March 24, 2017

When To Call Provider (Graduate Nurse Cheat Sheet)

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When To Call Provider (Custom Floor Checklist)
Created By | Nurse Nacole

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Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Acute cholecystitis is often precipitated by a large or fatty meal and is characterized by the sudden appearance of steady pain localized to the epigastrium or right hypochondrium, which may gradually subside over a period of 12-18 hours.

March 23, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Lactulose, a synthetic disaccharide syrup, is digested by bacteria in the colon to short-chain fatty acids, resulting in acidification of colon contents. Lactulose leads to a change in bowel flora so that fewer ammonia-forming organisms are present.

March 22, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Hepatic encephalopathy is a state of disordered central nervous system function resulting from failure of the liver to detoxify noxious agents of gut origin because of hepatocellular dysfunction and portosystemic shunting.

March 21, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment of variceal bleeding refractory to standard therapy (endoscopic band ligation) and has shown benefit in the treatment of severe refractory ascites.

March 20, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
The clinical features of cirrhosis result from hepatocyte dysfunction, portosystemic shunting and portal hypertension. Patients may have no symptoms for long periods. The onset of symptoms may be insidious or, less often, abrupt.

March 19, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Clinically, cirrhosis is considered to progress through three stages that correlate with the thickness of fibrous septa: compensated, compensated with varices and decompensated (ascites, variceal bleeding, encephalopathy or jaundice).

March 18, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
The principal causes of nonalcoholic fatty liver disease (NAFLD) are obesity, diabetes mellitus and hypertriglyceridemia, in association with insulin resistance as part of the metabolic syndrome. 

March 17, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Excessive alcohol intake can lead to fatty liver, hepatitis and cirrhosis. Alcoholic hepatitis is characterized by acute or chronic inflammation and parenchymal necrosis of the liver induced by alcohol. 

March 16, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Hepatitis B Virus (HBV) is usually transmitted by inoculation of infected blood or blood products or by sexual contact and is present in saliva, semen and vaginal secretions. HBsAg-positive mothers may transmit HBV at delivery.

March 15, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Unvaccinated persons who are exposed to Hepatitis A Virus (HAV) are advised to receive postexposure prophylaxis with a single dose of HAV vaccine or immune globulin (0.02 mL/kg) as soon as possible.

March 14, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Hepatitis A Virus is a 27-nm RNA hepatovirus (in the picornavirus family) that causes epidemics or sporadic cases of hepatitis. The virus is transmitted by the fecal-oral route and its spread is favored by crowding and poor sanitation. 

March 13, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Jaundice (icterus) results from the accumulation of bilirubin (a product of heme metabolism) in body tissues. Hyperbilirubinemia may be due to abnormalities in the formation, transport, metabolism or excretion of bilirubin.

March 12, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Internal hemorrhoids are subepithelial vascular cushions consisting of connective tissue, smooth muscle fibers and arteriovenous communications between terminal branches of the superior rectal artery and rectal veins.

March 11, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Lynch syndrome is a condition in which there is a markedly increased risk of developing colorectal cancer as well as other cancers, including endometrial, ovarian, renal or bladder, hepatobiliary, gastric and small intestinal cancers.

March 10, 2017

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Diverticulitis is defined as macroscopic inflammation of a diverticulum. Most patients report mild to moderate aching abdominal pain, usually in the left lower quadrant. Constipation or loose stools may be present. Nausea and vomiting are frequent.

March 9, 2017

I Am Black. I Am A Nurse.


I don't represent all African Americans, nor are my personal experiences universal. I'm writing this post as an African American nurse working in Orlando, Florida. I'm writing about my perspective on how my blackness affects my job as a nurse. Now, we can begin...

My skin color is the first thing some individuals focus on when I walk into the room and introduce myself as their caregiver. I'm fully aware that, as humans, we judge each other based on our personal preferences and life experiences. In my opinion, those innocent moments of judgment can morph into racial bias in some individuals. I'm a pragmatic person. I recognize that not everyone has to like me. But what I find incredibly unsettling is that I'm constantly reminded that I'm African American, and nothing else about me or my character will ever be considered other than that fact.

Here's some background for you. Yeah, I've been called the n-word before. The first time was in elementary school. A boy named Brandon said it, pushed me, and ran away. I was born and have been raised in Florida. I know Florida. I know its history (google the Ocoee Massacre) and its culture. There are still "black" parts of town and "white" parts of town. Don't let the Barack Obama presidency fool you. Yes, that was a great historical experience, but that didn't abolish racism. Racism is everywhere, even in healthcare. Racial slurs are not something of the past. They are the present and judging from the news, the future. I know there are racists in the world, I'm not naive. But what I didn't expect to occur was the blatant display of racism, while I was merely attempting to care for these individuals. You came to the hospital, sick and ill. I'm a nurse, I work here. Our paths only crossed because you came here.

It was a random Tuesday, I had received report and walked into my patient's room to introduce myself. The patient was a young man, and alongside him was his wife and mother. I washed my hands, smiled, started my introduction, and while I was attempting to write my name on the dry-erase board, the mother interrupted me and said, "Can we speak to your boss? This isn't going to work, honey." I didn't know what I had done wrong, but I recapped the marker and slowly moved toward the sink to re-wash my hands and exit. As I turned around to exit the room, I remembered I left my pen and the plan of care on the counter. I quickly turned around to grab the items and heard the patient say, "I don't want this n-word taking care of me. They better get this bitch out of here." The patient and guests seem surprised I had abruptly turned around and overhead the comment, but they had no shame on their faces. They were completely content with what had occurred. I'm not going to lie, it shook me for a second. I grabbed my pen and left, blank-faced and lost in indescribable emotions. I wanted to say and do many things but I needed this job. I didn't know what I could say or what would get me fired. So I said nothing, which was its own form of personal humiliation and self-betrayal. I don't know where you live but Florida is an "at-will" employment state. Meaning, your employer can terminate your employment relationship for any reason at all. Let that sink in for a minute and now try to understand why I was so hesitant.

I slowly walked up to my charge nurse and told her I needed to speak to her about a patient request. I wanted to keep the context neutral until we got into the office. I didn't want to discuss this in the hallway. I was already about to cry, and I didn't want my co-workers to see this whole thing play out. I didn't know what would happen next, but to be honest with you, I assumed management would at least support me and explain to the patient and his guests that this type of language would not be tolerated. Nevertheless, I relayed the series of events to my charge nurse. I made a point not to get emotional and to simply state the facts. I feel when people get emotional, their message can potentially get buried. I grew up in a house filled with emotional people. I work very hard at controlling my emotions. I feel certain thoughts require proper processing, and I work very had to make sure I'm professional at work.

Do you know what happened next? She gave me a look of sheer indifference. It was something I've never entirely gotten over. This woman hired me as a nurse technician, trained and educated me regularly, we were even in the same social circles, and this was her response? That was even more jarring than the patient encounter. Long story short, my charge nurse spoke to the patient and the guests. Upon her exiting the room, she stated (in front of a few other nurses), "Let's change the assignment and keep them happy. I think you're just a little sensitive about this whole thing. They didn't mean anything by it Nacole." Do you know, the following two days, all the African American nursing staff had to be re-assigned? You could chalk this up to misinformed people who only represent a small percentage of individuals. But, that sadly isn't true. This type of thing occurs in the nursing profession often to people of color. Oh, and please don't think this was a one-hit wonder. I've been a nurse for over five years now and this situation of "no black nurses" has happened a handful of times. And every time, management pretends it's a customer service issue. They continue to say that it's about calming both parties and keeping everyone happy. It's NOT about that! It's about the acceptance of racism in light of health care. When management grants these requests, the individuals become more emboldened and continue the behavior.

Fast forward two years later. I was sitting beside a nurse practitioner and the floor charge nurse one night. They were discussing hiring more individuals since we were short staffed and needed help. The conversation was bland and boring, up until I heard the nurse practitioner say, "I wouldn't hire someone with an afro or dreadlocks. It's unprofessional. They could be gangbangers or something." What. The. Hell?! Yeah, there are people in the world that relate a hairstyle to criminal activity. Not surprisingly, the hairstyles were African American in origin. Oh, and did I mention I was sitting an arm's length away? My presence, like the previously mentioned incident, was of no concern. It was as if I was invisible. My skin color and culture was being judged, and there I was, sitting right there, lost in it all. I ended up going to management and discussing the implications of the conversation I had overheard. Like before, I got a "sorry for the misunderstanding" and that was it. I never knew if they were or were not going to hire any more African American people who had those distinct hair characteristics. And, how did I slip through the cracks considering their preferences? I'm not a victim, and I don't need sympathy. I'm just an African American nurse sharing a few stories. I want people out there to understand that racism is alive and well. Racism occurs at all levels of education and income.

Silence, compliance, and intolerance are the "new" forms of racism. They're the quieter, camouflaged versions. Again, I'm not stating that this happens to all African Americans who work in the nursing community. I can only speak to my own experiences. But, I've had many minority nurses tell me stories just like mine. They message me about the difficulties they face in the nursing professional and their efforts for advancement being obstructed due to their skin color. My education, my kindness, my care, my credentials, and my passion for nursing are all non-factors. The only factor that is considered is that I'm African American. It is sad, frustrating, and it's something I'm reminded of often by patients, their loved ones, and even health care professionals I work with.

What can we do? Understand that these are events and not a representation of an entire group of individuals. There are people in this world who find this behavior deplorable and will see you for more than your skin color. Seek these people out and create a positive nursing network. Continue to be who you are and continue to care for your community. Don't let moments stop you from wanting to help others. Don't let these moments devour your passionate for health care. I'm going to be honest with you, experiences like this can be hiccups for some, and outright barriers for others. Keep working hard, and hopefully, you will overcome them. Being upset and frustrated is expected, but don't allow those feelings to negatively impact your life.

Nursing Tip of the Day! - Fundamentals

Category: Fundamentals 
Ulcerative colitis is an idiopathic inflammatory condition that involves the mucosal surface of the colon, resulting in diffuse friability and erosions with bleeding. The clinical profile in ulcerative colitis is highly variable. Bloody diarrhea is the hallmark.

March 8, 2017

The Customer Service of Nursing


So you've been waiting forever and a day and you feel like your nurse isn't doing what you need or isn't doing what is in your best interest? I understand, I've been there. My family has been there too, and I'm going to tell you what I've told my loved ones. If you want or need assistance, you have to speak up (figuratively, not in volume - no screaming or yelling please) and speak to the appropriate parties. Your suggestions and complaints must be heard by the right people. The hospital setting is massive, with intertwining departments, and varying levels and administrators. I won't lie, like all professions, there are some good individuals, and sadly, there are some people who shouldn't be in health care. Meaning, you might get a caregiver that truly isn't concerned with your wellbeing. And if you do, you need to get your complaints or suggestions elevated to someone who does. For example, I could be upset with my state senator about a particular state policy, but if they had no control over said political process or its execution, my anger is in vain. If you want prompt, swift change, you need to present your concerns to the movers and the shakers. Here is my advice on how to get that done in the fastest and calmest way possible.

Nursing Aides
Okay, let us begin with the nursing assistants (NAs), certified nurse assistants (CNAs), and nursing technicians (NTs). These people are the workhorses of the floor. You have probably seen them running around making sure everyone is out of bed, clean, and moving around. These individuals will help you with your activities of daily living (ADLs), such as eating, bathing, dressing, toileting, and ambulating. Think of these people as your "person." They are there to help you with minor things (non-drug, non-medical judgment related). Please understand, they often have high patient ratios, for example, 10 to 30 patients per individual. They will help you, but understand there could be a lengthy wait. This is due to inappropriate patient ratios, which is a national concern. Please understand this doesn't occur at every institution. Each institution has different ratios and staff, depending on the acuity of care. Currently, where I work, we have no aides. So I, the nurse, have to absorb this role, in addition to my other responsibilities. If you have a medication issue, a time-sensitive matter, or would like to relay a message to your provider, you should escalate your concern to your nursing caregiver (mentioned next). The individuals mentioned above will not be able to help you in that regard. The nursing aides will be able to relay your request, but the execution of these advanced orders will be done by your nursing caregiver.

Nursing Caregivers 
Your nurse is the individual with one of the following titles: Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN), or Registered Nurse (RN). This type of caregiver can administer medications, contact your health care providers with any changes in your condition, monitor your health, and keep you safe (physically, pharmacologically, and emotionally). Nursing is a state regulated profession and nurses have a scope of practice that they operate within. Within the state’s scope of practice sits institutional and unit-based scopes of practices. A scope of practice is a set of rules regarding what the nurse can and can't do. One major principle is collaboration. A nurse cannot make an independent, unilateral decision and then, execute said decision without a provider. Every action or inaction performed by a nurse is an order approved by an advanced practice provider: Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Physician Assistant (PA), or Nurse Practitioner (NP).

For example, let's say you would like ten milligrams of morphine instead of the five milligrams of morphine you have been receiving during your admission. The nurse can relay your request to a provider, but morphine is a medication and nurses don't have state authority to alter medication orders. Nurses are only authorized by the state to dispense the orders given by your provider. The nurse's entire program is dependent upon the parameters of care, medical plan, and provider's directions. All of these three elements are created and altered by your health care provider. Nurses and providers (MD, DO, PA, NP) are tightly knit groups of people working in your best interest. We communicate often and want what is best for you, but each of us have a role and we operate within that role - we have to legally. Just because you only see the nurse does not mean the nurse is making all of the decisions.

If your request is for medications (e.g., you want more pain medications), the nurse will call the provider for you and forward your request. The approval or denial process is an independent factor from the nurse's role. They will provide you with the final decision (once the provider informs the nurse of the answer), but the nurse isn't the decision-maker in this example. If you would like your room changed or a diagnostic tested completed, the process is the same. The nurse will convey your message to the appropriate provider and remind the provider continuously (escalating your issue when necessary and within the organization chart), but the decision is that of the health care provider. If you aren't satisfied with your nurse's performance or the decisions being made about your care, you then can escalate your concern to the charge nurse.

Charge Nurses
The charge nurse is an individual who is the manager of the floor. You ever go to a fast food restaurant, get bad service, and ask for the manager? The charge nurse is that "manager" (manager for that shift anyway). The charge nurse, often called "head nurse," supervises the unit, manages bed assignments, and collaborates with nursing management and executives. If you need a different nurse, or if you feel your nurse is neglecting their role, this is the person with whom you need to communicate. A simple, "Can I speak to your charge nurse please?" will do. No need to yell or scream. The charge nurse will come in, and this person has the proper leadership skills to get what you need done. If the charge nurse isn't assisting you in a manner you deem appropriate, you can escalate your concern to the Nursing House Supervisor (NHS) or Nurse of Duty (NOD).

Supervising Nurses
The Nursing House Supervisor (NHS) or Nurse on Duty (NOD) are individuals who work throughout the entire hospital. They are not regulated to a certain unit or floor. They are the worker bees of the hospital, making sure things are running appropriately. These nurses usually have extensive bedside nursing experience with an executive background and education. These nurses are the official problem solvers, and the buck stops there (usually). They are often called to confirm that proper sequences are taking place and that resources are functioning accurately. These individuals manage all things nursing and have the knowledge base to present new approaches to problems. Use these individuals to assist you and your family members in finding an appropriate solution.

And that's it, we are done. You have just been given four tiers to nursing escalation.

Nursing Aides ---- Nursing Caregivers ---- Charge Nurses ---- Supervising Nurses

You don't have to yell to be heard or for action to take place, you just need to know the "who." Knowledge is power, and now you can take this power and make sure your concerns are heard by the right people. I know health care can be arduous and annoying. But please understand, we (caregivers) want to help but we are limited by institutional protocols, health guidelines, and state laws. We are also limited by provider orders and medical plans. Health care is a structured system with various faults and gaps. Always advocate and always communicate your needs and concerns. If we don't know, we can't fix the problem.

Please Note: This is for inpatient (hospital) setting escalation. Some institutional titles may vary.