It’s been 2 weeks since I attended Nursing2012 Symposium and I am finally organizing all my notes! My pencil was giving off sparks as I tried to keep track of all that I was learning from the experts during the conference. What a great time I had learning, connecting with nurses (old friends and new!), and answering questions and sharing our ‘goodies’ in the NursingCenter booth in the exhibit hall. Of course, being in Orlando during some glorious weather also added to a wonderful getaway!

The opening address – Livin’, Laughin’, and Learnin’ through the Years – was presented by Barb Bancroft, RN, PNP, MSN. That title sums it up perfectly! The audience was laughing out loud as changes in nursing and medicine from the last 30 years were highlighted. I had forgotten just how many times classifications for diabetes have changed and was reminded of the funny things that patients sometimes say. Ms. Bancroft also shared her 8 ‘best bets’ in nursing. My favorites were “Never stop being a student” and “Work well with others.” 

Steve L. Robbins, PhD., presented the Keynote Address, entitled Unintentional Intolerance. This was powerful! In his presentation, Dr. Robbins used various exercises to demonstrate to the audience how we all have ‘gut reactions,’ and that the important thing is how we handle them. I wish I could demonstrate these exercises here via this blog post (I did use them on my family!). It was incredible – his discussion included topics such as cognitive scripts (how mindlessness and multiple remnant messages lead to this ‘unintentional intolerance’), drive-by greetings (we all do it…say “Hi. How are you?” without actually hearing the response), branding, and mindlessness (think of the things we do without thinking about them, for example, showering and then wondering “Did I wash my hair?”) The best quote that I took away from Dr. Robbins was “Leverage human differences to solve complex problems.”

In Your Patients at Risk: Preventing Complications, I was thrilled to listen to a former colleague of mine present! JoAnne Phillips, MSN, RN, CCRN talked about patient safety and nine adverse events that all hospitals should be working on: falls, ventilator-associated pneumonia, adverse drug events, central line-associated blood stream infections, catheter-associated urinary tract infections, pressure ulcers, obstetrical adverse events, surgical site infections, and venous thromboembolism. Ms. Phillips shared some great resources, namely Partnerships for Patients and the IHI Improvement Map. She also reminded us that “Patient safety is not about decreasing errors, it’s about decreasing harm.”

The next session that I attended was Stop the Revolving Door. Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC discussed the importance of “shifting the healthcare paradigm from a volume-based system to a value based system.”  Ms. Woods stressed 3 things to help reduce the numbers of ICU bounce-backs and hospital readmissions: better care, better communication, and better follow-up. Other points that stayed with me since her presentation include using ‘teach back’ in patient education, scheduling follow-up appointments prior to discharge, and tuning into noncompliance, meaning if a patient is noncompliant, we need to find out why. 

In Faculty-Guided Poster Tour: Ask the Experts, three experts – Frank Myers, MA, CIC; Cheryl Dumont, PhD, RN; and Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC – led an informal tour of the posters being presented at the conference. They pointed out key features of the posters themselves as well as the research being presented. Here are some of the things that I learned and I hope that you find them useful too! 

Linda Laskowski-Jones, MS, RN, ACNS-BC, CEN, FAWM and Captain Jeffrey R. Evans, BS, NREMT-P shared patient scenarios and the hospital and police responses in Bad Boys, Bad Boys…Whatcha Gonna Do? I learned a lot from these experts including never touching a weapon whether it’s immediately apparent or perhaps falls out when cutting off a trauma patient’s clothes, not using cell phones around suspicious packages (did you know they can detonate bombs?), and the importance of being aware of active gangs in your area. The most important advice I remember was always maintaining "situational awareness."

That’s just a sampling of the many presentations offered this year at Nursing2012 Symposium. All of the presentations were recorded and can be found at Lippincott’s eConference Center.com. If you have the opportunity to attend in the coming years, go for it! Maybe I’ll see you there!

My eyes have really been opened over the past year. Since launching the Skin Care Network in collaboration with the Dermatology Nurses’ Association and becoming a member of the editorial board of the Journal of the Dermatology Nurses’ Association, I have learned A LOT about skin cancer, indoor tanning, and prevention. I’ve written about skin cancer before on this blog, not so much about the cancer itself, but my involvement (or lack of) when caring for my dad when he underwent Moh’s surgery (Is Nursing Really For me?) I digress a little, mainly to share that with a family  history of skin cancer, I should and will be more proactive in prevention methods for myself and my family. 

Recent publications demonstrating the increasing incidence of melanoma and its association with tanning bed use include Increasing Incidence of Melanoma Among Young Adults (Mayo Clinic Proceedings), Use of Tanning Beds and Incidence of Skin Cancer (Journal of Clinical Oncology), and Melanoma surveillance in the United States: Overview of Methods (Journal of the American Academy of Dermatology). Many states have enacted or are considering teen tanning bed restrictions (here’s  a nice list) and a Congressional Report revealed “the false and misleading health information provided to teens by the indoor tanning industry.”

I know those are a lot of links to sort through above, however, the number of reports & articles (and there are more) demonstrate what a big issue this is. What is critical here is that there are ways to prevent or minimize skin cancer occurrence, resources to educate our patients and the public, and important information to know to recognize skin cancer so it can be treated early. The following organizations and events are a good place to start! 

Organizations/Programs

National Council on Skin Cancer Prevention 

Children’s Melanoma Prevention Foundation 

SunAWARE 

Outrun the Sun 

Events

Melanoma Monday ~ the first Monday in May; the purpose is to raise melanoma awareness and encourage early detection.

Don’t Fry Day ~ the Friday before Memorial Day; the purpose is to increase sun safety awareness and remind everyone to protect their skin while spending time outdoors.

I was taken aback when I read that “one in five patients admitted to a hospital suffers from alcohol use disorder” in Managing alcohol withdrawal in hospitalized patients in the April issue of Nursing2012 (here’s the pdf for the best view). With numbers like this, it really is critical that we are aware and able to assess all patients for signs and symptoms of alcohol withdrawal. I’d like to bring this article to your attention because there are some great resources included to help assess patients and also care for those experiencing alcohol withdrawal. There is a table on timing of symptoms – when they might occur in relation to the last drink – and also a copy of the Clinical Institute Withdrawal Assessment for Alchohol Scale, Revised (CIWA-Ar), which is the gold standard for assessing for withdrawal. The CIWA-Ar is not copyrighted – so go ahead and print it out, share it, and use it (in accordance with your facility policy, of course.)

April is Alcohol Awareness Month. While those of us in the hospital setting may come in contact with patients at risk for or experiencing alcohol withdrawal, we all know that a critical component of alcohol awareness is prevention. This year’s theme is “Healthy Choices, Healthy Communities: Prevent Underage Drinking."  Won’t you read more about this and help spread the word?

He came in on room air – somewhat dyspneic with a respiratory rate of 28 and shallow breathing. His O2 saturation was 95%. He was a young guy, 32 years old, with no prior medical or surgical history. After settling him into his ICU room, I headed out to the nurses’ station to write my admission assessment. The physicians were at the bedside completing their physical examinations. Suddenly, alarms started ringing like crazy. I ran into the room and immediately started to bag this patient with 100% oxygen. A flurry of activity began --- intubation, heparin bolus and I.V. infusion begun --- before I knew it, someone had started CPR. Wow – what was going on? How had he decompensated so quickly?

I was reminded of this patient when I read Acute Pulmonary Embolism in the April/June issue of Critical Care Nursing Quarterly. Pulmonary embolism (PE) has always been one of the scariest diagnoses to me. When a patient came in with a ‘rule out PE’ diagnosis, I was nervous; a ‘road trip’ to Nuclear Medicine made me really nervous!

Fortunately, admissions similar to this were not a regular occurrence. You can imagine that the sudden death of a young patient had a great impact on me and the rest of the team that day. I was a pretty new nurse and the details of the events have faded a bit from my memory. What I do remember clearly is that one minute I was speaking with this new admission and within moments (or so it seemed) he was coding. 

PE occurs when the pulmonary artery or one of its branches is occluded by a thrombus that originates somewhere in the venous system or the right side of the heart. The thrombus essentially breaks free from where it formed and travels to the lungs. In the lungs, it blocks vessels and causes impaired gas exchange, which leads to hypoxia. Symptoms of PE are commonly nonspecific – tachypnea, crackles, tachycardia, cough, chest pain, dizziness, anxiety, and dyspnea. Patients may also present with frothy, pink sputum or hemoptysis. 

I’ve listed several resources below if you’d like to read more about PE. You can also search ‘pulmonary embolism’ on NursingCenter to see all of our journal content on this subject. 

Resources:

Gay, S. (2010). An Inside View of Venous Thromboembolism. The Nurse Practitioner: The American Journal of Primary Health Care, 35(9). 

McLenon, M. (2012). Acute Pulmonary Embolism. Critical Care Nursing Quarterly, 35(2). 

Moz, T. (2008). Pulmonary Embolism: More Than Just Short of Breath. LPN2008, 4(6). 

The holidays were not without incident at our house this year. Illness reared its head as it usually does when excitement builds and holiday events and preparations keep us too busy to get adequate rest and eat right. This year, however, it was my husband who was down-and-out, not one of our kids.

He had a cough for about a week and was fatigued, but, despite my clinical judgment that he should rest, I “encouraged” him to help out with all that still needed to be done before Christmas. On Christmas day, he really wasn’t looking so well – high fever, chills, productive cough that seemed constant. He spent the evening in bed taking ibuprofen around the clock to help alleviate his symptoms.

By late morning the next day, we called our primary care office and found that they were closed for the holiday. We ended up heading over to the emergency department (ED) at our local hospital. In triage, he was found to be febrile, tachycardic, and hypoxic. He got a stat dose of albuterol and was quickly taken back to a room in the ED. As we went through his medical and surgical history with the ED nurse, we both paused and looked at each other when he told her that he had a splenectomy when he was younger. 

Oops – did we forget the implications of being without a spleen and the need to seek care quickly when he gets sick? And hadn’t I just read something about the risks associated with splenectomy?

Shortly after, labs came back and his white blood cell count was 43,000. So, he spent 4 days in the hospital on I.V. antibiotics. His diagnosis? Pneumococcal pneumonia.

Yes, I had read “something” recently and even put in on our recommended reading list a few weeks prior. Needless to say, I did go back and read this one again: A close up view of Pneumococcal disease.

“Risk factors for acquisition of the disease are alcohol abuse, splenectomy, immunocompromised status, smoking, and asthma.”

All is well now. And next time, I’ll ease up on my “encouragement” and do a better job with my assessment!

MAP, or mean arterial pressure, is defined as the average pressure in a patient’s arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure (SBP). True MAP can only be determined by invasive monitoring and complex calculations; however it can also be calculated using a formula of the SBP and the diastolic blood pressure (DBP). 

To calculate a mean arterial pressure, double the diastolic blood pressure and add the sum to the systolic blood pressure. Then divide by 3. For example, if a patient’s blood pressure is 83 mm Hg/50 mm Hg, his MAP would be 61 mm Hg. Here are the steps for this calculation:

MAP = SBP + 2 (DBP)
                3

MAP = 83 +2 (50)
                3

MAP = 83 +100
             3

MAP = 183
           3

MAP = 61 mm HG

Another way to calculate the MAP is to first calculate the pulse pressure (subtract the DBP from the SBP) and divide that by 3, then add the DBP:

MAP = 1/3 (SBP – DBP) + DBP

MAP = 1/3 (83-50) + 50

MAP = 1/3 (33) + 50

MAP = 11 + 50

MAP = 61 mm Hg

There are several clinical situations in which it is especially important to monitor mean arterial pressure. In patients with sepsis, vasopressors are often titrated based on the MAP. In the guidelines of the Surviving Sepsis Campaign, it is recommended that mean arterial pressure (MAP) be maintained ≥ 65 mm Hg. Also, in patients with head injury or stroke, treatment may be dependent on the patient’s MAP. 

In what other clinical situations do you monitor MAP?  

References
Surviving Sepsis Campaign. Accessed December 8, 2011. 
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition. Philadelpha: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

It has been incredibly hot here in the outskirts of Philadelphia as well as in the rest of the northeastern United States.  Last night, as my family and I walked out of an air-conditioned sporting event, I was amazed at the wall of heat and the hot “breeze” that greeted us. It was after 10 pm, shouldn’t it have cooled off by then?

I was reminded how dangerous the extreme heat can be. I coughed as I took a deep breath of that hot air. How would someone with lung disease handle this? I looked at my children, school-age now, but I flashed back to my twins who spent most of their first year of life on oxygen after their premature birth. I thought of my parents, not elderly, but dealing with a fair amount of chronic illness.

For those of you dealing with the extreme heat these days, I urge you to be safe and to check on those around you, especially the elderly and the very young. Remind your patients to be mindful of the heat. Take care of yourself - stay hydrated and cool. Here is the link to the CDC’s Tips for Preventing Heat-Related Illness. Also, Nursing2011 published a great article last year, Summer Emergencies, Can You Take The Heat?  It has information about preventing and treating heat-related illnesses, as well as drowning, insect stings, snake bites, and lightning injuries. 

Stay cool and be safe!

I am very excited to introduce our new microsite, the Skin Care Network! This site was developed by the clinical and editorial team of Lippincott's NursingCenter.com in collaboration with the Dermatology Nurses' Association and the American Society of Plastic Surgical Nurses. Our goal is to share with you all the dermatology and skin care content from Lippincott's vast collection of nursing journals and keep you up-to-date with the latest research, news, and information your patients may be reading or hearing about in the media.

Here are some highlights of the Skin Care Network that I don't want you to miss:

• In News, you'll discover the latest research findings and evidence-based practice recommendations, as well as links to related mainstream media items that your patients may ask about.
• In Tools & Resources, we've organized content by clinical topic, created a page with all our dermatology and skin care continuing education opportunities, and compiled patient education tools for you to share with your patients.
• In Multimedia, find podcasts of presentations from Lippincott's nursing conferences. More resources will be coming soon to this section!
• Also learn more about the Dermatology Nurses' Association and the American Society of Plastic Surgical Nurses on our Society Partners page and the Journal of the Dermatology Nurses Association (JDNA), Plastic Surgical Nursing (PSN), and The Nurse Practitioner by visiting the Journals page.

Take some time to explore the site ~ I hope you find the Skin Care Network to be a valuable resource to meet your professionals needs!

I was on orientation in the Medical Intensive Care Unit and I had the most amazing preceptor. She really did know everything. I still have yet to meet a smarter nurse, or person, for that matter. Her knowledge of physiology, pathophysiology, medications, technology, and random entertaining facts to keep us going during night shift astounded me! Not only that, she was (and is) an amazing nurse --- caring, compassionate, a good listener, excellent at time management, and all things nursing!

And her teaching skills? Amazing.

I was a new graduate fortunate to work with and learn from this nurse every day. I had worked in this MICU as a nursing assistant for over a year, so I knew some of the basics (where to find supplies and knowing which room is which is huge when you are just starting out, right?) I’ll never forget this one time…

Amy (not her real name, of course) would often stand back in the corner of a patient’s room while I did my assessment at the start of a shift. Sometimes I’d forget she was there until she’d start with “the questions.” During this particular shift she said, “Lisa, what if all of a sudden the ventilator alarms for a high peak airway pressure?” I started to go through my list of troubleshooting ventilator alarms: look at the patient - is he in distress, what is his oxygen saturation, how is his color, listen to his breath sounds, is his endotracheal tube in place - and then moved on to the ventilator - any water in the tubing, is everything connected as it should be, etc.

Amy then said “Okay, you don’t find any concerns, but the high pressure alarm is still sounding. Now what?”  I replied, “I would disconnect the patient from the ventilator and bag him.” Amy said “Yes, and what else could you do to search for a reason for the alarm?” I could tell by Amy’s face that I was missing something.

She pretended to take a picture. Huh? I must have looked confused, because she did it again. I thought for a minute and then it hit me --- a chest x-ray!

It was Sunday night, 7 pm, and I was just starting my third 12-hour shift in a row. I was happy to see my assignment was the same as the previous two nights - two fairly stable patients. One was a “challenge-to-wean” patient who was recovering from ARDS and who had two restful nights on Friday and Saturday. The other was a patient who was post-stroke; she was not intubated, was minimally communicative, and had stable vital signs (I had been surprised that she had not been transferred out of the ICU during the day.)

I was a few minutes early so I went to print out telemetry strips for both of my patients before getting report. Part of our documentation each shift consisted of printing and interpreting each patient’s ECG intervals. We had a certain way to fold the strips so we could tape them in the appropriate spot on the flowsheet (next to the strip from the previous shift).

It was then, when I went to tape the strip on that I noticed something very different. The patient’s ST-segment was significantly elevated compared to the strip 8 hours before. The day shift nurse came over to start report and we compared the strips - same leads, definite ST-segment changes. She grabbed the 12-lead ECG machine and yelled for the resident while I assessed the patient. She was lying in bed and appeared comfortable. Her vital signs hadn’t changed and her oxygen saturation was 93%. She did not look like someone experiencing an MI. But she was.

Within minutes (or so it seemed), anesthesia had arrived to intubate her, cardiology was at the bedside, and we were hanging nitroglycerin and heparin infusions. After a very busy night and despite all of our efforts, this patient coded and died.

I tell this story because it is not often that “cutting & pasting” a six-second telemetry strip leads to this turn of events. As a critical care nurse, I was both exhilarated by noticing the change in her ECG and devastated by the outcome.

When I considered writing about this particular night, my first thought was that anyone could have noticed the change in her ECG. Would someone who was not a nurse have recognized the change and realized the implications? Perhaps. But is there anyone else but a bedside nurse who is present and in tune to the patients they care for 24 hours a day, 7 days a week, 365 days a year?

Nurses are there. Nurses are present. Nurses are paying attention.