NursingCenter’s In the Round

A dialog by nurses, for nurses

Nurses call to action

clock December 21, 2012 09:27 by author Lisa Bonsall, MSN, RN, CRNP

I have been trying to limit my watching of the Newtown, Connecticut events on television. I feel guilty about it, as those directly affected by the horrible massacre that occurred December 14th must face the tragedy every minute of every day. Like you, I am experiencing all sorts of feelings of sadness and anxiety and my thoughts and prayers are with the victims, their families, and the first responders.

I have not limited my reading though. I feel that by reading the stories shared by family members, I am getting to know the victims and in some small way, I am honoring them. I am reading the stories shared by the survivors and feeling that in some small way, by doing so I am helping them process the events by “listening.” I am reading the thoughts and feelings of how others are processing what happened, hoping to contribute to the discussion and let our voices be heard so that changes can be made to make our nation a stronger and safer place for ourselves and our children. 

Now I turn to the feelings of “How can I help?” and “What can I do?” I encourage you to see posts from our colleagues at AJN’s Off The Charts and Nursetopia for lists of resources and ways to help. Also, the American Nurses Association has assembled a list of more than 30 nursing organizations joining forces to call for change. 

“The nation’s nurses call on President Obama, Congress, and policymakers at the state and local level to take swift action to address factors that together will help prevent more senseless acts of violence. We call on policymakers to: 

• Restore access to mental health services for individuals and families 

• Increase students’ access to nurses and mental health professionals from the elementary school level through college 

• Ban assault weapons and enact other meaningful gun control reforms to protect society”

Nurses – we are the largest single group of health care professionals. We see the devastation caused by weapons and violence. We care for patients with mental illness and know there is need for improved services and access to treatment. It is time to take action.

To Those Affected By Hurricane Sandy...

clock November 2, 2012 08:29 by author Lisa Bonsall, MSN, RN, CRNP

What to say here? I am still in shock by the devastation caused by this hurricane. 

I grew up on Long Island. My parents, my brother and his family, and many childhood friends still live there. Yes, they experienced loss of ‘things’ and remain without power, but they are all safe. As the stories emerge of lives lost, I know how lucky we are. 

The accounts of hospitals closing and patients being evacuated are amazing. I am in awe of those who’ve worked so hard and continue to work so hard to keep patients safe and provide care to those in the hospital as well as out in the community. The evacuation and transfer of patients, especially of NICU babies from NYU Langone Medical Center, is incredible to me. As a mom of 2 NICU graduates, I remember well the challenges of repositioning a sick premature baby in his isolette; I can’t imagine moving across New York City during a hurricane. What more can I say but THANK YOU to our nurse colleagues and the other healthcare professionals who managed this incredible feat. 

To those dealing with loss, I imagine you will never see this post. If, by chance, you do come across this writing someday, know that at this moment, my thoughts and prayers continue for you. I hope that you have rebuilt your home, whether in the same location or somewhere new, and you’ve been comforted and supported in your grief. 

American Journal of Nursing has created a list of helpful resources (open access) to help us cope now and be ready for future emergencies. 

Wishing everyone safety and good health during recovery efforts. 

Resources for Alcohol Awareness

clock April 13, 2012 04:55 by author Lisa Bonsall, MSN, RN, CRNP

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?

One of those quirky nursing things

clock March 23, 2012 06:52 by author Lisa Bonsall, MSN, RN, CRNP

Have you ever cared for one of those patients who is ‘borderline’ unstable? You know --- kind of stable, but not well enough for you to feel too optimistic that they won’t crash? In the Medical Intensive Care Unit where I worked, I can recall many times where we had this one habit to help us get through the shift and keep a patient stable. Sounds silly, almost superstitious, but sometimes it worked…and I’m wondering if any of you have similar quirks or traditions that you use in your own practice. 

What is it? Here are some examples:

A patient is admitted and we settle him in his room – ECG monitor on, vital signs taken, alarms set, I.V. access established, history taken, and physical assessment completed. He seems fairly stable but when you walk out of the room, his alarm sounds for a systolic blood pressure of 90 mm Hg. His initial blood pressure had been 116/78. Your colleague asks, “Do you want some I.V. fluids?” to which you reply “Yes, let me just keep it in the room.” 

Another patient, who had been on the unit for a few weeks and had resolving ARDS (acute respiratory distress syndrome) was extubated 2 days ago and had been doing well breathing on her own. Throughout the shift, however, her oxygen requirements are increasing and her breathing is becoming more labored. The respiratory therapist asks “Do you think she’ll be reintubated?” and you reply “Please bring a ventilator to her room, just in case.” 

I can think of many patient scenarios similar to these, where we’d bring I.V. catheters, vasopressors or other medications, even urinary catheters, into the room but then didn’t need to use them. I know part of this is being prepared and having a treatment or intervention ‘ready to go’ is something that, as nurses, we do all the time. However, sometimes it seemed that the act of bringing something into the patient’s room was enough to keep him or her stable. Just coincidence? Probably. But if it works…

The impact of SBAR

clock January 30, 2012 15:52 by author Lisa Bonsall, MSN, RN, CRNP

A while back, I wrote a blog post about using SBAR (Situation-Background-Assessment-Recommendation) as a method to help organize change-of-shift report. First implemented by the U.S. Navy to reduce miscommunications, use of this tool is becoming more widespread in healthcare settings. It has been theorized that the use of a standardized approach such as SBAR creates a “common language” among healthcare professionals and thereby decreases communication errors and may even impact our behavior. A recent study published in Health Care Management Review explored this potential impact of SBAR on the daily activities of nurses.

The researchers interviewed nurses, nurse managers, and doctors in two hospitals where implementation of the SBAR protocol was in its early stages. Analysis of the data revealed two findings: first, that most thought of SBAR as strictly a means of standardizing communication, and second, that SBAR actually had a “more far-reaching effect than just being a communication tool.” 

So what are these “far-reaching effects?”

1. Schema development – SBAR facilitated the development of schemas which help nurses make intuitive decisions.

2. Contribution to the accumulation of social capital – The common language of SBAR serves as a means to integrate nurses into the organization.

3. Providing legitimacy – The common practice also helps individuals gain credibility.

4. Shift in logic – SBAR supports a shift from individual autonomy to standardization and formalization of the nursing profession.

Interesting findings! This fairly simple tool does have far-reaching implications – for our individual practice and our profession. If we communicate more effectively, make decisions more easily, and are integrated into the organization as a credible member of the healthcare team as a nursing professional, won't that ultimately lead to better patient care and outcomes?

Reference: Vardaman, J.M., Cornell, P., Gondo, M.B., Amis, J.M., Towensend-Gervis, M., Thetford, C. (2012). Beyond communication: The role of standardized protocols in a changing health care environment. Health Care Management Review 37(1), 88-97.


clock June 12, 2011 06:54 by author Lisa Bonsall, MSN, RN, CRNP

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!

8 rights of medication administration

clock May 27, 2011 00:10 by author Lisa Bonsall, MSN, RN, CRNP

Chances are that some of you may not have known that in addition to the well-known 5 right of medication administration, some experts have added 3 more to the list.When it comes to patient safety, it’s never a bad time to review some of the basics and increase your awareness of newer recommendations.

Please add any of your own tips and medication safety advice by leaving a comment. For more reading and learning related to this topic, please explore our CE collection on medication safety. Thank you!

Rights of Medication Administration

1. Right patient

  • Check the name on the order and the patient.
  • Use 2 identifiers.
  • Ask patient to identify himself/herself.
  • When available, use technology (for example, bar-code system).

2. Right medication

  • Check the medication label.
  • Check the order.

3. Right dose

  • Check the order.
  • Confirm appropriateness of the dose using a current drug reference.
  • If necessary, calculate the dose and have another nurse calculate the dose as well.

4. Right route

  • Again, check the order and appropriateness of the route ordered.
  • Confirm that the patient can take or receive the medication by the ordered route.

5. Right time

  • Check the frequency of the ordered medication.
  • Double-check that you are giving the ordered dose at the correct time.
  • Confirm when the last dose was given.

6. Right documentation

  • Document administration AFTER giving the ordered medication.
  • Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.

7. Right reason

  • Confirm the rationale for the ordered medication.  What is the patient’s history? Why is he/she taking this medication?
  • Revisit the reasons for long-term medication use.

8. Right response

  • Make sure that the drug led to the desired effect.  If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant?
  • Be sure to document your monitoring of the patient  and any other nursing interventions that are applicable.

Reference: Nursing2012 Drug Handbook. (2012). Lippincott Williams & Wilkins: Philadelphia, Pennsylvania.

Editorial round-up 3

clock April 9, 2011 01:59 by author Lisa Bonsall, MSN, RN, CRNP

Here are some of the latest thoughts from our journal editors ~ enjoy!

  • In Forging the future of nursing, Linda Laskowski-Jones MS, RN, ACNS-BC, CEN, FAWM writes: “We're at a historic crossroad as nurses. We must awaken as a profession and grasp the unparalleled opportunity to move forward in the same direction if we want our rightful place at the table. This means committing to ongoing education, actively engaging in dialog and decision making, and finally resolving the debate over entry-level educational requirements.”
  • In Taking responsibility for our practice, Elizabeth M. Thompson MSN, RN, CNOR  shares her thoughts on relating the theme of this year’s AORN Congress “Freedom to be” to perioperative nursing practice. She also uses a clinical example to help define the terms responsibility and accountability.
  • Kathryn Murphy DNS, APRN comments on The importance of cultural competence in the March/April editorial of Nursing Made Incredibly Easy! She reminds us that to be culturally competent nurses, we must remember knowledge (of cultures in your service area), attitude (avoid making assumptions and be aware of your own prejudices) and skills (learn new communication skills to simplify language).
  • In Food for thought about our most frequently used anticoagulants, AnneMarie Palatnik MSN, RN, APN-BC writes about the challenges of caring for patients on warfarin and heparin and reminds us to “Follow the protocols that have been put into place in your organization, and remember that these protocols are there to keep your patients safe.”
  • Suzanne K. Powell MBA, RN, CCM, CPHQ writes “…although many consumers are not clear what a "case manager" is and does, a case manager holds the promise of support and help during their experience in a complex, scary, and ever-changing healthcare environment.” Read more about case management professionalism in her editorial A Rose by Any other Name.

Thanks for reading!

Patient Safety

clock March 7, 2011 03:37 by author Lisa Bonsall, MSN, RN, CRNP

This week is Patient Safety Awareness Week, an annual education and awareness campaign led by the National Patient Safety Foundation. I did a quick search of articles from our nursing journals to bring you some of the great content we have related to patient safety...

Want to read more? We also have an entire collection of resources devoted to the topic of patient safety. In addition to articles and continuing education opportunities, Focus On: Patient Safety includes a PowerPoint presentation on medication error prevention and a quick reference on pressure ulcer prevention. Have a good week!

Editorial round-up

clock January 25, 2011 04:41 by author Lisa Bonsall, MSN, RN, CRNP

When I receive a new issue of a journal, I eagerly turn to the editorial right away. I like to feel that connection with the person bringing me the content within the pages (or through the links of online journals.) I find that editorials often tell me more than what is featured in the issue. Oftentimes, editors share their views and opinions on current events, clinical experiences, and sometimes personal stories. I thought I’d share some of my favorite editorials from recent issues here in this “Editorial Round-Up.”

  • In Defining a Culture of Safety, OR Nurse2011 editor-in-chief Elizabeth M. Thompson, MSN, RN, CNOR, shares her beliefs about leadership and how a team approach by perioperative nurses has impacted the patient safety movement.
  • In Leading Change, Advancing Health, AnneMarie Palatnik, MSN, RN, APN-BC writes “If we don't control our practice, someone else will. If we stay focused on the goal of providing accessible, affordable, quality care, and promoting health, how can we go wrong?”
  • In LACE, APRN Consensus... and WIIFM (What's in It for Me)?, Kelly A. Goudreau DSN, RN, ACNS-BC teaches us about the LACE (Licensure, Accreditation, Certification, Education) model and how advanced practice nurses are stakeholders in this regulatory movement.
  • In the January issue of Nursing Management, Richard Hader PhD, NE-BC, RN, CHE, CPHQ, FAAN reminds us in Circle Back Before Moving Forward that “No one knows everything and you don't have to either!!”
  • In Year of Pain, Year of Promise, Maureen Shawn Kennedy MA, RN  reflects on events of 2010 and looks ahead to 2011 while asking the question “There's a way to move forward, but are we willing?”

This is just a sampling of what our editors are writing about. I hope you enjoy reading them!

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