April 22, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Resuscitation after cardiac arrest is likely to fail if PETCO2 values of 10 mm Hg or more are not achieved. Therefore, values less than 10 mm Hg should prompt the clinician to enhance the quality of CPR, improving compression rate, depth or recoil.

April 21, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Invasive arterial pressure monitoring during CPR may also be useful to distinguish PEA with or without mechanical heart contraction, detect ROSC and assist in serial arterial blood gas monitoring.

April 20, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Electrocardiographic monitoring during cardiac arrest indicates the presence or absence of electrical but not mechanical activity. It does not provide reliable information regarding the effectiveness of CPR and interventions or prognosis.

April 19, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Dependent lividity and rigor mortis develop after hours of cardiac arrest. Temperature is an unreliable predictor of duration of cardiac arrest because it does not decrease significantly during the first hours of arrest.

April 18, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
After the initial minutes of cardiac arrest, the physical examination may provide little evidence of the duration of arrest. Pupils dilate within 1 minute but constrict if CPR is initiated immediately and performed effectively.

April 17, 2018

From Bedside Nurse ➡️ NP Student: Certification Boards

I'm set to graduate in two weeks, and it's now time to pick a certification organization and see what jobs are out there. I am in a Dual Role (Family NP/Adult-Gerontological Acute Care NP) program, so that means I would need to take a certification exam for each track. That means two, separate exams. Family and adult-gerontology acute care tracks cover entirely different age ranges, demographics, and disease processes, hence the need for two exams. Since there are multiple certification organizations out there, I first went to the institutions I would like to work at and found out what credentials they accepted. Some employers only accept the American Nurses Credentialing Center (ANCC), while others only accept the American Association of Nurse Practitioners (AANP) credentialing organizations. It really depends on where you want to work and what credentials your employer will accept. Most local employers (in my area) accept both organizations, but I chose the ANCC because it offers certification for both tracks in my program. It's easier to do them both with one organization, in my opinion.

I would love to work in critical care, so I'm going to take the adult-gerontology acute care exam first. Wait a month or two and then take the family portion. I'm doing both because I want as many opportunities for employment as possible. I'm also considering working in the emergency department and that might require both certifications too. One cardiology group I'm looking into wants the family NP credential, while a critical care group wants adult-gerontology acute care NP credential. And by "looking into" I mean merely checking online. When I see a job I might be interested me, I look in the sections titled: Licensure, Certification or Registration. These tend to give me the information regarding the credentials that are required for the position.

I haven't started studying for boards yet. But my school advisor told me to apply for boards now, while I'm in my final semester. So that when the school sends my name and official transcript (once final grades are posted), confirmation occurs smoothly and the organization will already have all my information on file. I took her advice and applied. Nothing will happen until my school sends my information but at least it's all in place and ready. For those who are curious, below explains the difference between the two exams.



The cost of the exam was originally $395. Yeah, hurts my chest too. Especially after I already spent $100 renting a cap and gown, and setting up travel to stay in Mobile, Alabama for the weekend with my family. But, then I did a little research and went to the ANCC Facebook page and found a working discount code which dropped the price to $270. The link is below.


That's my quick credentialing introduction. I will track my progress through the entire journey and hope I make sense along the way, haha. It's a bit overwhelming, but once you get all the details, it's easy to decide how you want to proceed.

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
With sudden onset of cardiac arrest, loss of consciousness occurs within 15 seconds. Respiratory arrest results in transient tachycardia and hypertension due to mounting hypoxia, loss of consciousness, bradycardia and pulselessness.

April 16, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Cardiopulmonary arrest is defined by the triad of unconsciousness, apnea and pulselessness. The pulse is palpated in a large artery (carotid or femoral). If any question exists about the diagnosis of pulselessness, CPR should be initiated.

April 15, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Important past medical history during a cardiopulmonary arrest includes baseline health, previous heart, lung or renal disease, malignancy, hemorrhage, and infection, and risk factors for coronary artery disease and pulmonary embolism.

Crashing Patient | Chaos & Panic Not Necessary


So, you were doing your assessment, and your patient starts crashing. This is becoming a common occurance for me, and I wanted to offer my two cents on how to manage these events. I've noticed some nurses going into a full-on panic mode when their patient start crashing. He or she starts yelling commands to random people in no particular order, starting five things but finishing none, and finally calling the provider but unable to answer common questions because of their lack of investigation. I get it, someone is about to code or is in the process of coding and it's frightening. I've been there, but you must understand that panic mode is unproductive and serves no purpose. You must also understand yelling random things out in a hallway will get you nowhere. This is your profession, your career, take a breath and do what you already know you need to do...

Initial Event 
Okay, your patient is in respiratory distress or severely hypotensive, what do you do? Elevate the head of the bed, apply a non-rebreather mask, auscultate those lung sounds, check cuff blood pressures q5 minutes, get some labs (a rainbow, perhaps), get an arterial blood gas or maybe a chest x-ray (depending on what items are nurse-order driven), and let's do this! You already know what needs to be done. It's the emotions that get the best of some people. Yes, a crashing patient is terrifying. You replay the entire shift in your head, trying to remember if you did anything wrong. But you need to be focusing on the current problems and manage them BLS/ACLS style until the provider arrives. Nursing isn't rocket science, and no one expects you to make unilateral decisions. You have the toolkit within yourself. You just need to focus on the right things in times of crisis.

You remember the primary survey right, ABCDE (airway, breathing, circulation, disability, exposure)? Whenever my patient is crashing, I go into primary survey mode and work my way down. I assess my patient and lookup pertinent information while in the room. If your patient is unstable, you need to stay in that room until the cavalry arrives (if feasible). Because when the provider comes, he or she will want to know the background and not just the event specifics. Your patient is in respiratory distress, huh? Well, has the patient been tachypneic all day or is this a new finding? Any fever in the last 24 hours? Any history of COPD or lung disease? Yes, all this seems unimportant, but decisions are based on the patient's background, as well as the current clinical picture. The provider is attempting to whittle-down to a few differential diagnoses. To do that, he or she needs information. The faster you can access this information, the sooner your crashing patient can get the care he or she needs.

Communication
Once you have your orders, you need to execute them in a timely fashion. Your patient is unstable, right? So getting that bolus hung and infused is essential. Getting that BIPAP order and calling respiratory therapy is critical. If a provider is giving me tons of orders, I get out a pen and napkin or glove (because who has paper) and I start writing (verbal orders in times of crisis). Once you read back the orders, you then need to begin your closed-loop communication threads. Screaming random orders down a hallway will get you nowhere fast. You need to find a particular person and say, "Amber, can you grab me a 1-liter normal saline bag and some primary tubing, please? My patient is crashing." You then wait for her to say, "Yes, I will get you a 1-liter normal saline bag with some tubing." You need the confirmation. You need the feedback! You then know she is working on it (hopefully quickly). You can scratch it off your list and continue. So many people scream things during a code, and you know what happens? Nothing, because, umm, who is getting what? What did you ask for? Your command was non-specific, so you got non-specific results. Do you want help? You need to command people's attention and ask properly. This isn't the time to be coy. Ask for what you need and get confirmation someone is working on it. You can't be mad if no one does what you're asking if you're asking the ceiling.

Follow Through 
Once you have the orders, it's on you. It's on you to execute these orders. And if the patient keeps deteriorating, providers are expecting you to update the team. You gave the bolus, what is your blood pressure? Still 60/40? You need to call the provider (again) and update him or her on the intervention's outcome. You must update the provider, and you must follow through on hemodynamic instability, change in a patient's condition, or abnormal vital signs. This is where some people fall off completely. Some folks will complete an intervention (a bolus given r/t hypotension), but then chart a blood pressure of 65/35 for four straight hours. Are you insane?! If the response was unsuccessful in keeping your patient hemodynamically stable, your job is not finished. You need to update the provider on the completed intervention and seek additional orders. This isn't a middle school soccer game. You don't get an award for merely showing up. I know, we get super busy. But you must finish what you started. And updating is as significant as the initial event. No update to the provider means the initial intervention worked and you no longer need an escalation of therapy. Understand that providers can monitor an upward of 30 patients at a time. No call from you means the issue is resolved, certain parameters were met, and the intervention was successful. No news is good news.

That's really it. It all comes down to proper communication and feedback. Yeah, it seems self-explanatory but you have no idea how many times people do not communicate properly and things are missed. Assess, communicate, implement and follow through. It's that simple. Managing a crashing patient doesn't need to be convoluted. You just need to be clear in your instructions and evaluations. You know what you need to do, just get in nursing rockstar mode and do it.

April 14, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Drowning is a form of asphyxia usually resulting in bradyasystolic arrest. Because drowning often is accompanied by hypothermia, the victim may benefit from prolonged resuscitation efforts, similar to resuscitation efforts for hypothermia.

April 13, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Electrocution causes cardiac arrest through primary dysrhythmias or apnea. Alternating current in the range of 100 mA to 1 A (household) generally causes VF, whereas currents greater than 10 A (heavy industry) can cause ventricular asystole.

April 12, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
The most common metabolic cause of cardiac arrest is hyperkalemia, which is usually seen in patients with renal failure. Hyperkalemia results in gradual widening of the QRS complex, which can deteriorate to pulseless VT, VF, asystole or PEA.

April 11, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Respiratory failure generally causes hypertension and tachycardia, followed by hypotension and bradycardia and progresses to PEA, VF or asystole. Other less common causes of cardiac arrest include drug toxicity and electrocution.

April 10, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
PEA and asystole may occur as rhythms in patients in cardiac arrest as a response to respiratory insufficiency secondary to cardiac dysfunction or a deterioration of VF or pulseless VT when cardiac arrest is prolonged.

April 9, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Cardiac arrest caused by ventricular fibrillation or pulseless ventricular tachycardia usually has a primary cardiac origin. Coronary artery disease is a common pathologic condition found in patients who experience out-of-hospital arrests.

April 8, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Seizures can result from global cerebral ischemia and may exacerbate underlying brain injury. Seizure activity can increase brain metabolism by 300% to 400%, worsening the mismatch between oxygen delivery and demand.

April 7, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Fever exacerbates brain injury and worsens neurologic outcome. Elevated body temperature increases cerebral metabolic demand, escalates glutamate release and increases oxygen free radical production.

April 6, 2018

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
To ensure adequate cerebral perfusion, the MAP should be maintained above 65 mm Hg in all patients at risk for ICP elevation, and a CPP of 50 to 70 mm Hg should be targeted when ICP monitoring is available.