January 22, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
When administered via the IV route, morphine reaches a peak of action in 15 to 20 minutes, with a half-life of 1.5 to 2 hours in healthy young adults and slightly longer in older adults. Its duration of action is 3 to 4 hours.

January 21, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Sedation and respiratory depression can occur with opioid administration for acute pain. Opioids decrease medullary sensitivity to carbon dioxide, resulting in respiratory depression.

January 20, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Immunoglobulin-mediated allergies are rare for morphine and other opioids. Many patients experience pruritus of the trunk and face after parenteral administration. This side effect is related to histamine release from opioid receptors on mast cells.

January 19, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
The most common side effect of opioids is constipation. Constipation is attributed to opiate binding of receptors located in the antrum of the stomach and proximal small bowel. Constipation can be anticipated with long-term opioid use.

January 18, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Whether delivered as a set volume or set pressure, invasive positive pressure ventilation forcibly distends the lung and can be injurious. Injuries from elevated lung volume or lung pressure are known as volutrauma and barotrauma.

January 17, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Decreases in lung pressure, indicate decreased resistance or decreased airflow in the ventilatory circuit and should prompt investigation for leaks. Large or sudden decreases in pressure suggest disconnection or unintended extubation.

January 16, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Acute increases in measured pressure indicate increased airway resistance or changes in compliance of the respiratory system (eg, those associated with pneumothorax) and can indicate potentially dangerous clinical deterioration.

January 15, 2018

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Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
The PIP measures the maximum amount of pressure in the ventilator circuit during a breath cycle. It reflects lung compliance and airway resistance, including resistance in the circuit itself.

January 14, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
In addition to maintaining adequate gas exchange, care should be taken to ensure that pressure in the ventilator circuit is appropriate. The two main measurements of pressure during mechanical ventilation are the PIP and plateau pressure (Pplat).

January 13, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Changes to ventilator settings are guided dynamically by multiple factors, including pulse oximetry, end-tidal carbon dioxide (ETCO2) measurement, ventilation pressures and blood gas levels.

January 12, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Although PEEP and CPAP represent positive airway pressure at the end of expiration, PEEP refers to pressure applied during invasive mechanical ventilation, whereas CPAP is the application of positive pressure during spontaneous breathing.

January 11, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Continuous positive airway pressure (CPAP) provides constant pressure, whereas bilevel positive airway pressure (BiPAP) alternates between higher pressure during inspiration (IPAP) and lower pressure during expiration (EPAP).

January 10, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Applied PEEP must be differentiated from intrinsic PEEP (iPEEP or auto-PEEP), which may result from improper assisted ventilation when adequate time is not allowed between breaths for complete exhalation.

January 9, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Positive end-expiratory pressure (PEEP) increases intrapulmonary and intrathoracic pressures. Potential adverse effects of PEEP include decreased cardiac output, lung overdistention and pneumothorax.

January 8, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Positive end-expiratory pressure (PEEP) is the maintenance of positive airway pressure after the completion of passive exhalation. PEEP increases functional residual capacity, improves oxygenation and decreases intrapulmonary shunting.

January 7, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Synchronized intermittent mandatory ventilation (SIMV) allows mandatory and spontaneous breaths. A mandatory breath is given at a preset rate, but the breath is synchronized as much as possible with spontaneous patient effort.

January 6, 2018

Nursing Tip of the Day! - Critical Care Nursing

Category: Critical Care Nursing 
Continuous mechanical ventilation (CMV) is intended to provide full ventilatory support for patients with little or no spontaneous respiratory activity continuous delivery of preset breaths.

January 5, 2018

Unsafe Nursing Assignments | Documentation Strategies


You've clocked in and just finished the morning huddle. You received your assignment and begin bedside report. While getting bedside report, you notice the assignment is unsafe based on either your training, patient presentation or scope of practice. You have two options here, you can stop the reporting process altogether and refuse the assignment (see endnote), or you can take the following steps in case things go sideways and you see yourself getting caught up in legal matters later on.

The first thing you need to do is notify management and do this immediately. I get it, the nurse giving report wants to leave, but the priority is notification and quickly. Don't allow time to pass. Don't let things to get comfortable, and then your voice concerns later in the shift. It loses it's urgency the longer you wait, and your stance seems unreasonable the longer you delay notification. And by notification, I mean verbal AND written. If your charge nurse for the shift is mid-report, simply say excuse me and explain your case. Explain the assignment is unsafe and explain the reasons why (be concise and use specifics, no generalizations). You must elaborate on your concerns as to why the assignment is unsafe, and you must remain calm and professional while doing so. Oddly enough, sometimes assignments are made last minute, and management is unaware of the inappropriate assignment selection. Notification alerts management to this problem and changes can be made. Let's say the verbal notification does nothing. Your next move is to document the notification. If you don't document it, the conversation never took place. You must skillfully and professionally state your concerns in the chart. I'm all about teamwork, but I refuse to allow something I have no control over to result in me losing my nursing license. I've been in this situation before and here is a template I've used in the past:

07:15 PM: Oncoming nurse notified nursing management (PM charge nurse) of patient assignment and safety concerns. Nursing management and oncoming nurse reviewed patient's current condition and needs. A decision by nursing management was made to keep the assignment as is, unchanged. The oncoming nurse will continue to monitor safety concerns. 

The goal is to document your concerns. You don't want to create a problem, but you also don't want your concerns to be ignored if future litigation occurs. Again, this is your nursing license. You worked very hard to get to where you are as a nursing professional. Don't dismiss your concerns and don't miss an opportunity to document them either. Documentation is the name of the game. Conversations can be forgotten, and people an overlook things. But a documentated encounter is a different beast. During this conversation, you could also mention your unit's scope of practice and your training, if applicable. There have been times (when I was a graduate nurse) that I was assigned a patient who was on a particular initiative (Code Cool, CRRT, or Nimbex) I hadn't been trained on it yet. I simply explained I didn't have the training to meet the patient's needs. I have nothing to prove and I don't want to kill someone because of ego. There is a difference between having a professional drive and rising to the occasion versus drowning and potentially causing someone permanent harm. Know your professional limitations and vocalized them when necessary.

If nursing management still isn't listening and you feel you can't take the assignment, you must escalate this situation to the nursing house supervisor. You've already told the charge nurse. He or she has heard your concerns and deemed them unimportant. Simply notify your charge nurse that you will be calling the nursing supervisor as you are passionate about safety matters. This happened to me once and I made sure I remained calm throughout the entire process. No one will take a hysterical person seriously. You must express your concerns in a professional manner while explaining them in great detail. Don't merely state, "because it's not safe." What does unsafe mean to you? Explain all the possible outcomes that could occur if the assignment remains the same. I'm really big on emphasizing patient outcomes, and I lay them out so all parties involved are aware of what a "no" could result in. It's easy to say "no" when you haven't heard terms such as falling, brain injury or bleeding risk. But once you hear these phrases, they paint a picture. Oh, don't forget to document this encounter as well. This will display your repeated attempts to advocate for your patient.

07:30 PM: Oncoming nurse escalated concerns to nursing house supervisor. Nursing house supervisor and oncoming nurse reviewed patient's current condition and needs (second review). A decision by the nursing house supervisor was made to keep the assignment as is, unchanged. The oncoming nurse will continue to monitor safety concerns. Escalation of concerns completed at this time. Oncoming nurse obtained bedside report as required by institutional standards.

And if all else fails and you are stuck, you will make it work. But you have clear, detailed documentation of your attempt to right a wrong. I've worked in private and government sectors of nursing, travel and permanent positions. Inappropriate nursing assignments happen in all settings and to AM and PM nursing staff. You have done your job, you have gone above and beyond for patient safety. If any legal ramifications occur due to management's decision or lack thereof, you are covered. Are you legally covered 100%? I can't answer that for sure. But this documentation method has helped me months later when I'm asked what happened, in what order, and why. These tips aren't meant to blame anyone or incite a riot. These tips are simply meant to document a series of events in the most professional way possible. But when someone is documenting, roles will need to be mentioned (for event sake), and results will need to be specified (for accountability sake). If someone feels uneasy about a decision being documented, perhaps it's the wrong one. But I'm not going to fall on the sword so other parties can keep working while I'm without a nursing license and career. Healthcare is a business. Businesses can cause individuals to cut corners and make decisions that don't favor the community. Don't get caught up or overwhelmed by the series of events. You have no control over how management will respond or react. You are simply advocating for your patient.

Note: Please check your state nurse practice act regarding this topic. When you take the report (redline and all, report completed) in some states you are "accepting" the assignment as is. You can't refuse later or it's "abandoning" your patient in some states.