A Tale of Two Patients

In 1859, Charles Dickens wrote the book, "The Tale of Two Cities," which was a comparison of life in London and Paris and compared life of the aristocracy versus life of the peasantry in those two cities. Throughout my 30 plus years of being a nurse and nurse practitioner, I have watched and participated in the ethical dilemmas nurses and other healthcare providers encounter on a day to day basis. I have spent the majority of my professional nursing career in acute and critical care. As a nurse practitioner, my role is different than when I was a nurse; however, the issues I face are the same as all nurses in regards to ensuring patients receive optimum care that improves quality of life, not necessarily extending it.  This brings me to, "The Tale of Two Patients."

A few weeks ago I took care of two patients; two patients with similar stories, both had end-stage COPD and both were admitted to the ICU for a COPD exacerbation. Both patients received similar treatment, and both patients continued to deteriorate simply because their disease had progressed beyond recovery.  As a nurse, I was always taught to focus on quality not quantity of life, and quality of life is defined by the patient, not the healthcare professionals or the family.

The first patient had an advanced directive and had obviously communicated well with her family. They were all in agreement the patient should not be intubated, and instead, be placed on hospice and made comfortable. There was great peace among the patient, her family members and the entire nursing and healthcare staff. They rejoiced in the fact the patient had lived a full life and could now go on to a better place to be with her husband who had passed two years prior. Everyone agreed -- following the patient's advanced directive and making her a do not resuscitate was the right thing to do.

The second patient did not have an advanced directive, and had never spoken to her family about her wishes. Despite numerous attempts to discuss the patient's prognosis with the patient and her family, the family insisted everything be done and the patient capitulated to their demands. The patient was intubated and placed on a ventilator. Everyone knew the patient would never come off the vent and would eventually die in the ICU. After several days, the patient went into multiorgan failure and the family finally agreed that the patient should be allowed to die in peace. The patient was placed on a morphine infusion for comfort and died with the family still fighting over her. There was great sorrow in the eyes and hearts of everyone taking care of her. Nurses are about quality care, and even though the patient eventually died comfortably, everyone knew the situation could have been avoided if the patient had discussed her wishes with her family and her primary care provider and had an advanced directive.

As nurses, we see the ethical importance of doing what our patient's want; we are their advocates and their voice even in their most desperate hour. Healthcare professionals have an obligation to speak with their patients before the patient is in a life-threatening situation. The first time a discussion occurs should not be when the patient is critically ill and facing no chance of recovery. Quality of life must be defined by the patient and no one else. In this day and age, the tale of two patients should not be a story we tell in healthcare.

Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC
Chief Nurse
Wolters Kluwer
Health, Learning & Practice
 
Nurse Practitioner, Critical Care Services
Penn Medicine Chester County Hospital
 
Adjunct Faculty
Drexel University
College of Nursing & Health Sciences


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Ethics in Nursing – Upcoming blog series

We face ethical issues and make related decisions – or help others to do so – every day. As we focus on nursing ethics for National Nurses Week, we will be bringing you daily blog posts related to nursing ethics. We have some guest blog authors lined up to cover ethical topics important to nurses, including informed consent, advance directives, moral distress, horizontal violence, pain management, elder abuse, and end-of-life issues. We hope that you’ll join this important conversation with us. Have a great week everyone!
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Posted: 5/4/2015 6:55:46 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments
Tags: ethics, ethics in nursing
Categories: Patient Safety


YOUR Words about Nursing

Last week, we asked nurses on Facebook, twitter, LinkedIn, and Google+ to share words that describe nurses and what we do. Here's the result! Any more to add? 

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Posted: 4/29/2015 8:37:06 PM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments
Tags: inspiration, nurses
Categories: Inspiration


How to Celebrate National Nurses Week 2015

National Nurses Week runs from May 6 through May 12, ending on Florence Nightingale’s birthday. Every year, NursingCenter hosts a variety of celebrations, ranging from discounts on continuing education activities, journal articles, and nursing eBooks, to special giveaways, blog posts, and more. 

This year,  the American Nurses Association has given National Nurses Week the theme, “Ethical Practice, Quality Care,” and we are gearing up to bring you the same great week of celebrations as a special thank you to all of our members. 

Be sure to check our National Nurses Week page each day that week for discounts, activities, and blog posts. 

We will be developing an exciting CE Collection around topics dealing with “Ethical Practice, Quality Care.” 

Don’t forget to register for any of our free nursing newsletters, as we will be gifting a variety of offers to our newsletter members.

As a bonus, there are two Lippincott conferences running during National Nurses Week this year, the National Conference for Nurse Practitioners and the Lippincott Clinical Nursing Conference.  Both nursing conferences are being held in Philadelphia. 

Stay tuned for more information on how to celebrate National Nurses Week with NursingCenter. 



Gender pay gap in nursing – are male nurses worth more?

The salary gap, in general, is upsetting. For some reason, I just didn’t expect it to exist in nursing. In a profession that is predominantly female (according to a 2011 census report, only 9.6% of nurses are male), it really never occurred to me that such a discrepancy in pay was realistic. The results of recent research published in the Journal of the American Medical Association demonstrate that pay inequality not only exists in nursing, but is quite significant.

Here are some highlights from the research letter, which looked at two large data sets (the National Sample Survey of Registered Nurses [1988 to 2008] and the American Community Survey [2001 to 2013]) to assess salary trends by gender:

  • Male RN salaries were higher than female RN salaries every year, with an overall annual difference of $5,148. 
  • In ambulatory care, the salary gap was $7,678; in hospitals, it was $3,873. 
  • With the exception of orthopedics, male nurses out-earned female nurses in every specialty with the gap ranging from $3,792 in chronic care to $17,290 for nurse anesthetists. 

Like many others, I find these results discouraging. However, I am hopeful that nurses will be encouraged to speak up about our worth and engage in salary negotiations. I also am hopeful that employers will recognize these inequities and examine their pay structures. 

What’s missing in this research is the reason for this gap in pay. Care to share your thoughts on this? 

Posted: 3/25/2015 11:09:12 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments
Tags: gender pay gap, jama, male nurses, nurses, nursing
Categories: Education & Career


Nurse On the Move: Scott DeBoer

“Nursing has been a blessing to me and my family that has allowed me to travel the globe and care for the sickest of the sick across the lifespan.” Scott DeBoer RN, MSN, CPEN, CEN, CCRN, CFRN is a nurse leader with more than 20 years of experience. Currently, he serves as a flight nurse for the University of Chicago Hospitals. He is also a founder of Peds-R-Us Medical Education, a seminar company interested in enhancing the care of children. 

DeBoer wrote the Certified Pediatric Emergency Nurse Review book, which is now in its third edition, as well a body piercing removal handbook, and a book on emergency care for newborns. He earned his master's degree in critical care nursing from Purdue University in 1996 and spent time there as a clinical nursing instructor. 

As our next Nurse On the Move, DeBoer is eager to promote the nursing profession and offer his views on nursing education, pediatric care, and the future of nursing. 

Q: Why did you choose nursing as a profession?
A: I grew up thinking I was going to be a pediatrician, however, after several orthopedic injuries in high school and way too much time spent in the ER, I learned to love the nurses and not be so enthralled with the physicians. Nursing has been an absolutely amazing career.

Q: What attracted you to the career of a flight nurse?
A: Very early in my career, the flight team picked up a 3-month old child in status epilepticus from our ER. I was freaking out to say the least, as I’d never given Valium to anyone that small in my life. The flight crew was nothing short of amazing; I knew from that point on that flight/transport nursing was what I wanted to do as a career.

Q: How important is it for nurses to continue their education?
A: I would say education is crucial, especially for nurses just entering the profession. A bachelor's degree is essential. I work with many incredibly skilled paramedics who obtained their associate's degree in nursing from local community colleges, however, they can't get nursing jobs as many hospitals won't even interview without a bachelor's degree.

Q: Why is pediatric emergency care important to you?
A: Simply, I don't really like taking care of big people. If have a choice, I prefer taking care of sick kids – kids are amazing. They tend to get really sick, really fast, which of course can be scary, but, when they get better, they get better really fast as well. They haven't had years of bad habits (Burger King, beer, etc.) to result in their illness or injuries. They're good kids who’ve bad things happen to them. I just try to help them (and their families) get better.

Q: For a nurse starting out, what would be your number one piece of advice? 
A: Beyond getting your bachelor's, it's not being afraid to ask questions of experienced nurses on the unit. The idea that there is no stupid question, especially when it applies to patient care, is really true. What you learned in school is a very, very small part of what you learn on the job from everyone from housekeeping and unit secretaries (they are truly invaluable) to the chief of surgery. Everyone has something they are an expert at and most times are willing (and happy) to teach, if asked by those honestly desiring to learn.

Q: What do you see as a major obstacle/problem in the current nursing environment? 
A: The electronic medical record epidemic – they aren’t going anywhere. I know this and have resigned myself to this fact, however, I truly miss the ability to sit on the patient's bed, look them in the eye, and get a quick history. In many facilities, I have to look at a computer screen bolted to the wall while trying to talk to the patient or their family in another part of the room. This is not ideal – the focus needs to be on the patient and their family, not on clicking computer keys. 

Q: What do you envision for the future of nursing?
A: I envision an ongoing advancement in the roles of advanced practice nurses, especially with continued financial considerations and changes in healthcare reimbursement. On the transport medicine side, more patients will be transported by ambulance versus helicopters, and emergency departments will continue to see more patients, as access to primary care practitioners remains an issue. 

*Do you know an inspiring nurse to be featured for the next Nurse On the Move? Email your submissions to ClinicalEditor@NursingCenter.com.

Posted: 2/25/2015 3:08:39 PM by Cara Gavin | with 0 comments
Tags: nurse leader, nurse on the move, scott deboer
Categories: Leadership


Complications of Peripheral I.V. Therapy

If you are administering I.V. fluids or medications to a patient through a peripheral I.V. site, be alert for signs and symptoms of complications, institute preventive measures, and know how to intervene when complications do occur. 

Infiltration

infiltration.PNGInfiltration occurs when I.V. fluid or medications leak into the surrounding tissue. Infiltration can be caused by improper placement or dislodgment of the catheter. Patient movement can cause the catheter to slip out or through the blood vessel lumen. 





 


Signs and symptoms

  • Swelling, discomfort, burning, and/or tightness 
  • Cool skin and blanching
  • Decreased or stopped flow rate
Prevention
  • Select an appropriate I.V. site, avoiding areas of flexion. 
  • Use proper venipuncture technique.
  • Follow your facility policy for securing the I.V. catheter.
  • Observe the I.V. site frequently.
  • Advise the patient to report any swelling or tenderness at the I.V. site.
Management
  • Stop the infusion and remove the device.
  • Elevate the limb to increase patient comfort; a warm compress may be applied.
  • Check the patient's pulse and capillary refill time.
  • Perform venipuncture in a different location and restart the infusion, as ordered.
  • Check the site frequently.
  • Document your findings and interventions performed.

Extravasation

Extravasation is the leaking of vesicant drugs into surrounding tissue. Extravasation can cause severe local tissue damage, possibly leading to delayed healing, infection, tissue necrosis, disfigurement, loss of function, and even amputation.

Signs and symptoms

  • Blanching, burning, or discomfort at the I.V. site
  • Cool skin around the I.V. site
  • Swelling at or above the I.V. site
  • Blistering and/or skin sloughing
Prevention 
  • Avoid veins that are small and/or fragile, veins in areas of flexion, veins in extremities with preexisting edema, or veins in areas with known neurologic impairment.
  • Be aware of vesicant medications, such as certain antineoplastic drugs (doxorubicin, vinblastine, and vincristine), and hydroxyzine, promethazine, digoxin, and dopamine.
  • Follow your facility policy regarding vesicant administration via a peripheral I.V.; some institutions require that vesicants are administered via a central venous access device only. 
  • Give vesicants last when multiple drugs are ordered.
  • Strictly adhere to proper administration techniques.
Management
  • Stop the I.V. flow and remove the I.V. line, unless the catheter should remain in place to administer the antidote.
  • Estimate the amount of extravasated solution and notify the prescriber.
  • Administer the appropriate antidote according to your facility's protocol.
  • Elevate the extremity.
  • Perform frequent assessments of sensation, motor function, and circulation of the affected extremity. 
  • Record the extravasation site, your patient's symptoms, the estimated amount of extravasated solution, and the treatment.
  • Follow the manufacturer's recommendations to apply either cold or warm compresses to the affected area.


Phlebitis


Phlebitis is inflammation of a vein. It is usually associated with acidic or alkaline solutions or solutions that have a high osmolarity. Phlebitis can also occur as a result of vein trauma during insertion, use of an inappropriate I.V. catheter size for the vein, or prolonged use of the same I.V. site.






Signs and symptoms

  • Redness or tenderness at the site of the tip of the catheter or along the path of the vein
  • Puffy area over the vein
  • Warmth around the insertion site
Prevention
  • Use proper venipuncture technique.
  • Use a trusted drug reference or consult with the pharmacist for instructions on drug dilution, when necessary.
  • Monitor administration rates and inspect the I.V. site frequently.
  • Change the infusion site according to your facility's policy.
Management
  • Stop the infusion at the first sign of redness or pain.
  • Apply warm, moist compresses to the area.
  • Document your patient's condition and interventions.
  • If indicated, insert a new catheter at a different site, preferably on the opposite arm, using a larger vein or a smaller device and restart the infusion.

Hypersensitivity

An immediate, severe hypersensitivity reaction can be life-threatening, so prompt recognition and treatment are imperative.

Signs and Symptoms

  • Sudden fever
  • Joint swelling
  • Rash and urticaria
  • Bronchospasm
  • Wheezing 
Prevention
  • Ask the patent about personal and family history of allergies.
  • For infants younger than 3 months, ask the mother about her allergy history because maternal antibodies may still be present.
  • Stay with the patient for five to 10 minutes to detect early signs and symptoms of hypersensitivity.
  • If the patient is receiving the drug for the first or second time, check him every five to 10 minutes or according to your facility's policy. 
Management
  • Discontinue the infusion and notify the prescriber immediately.
  • Administer medications as ordered.
  • Monitor the patient's vital signs and provide emotional support.

Infection

Local or systemicinfection  is another potential complication of I.V. therapy. 

Signs and symptoms

  • Redness and discharge at the I.V. site
  • Elevated temperature
Prevention
  • Perform hand hygiene, don gloves, and use aseptic technique during I.V. insertion. 
  • Clean the site with approved skin antiseptic before inserting I.V. catheter.
  • Ensure careful hand hygiene before any contact with the infusion system or the patient. 
  • Clean injection ports before each use.
  • Follow your institution’s policy for dressing changes and changing of the solution and administration set. 
Management
  • Stop the infusion and notify the prescriber.
  • Remove the device, and culture the site and catheter as ordered. 
  • Administer medications as prescribed.
  • Monitor the patient's vital signs.
With careful attention and skill, you’ll be able to recognize, prevent, and manage these complications of peripheral I.V. therapy.

References
(2008). I.V. Essentials: Complications of Peripheral I.V. Therapy. Nursing Made Incredibly Easy!, 6 (1).
Smeltzer, S. (2010). Brunner and Suddarth's Textbook of Medical Surgical Nursing, 12e. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Spencer, S. & Gilliam, P. (2015). Teaching patients about their short peripheral I.V. catheters.  Nursing2015, 45 (2).
Vacca, V. (2013). TIME CRITICAL: Vesicant extravasation. Nursing2013, 43(9).


The Interspersing of Nursing: A Geographical Look at the Demand for Nurses

Use the infographic below to learn about the demand for nurses in the U.S. This was created by Adventist University of Health Sciences Online RN to BSN program.

Adventist University of Health Sciences



Measles Update

The current outbreak of measles, which has been linked to a California amusement park, continues to make headlines in the United States. The Centers for Disease Control and Prevention (CDC) is tracking data on the states affected and the number of cases. I encourage you to stay informed so you’ll be able to best educate your patients and answer their questions.

Before I get to the purpose of this post – to review transmission, signs and symptoms, and treatment of measles – I’d like to briefly address why we are seeing this resurgence in cases. In 1998, a study was published in the Lancet which suggested a link between the measles, mumps, and rubella (MMR) vaccine and autism. As a result, increased numbers of parents opted to refuse the MMR vaccine for their children. The researchers later retracted their study, and current evidence concludes that there is no association between vaccines and autism.

As nurses, we have a responsibility to educate patients about the importance of vaccinations and the implications when vaccine-preventable diseases reemerge. Measles is extremely contagious and can have serious complications, especially for certain high risk groups. Please stay informed about the current outbreak and recommendations for vaccinations. 

What is measles?


Measles is an acute viral illness, transmitted by direct contact with infectious droplets or by airborne spread. After exposure (the incubation period can range from seven to 21 days), a prodromal syndrome of high fever, cough, runny nose, and conjunctivitis is characteristic. Koplik spots (white or bluish-white spots on the buccal mucosa) may occur and then the development of the characteristic maculopapular rash, which typically spreads from the head to the trunk to the lower extremities, follows. 

 


Complications of measles

Common:

  • Otitis media
  • Bronchopneumonia
  • Laryngotracheobronchitis
  • Diarrhea

Severe:

  • Encephalitis
  • Respiratory complications
  • Neurologic complications
  • Subacute sclerosing panencephalitis (SSPE)

Who’s at risk for severe complications?

  • Infants and children younger than five years; adults over 20
  • Pregnant women
  • Immunocompromised patients

Need-to-know information for nurses

  • After appearance of the rash, infected patients should be isolated for four days in a single-patient airborne infection isolation room (AIIR).
  • Measles is a reportable disease and local health departments should be notified within 24 hours of suspected measles cases. 
  • Routine childhood immunization for MMR vaccine starts with the first dose at 12-15 months of age, and the second dose at 4-6 years of age or at least 28 days after the first dose. (More vaccine schedules and information, including contraindications to vaccination, can be found here.)

References
Finerty, E. (2008). Did you say measles? American Journal of Nursing, 108(12). 
Skehan, J. & Muller, L. (2014). Vaccinations: Eliminating Preventable Illness. Professional Case Management, 19 (6).
Wade, G. (2014). Nurses as Primary Advocates for Immunization Adherence. The American Journal of Maternal/Child Nursing, 39 (6). 
Centers for Disease Control and Prevention. (2015, January 30). Measles (Rubeola): For Healthcare Professionals.

Posted: 2/2/2015 3:29:18 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments
Tags: measles, nurses, outbreak, vaccination, vaccines
Categories: Diseases & Conditions


Nurse On the Move: Jeff Doucette

“The number one thing that a nurse can do is guard their integrity as if it is their most prized possession.” Jeff Doucette DNP, RN, FACHE, CENP, understands just how small the nursing community is. Regardless of where a nurse works, their actions and choices will follow them, he explains. 

With a career like his, he should know. Doucette is currently the vice president of patient care services and chief nursing officer at Bon Secours Mary Immaculate Hospital in Newport News, Va. He is an executive nurse fellow with the Robert Wood Johnson Foundation, as well as adjunct faculty in the DNP program at Old Dominion University. He is also the chairperson for Nursing Management Congress2015 and on the editorial advisory board for the Nursing Management journal. 

This month, I had the opportunity to speak with Doucette, our next Nurse On the Move, and learn why integrity is a nurse’s most valuable asset. We also discussed why Lean management can improve healthcare, what Nursing Management Congress has planned this year, and what he sees for the future of nursing. 

Listen for the whole interview… Jeff Doucette NOTM_January 2015.mp3 (13.57 mb)

*Do you know a great candidate to be featured for Nurses On the Move? We want to know about the nurses who are advancing the profession and inspiring others to do the same. We will feature a new nurse every month. Email your submissions to ClinicalEditor@NursingCenter.com.

 

 



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