton @ https://hbr.org/2006/01/evidence-based-management


My first paper was a disaster. I read all the course material, but I wasn't getting it. All the basic concepts were foreign to me, and I just couldn't relate to them. I had to read articles three times for them to finally sink in. Then last week, I had an epiphany. I stopped thinking of the course as a "business class" and started thinking of it as "life education." All these business concepts can be applied to nursing and my personal life. After that, things started clicking, and the previous barriers disappeared. I'm talking Lego Master Builder mode. This isn't just a class, and these aren't merely assignments. I'm learning things that will help me professionally and personally.

I'm new to Capella University, but I'm very impressed with the school thus far. Each assignment comes with pages and pages of resources. You are given the tools you need to complete the assignments. You aren't given an assignment and expected to find journals and articles on your own.  For the first assignment, I was given eighteen resource articles to educate myself on the necessary content. Capella offers access to various business journals through their library. My current favorite is the Harvard Business Review.

Overall, these two weeks have been eye-opening, and I'm learning so much!

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Corneal ulcerations caused by overuse of contact lenses are treated with prophylactic antibiotics and avoidance of the lenses for at least 72 hours. A follow-up with an ophthalmologist or optometrist before contact lens use is recommended.

May 18, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Alkaline caustic agents to the eye cause a liquefactive necrosis of the cornea by reacting with the corneal layers, and destruction is severe and relentless. Acid injury causes coagulation necrosis, which tends to limit the depth of injury.

May 17, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Funduscopy is used to examine posterior eye structures. Emergency physicians most commonly perform a nondilated funduscopic examination, because there are several eye conditions in which dilation may be harmful (angle-closure glaucoma).

May 16, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Fluorescein examination with cobalt blue light from the slit lamp identifies corneal defects. Fluorescein is not taken up by intact corneal epithelium but concentrates in areas where corneal epithelium is breached by abrasion, foreign body or ulcer.

May 15, 2018

Defining Painstipation

Note: I was compensated by Salix Pharmaceuticals for this post. However, all opinions are my own. 

As a critical care nurse, I’ve cared for many individuals living with chronic pain who suffer from opioid-induced constipation. From what I’ve heard from patients, it is very frustrating and I’ve even seen some people in tears. Recently, I learned about a new pharmaceutical drug that may help these folks named RELISTOR® (methylnaltrexone bromide) and I wanted to share some information with you.

INDICATIONS 

  • RELISTOR is a prescription medicine used to treat constipation in adults that is caused by prescription pain medicines called opioids.
  • RELISTOR tablets and RELISTOR injection are used to treat constipation caused by opioids in adults with long-lasting (chronic) pain that is not caused by active cancer.
  • RELISTOR injection is also used to treat constipation caused by opioids in adults with advanced illness or pain caused by active cancer and who need increases in their opioid dose for pain management.

IMPORTANT SAFETY INFORMATION 

  • Do not take RELISTOR if you have a bowel blockage (called an intestinal obstruction) or have a history of bowel blockage.

Please click here for full Prescribing Information for RELISTOR tablets and RELISTOR injection 

“Patients may not mention opioid induced constipation with their practitioner, so we need to have a “do ask, do tell” policy. It’s important to realize that it starts with conversation. I like to use the phrase “Painstipation.” These are chronic pain patients who are experiencing constipation due to their opioids.” - Dr. Joseph Pergolizzi, Senior Partner & Director of Research, Naples Anesthesia and Pain Associates

Defining Painstipation:

Painstipation, also known as opioid induced constipation (OIC), is the constipation caused by opioid pain medication, which is often taken for chronic pain.

On March 6, 2018, Salix brought together a group of chronic pain patient influencers, HCPs and advocacy organizations to discuss OIC. At the event, Salix shared responses from an OIC online survey that it sponsored in partnership with the U.S. Pain Foundation and asked the influencer attendees to transform the numbers into abstract artwork. These paintings were then unveiled to a group of HCPs later that evening. Attendees also got to hear from Dr. Joseph Pergolizzi about the benefits and risks of RELISTOR and the importance of patients and physicians adopting a “do ask, do tell” policy when it comes to OIC.


The responses presented below are from a national, 1-week online survey sponsored by Salix Pharmaceuticals, in partnership with the US Pain Foundation and conducted by Wakefield Research, which evaluated responses from 441 US adults, aged 18 years or older, who were living with chronic pain, on opioid therapy, and suffering from opioid induced constipation (OIC).

  • More than 37% of these patients reported changing the dosage of their opioid medication to try to alleviate the pain or discomfort from OIC
  • 77% of these patients reported suffering from OIC for at least one year
  • These patients reported waiting an average of 18 hours to have a bowel movement after taking their constipation medication
  • 43% of these patients reported suffering from OIC for more than 3 years
  • 53% of these patients said they would have preferred for their OIC medication to induce a bowel movement in less than 4 hours
  • 47% of these patients reported taking between 6 to 10 total prescription medications on a regular basis
  • 20% of these patients reported taking more than 10 prescription medications on a regular basis


INDICATIONS

  • RELISTOR® (methylnaltrexone bromide) is a prescription medicine used to treat constipation in adults that is caused by prescription pain medicines called opioids. 
  • RELISTOR tablets and RELISTOR injection are used to treat constipation caused by opioids in adults with long-lasting (chronic) pain that is not caused by active cancer. 
  • RELISTOR injection is also used to treat constipation caused by opioids in adults with advanced illness or pain caused by active cancer and who need increases in their opioid dose for pain management. 

IMPORTANT SAFETY INFORMATION

  • Do not take RELISTOR if you have a bowel blockage (called an intestinal obstruction) or have a history of bowel blockage. 
  • RELISTOR can cause serious side effects such as a tear in your stomach or intestinal wall (perforation). Stomach pain that is severe can be a sign of a serious medical condition. If you get stomach pain that is severe, does not go away, or gets worse, stop taking RELISTOR and get emergency medical help right away. 
  • Stop using RELISTOR and call your healthcare provider if you get diarrhea that is severe or that does not go away during treatment with RELISTOR. 
  • You may have symptoms of opioid withdrawal during treatment with RELISTOR including sweating, chills, diarrhea, stomach pain, anxiety, and yawning. Tell your healthcare provider if you have any of these symptoms. 
  • Tell your healthcare provider if you have kidney or liver problems. 
  • Tell your healthcare provider if you have any stomach or bowel (intestines) problems, including stomach ulcer, Crohn’s disease, diverticulitis, cancer of the stomach or bowel, or Ogilvie’s syndrome. Tell your healthcare provider if you are pregnant or plan to become pregnant. Taking RELISTOR during pregnancy may cause opioid withdrawal symptoms in your unborn baby. Tell your healthcare provider right away if you become pregnant during treatment with RELISTOR. 
  • Taking RELISTOR while you are breastfeeding may cause opioid withdrawal in your baby. You should not breastfeed during treatment with RELISTOR. You and your healthcare provider should decide if you will take RELISTOR or breastfeed. You should not do both. 
  • Also, tell your healthcare provider about all of the medicines you take, including prescription and over the-counter medicines, vitamins, and herbal supplements. 
  • In a clinical study, the most common side effects of RELISTOR tablets in people with long-lasting (chronic) pain that is not caused by cancer include: stomach-area (abdomen) pain, diarrhea, headache, swelling or a feeling of fullness or pressure in your abdomen, sweating, anxiety, muscle spasms, runny nose, and chills. 
  • In a clinical study, the most common side effects of RELISTOR injection in people with long-lasting (chronic) pain that is not caused by cancer include: stomach-area (abdomen) pain, nausea, diarrhea, sweating, hot flush, tremor, and chills. 
  • In clinical studies, the most common side effects of RELISTOR injection in people receiving treatment for their advanced illness include: stomach-area (abdomen) pain, gas, nausea, dizziness, and diarrhea. 


You are encouraged to report side effects of prescription drugs to FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

For product information, adverse event reports, and product complaint reports, please contact:
Salix Product Information Call Center
Phone: 1-800-321-4576
Fax: 1-510-595-8183
Email: salixmc@dlss.com

Please click here for full Prescribing Information for RELISTOR tablets and RELISTOR injection

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
If the patient cannot distinguish letters or shapes on a chart, visual acuity must be determined qualitatively. Any printed material suffices. The result may be recorded as, for example, “patient able to read newsprint at 3 feet.”

May 14, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Visual acuity is quantitatively assessed by use of a Snellen chart test at a distance of 20 feet or a Rosenbaum chart at a distance of 14 inches. Young patients who cannot yet read letters and numbers should be tested with an Allen chart.

May 13, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Completely asymptomatic “red eye” is almost always a spontaneous subconjunctival hemorrhage, which is benign but often alarming to the patient. Spontaneous subconjunctival hemorrhage may follow coughing or straining.

May 12, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Nystagmus occurs when the synchronized vestibular information becomes unbalanced. Typically, it results from unilateral vestibular disease, which causes asymmetrical stimulation of the medial and lateral rectus muscles of the eye.