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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.



Snapshot

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. Thanks!

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!



Knowledge, A Power Source for Nurses

In relation to patient care delivery, knowledge can give nurses greater power to take action and lack of knowledge can leave nurses powerless to provide safe or effective care. Evidence of knowledge as a source of power is that many employers during this difficult economic time prefer to recruit experienced RNs rather than incurring the expense of training new graduates.

Anderson and Willson (2009) offer a conceptual framework for nursing knowledge management that supports using technology to offer health care providers many tools to effectively use data to transform it into knowledge. Clinical decision support software such as those integrated with electronic medical records or those that clinicians access through mobile applications (apps) are examples of using data effectively to support knowledgeable clinical interventions. An example of how powerful this can be is that two nurses sharing a clinical rotation have access to texts for purchase in the books store and mobile apps that they can use on a Smartphone. One nurse feels more comfortable using the text and the other is very adept at navigating information technology including mobile apps. The nurse with the mobile product completes medication administration quicker because he finds all the drugs in his reference while the nurse with a book misses out on recent drug releases requiring an extra step to call the pharmacy or to look up drugs online.

There are many other examples and some that may have life-threatening consequences such as drug to drug interactions that information systems recognize that health professionals frequently overlook. In a time when health care quality is a mandate, organizations and professionals who use knowledge effectively will have the power to take control over costs and attain a higher rate of insurance reimbursement due to fewer complications. 

Reference: Anderson, J. A., & Willson, P. (2009). Knowledge Management Organizing Nursing Care Knowledge. Critical Care Nursing Quarterly , 32 (1), 1 - 9.

 



Family meetings

clock December 20, 2010 05:27 by author Lisa Bonsall, MSN, RN, CRNP

I can remember a patient with an upper GI bleed, Minnesota tube in place, on maximum vent support and two pressors, who clearly was not doing well. I was checking yet another blood product with a nurse colleague, when a consulting clinician came in and told the family members at the bedside that “his numbers look good.” He then smiled and walked out of the room. The family responded with sighs of relief and “thank goodnesses” while the other nurse and I looked at each other as if to say “what just happened here?”

Have you experienced similar situations? I hesitate to name the clinician’s area of expertise because I don’t want to give any specialty a bad rap or make a generalization. However, the point is that sometimes a person not directly involved with a patient’s day-to-day care can make an observation to patients or families and give them a message that may not be correct. It isn’t always one of false hope either; perhaps a patient is doing better, yet his _______ (you can fill in the blank - rash, glucose level, wound, etc.) is not healing or normalizing and a caregiver might focus on that one clinical finding when talking with the patient and his family members.

It is for this reason that I was both surprised and discouraged when I read the results of a recent study published in Chest, “Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients.” In this study, 135 ICU patients received ‘usual care’ and 346 ICU patients had weekly family meetings where the patient’s progress and goals were discussed. The investigators were looking at the impact of this intervention on length of stay and no significant difference between the two groups was found.

Despite the negative findings of this study, it is important to remember the positives, or benefits, of sitting down with families for formal meetings where information can be shared and questions can be answered. For example, regular family meetings can allow you to:

• Provide personal contact
• Give updates on the patient’s medical condition and treatment options
• Discuss his prognosis
• Learn about the patient and family, including expectations and wishes
• Gain the opportunity to formulate a trusting and caring relationship
• Tailor the treatment plan according to the input of all staff and the patient’s family.

Please allow me to share the following quote from the authors in their conclusion of this study:

"Even if the use of regular formal family meetings does not alter resource use in all settings, the literature is replete with evidence of other beneficial effects of providing families with time to sit in a quiet location and talk at some length about the patient's goals and preferences and to explore issues related to quality of life, and providing families with consistent support as they face difficult decisions."

What is the standard procedure for initiating, scheduling, and attending family meetings where you work?



Complexity Compression

clock November 29, 2010 15:26 by author Lisa Bonsall, MSN, RN, CRNP

Have you ever heard the term complexity compression? I first learned of this term when reading Preserving a positive image of nursing in a complicated healthcare environment. This article caught my eye because although I had never heard the term, I certainly was familiar with the experience. By definition, complexity compression is "what nurses experience when expected to assume additional, unplanned responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame." Sound familiar? We’ve all been there - having to perform tasks that take us away from direct patient care and having to do more in less time.

It didn’t take long to find the source of this terminology. In 2007, nurse representatives from the Minnesota Nurses Association and faculty from the University Of Minnesota School Of Nursing sought to validate what nurses were experiencing every day - complex patients and complex systems, both with increasing demands. Through the use of focus groups, the researchers identified six major themes that contribute to complexity compression: personal factors, environmental factors, practice factors, systems and technology factors, administration and management factors, and autonomy/control factors.  You can read the published study in its entirety here: Complexity Compression: Nurses Under Fire. 

What's the biggest factor that contributes to complexity compression during your workday?

Reference: Krichbaum, K., Diemert, C., Jacox, L., Jones, A., Koenig, P., Mueller, C., & Disch, J. (2007). Complexity compression: Nurses under fire. Nursing Forum.



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