What happened? Acute PE.

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 ThromboembolismThe 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). 

Posted: 4/1/2012 3:50:39 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


EOL Care: Progress and Ongoing Issues

End-of-life (EOL) care has always been a special interest of mine. I know the frustrations that often arise with EOL care in a critical care unit – for example, when a patient can no longer make decisions for himself and his family is unsure of his wishes, or when family members disagree. However, I also know how satisfying it can be when a patient’s death is a positive experience for all involved. Sometimes providing end-of-life care is just as rewarding as seeing a patient ‘turn the corner’ and get better. I imagine that some nurses find that EOL care is even more rewarding. 

When I read Ethics in Critical Care: Twenty Years Since Cruzan and the Patient Self-Determination Act: Opportunities for Improving Care at the End of Life in Critical Care Settings, I was reminded that while challenges continue, we actually have come pretty far with regards to advance care planning (ACP) and EOL care. Resources such as the Center for Practical Bioethics’ Caring Conversations, Respecting Your Choices, and Five Wishes have emerged to help patients and families discuss their wishes with one another. Other highlights of progress include The Joint Commission standards on palliative care, advance care planning, and pain management; National Healthcare Decisions Day (April 16); palliative care consultation services at large numbers of hospitals; and increased numbers of people with advanced directives. I encourage you to read this article in its entirety to see the extensive list of examples provided by the authors. 

What issues remain? 

  • Advance care planning – increasing the number of patients with advance directives; living wills & power of attorney issues
  • Caring for patients who are in a minimally conscious state vs. persistent vegetative state
  • Providing hydration and nutrition
  • Communicating a patient's wishes or plan of care during transfer from one care setting to another (for example, from nursing home to hospital)

Take some time to read this article (it’s free to read online while on our Recommended Reading list!). On page 103 (page 5 of the pdf), you’ll find 'Ten Things Critical Care Nurses Can Do To Improve Advance Care Planning.' 

Reference: 

Rushton, C., Kaylor, B., & Christopher, M. (2012). Ethics in Critical Care:Twenty Years Since Cruzan and the Patient Self-Determination Act: Opportunities for Improving Care at the End of Life in Critical Care Settings. AACN Advanced Critical Care, 23(1). 

Posted: 2/11/2012 5:46:03 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


Pneumococcal pneumonia in the house

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!

Posted: 1/12/2012 4:01:19 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


From MICU nurse to NICU parent

In my last post, I wrote about a challenging case where a patient’s sister, who was a nurse, tried to limit the amount of pain medication we were administering. Now I’d like to share my feelings about being a nurse turned patient/family member. 

Many of you who are members of NursingCenter or who follow this blog already know the story about when my sons were born. It was a surreal time in my life when they were born prematurely and spent several months in the Neonatal Intensive Care Unit (NICU). In minutes, I had switched roles from critical care nurse to new mother of two critically ill babies.  Before this, I had seen family members through illness and surgery and even sat by the bedside of my grandmother when she died in the unit where I worked. However, I think it was my time as a NICU parent that really exposed me to what it was like to be on the “other side.”

As anyone who has ever been there can tell you, it is scary! Sure my knowledge and clinical experience were helpful in understanding what was happening, but I remember quickly (even immediately) reaching the point of being completely overwhelmed. While I understood terminology and the pathophysiology, I was used to caring for adults - premature babies were a whole different world. “What about his tachycardia?” I would think. Then, the nurse, without even knowing my question would tell me, “He’s not tachycardic, a heart rate of 140 bpm is normal!” I guess she could just see the panic on my face!

It was very stressful for me to be aware of all the potential complications that could come upon my sons. Sure, I knew that dopamine was necessary to perfuse “Baby A’s” kidneys. I also knew that when the nurses increased the dose, that the goal had changed and now maintaining his blood pressure was necessary. I didn’t want to know the possible consequences if it extravasated or that his high ventilator settings could cause a pneumothorax. 

I know that my knowledge and experience helped me advocate for my sons, be involved with their physical care, and explain what was happening to the rest of our family. I am so grateful for the staff that, while they knew about my background, they also saw me as a new mother who was scared.  So what did I learn from this? Yes, patients and family members, whether they are health care professionals are not, are more informed and educated about their health care than ever. That is a good thing, but it is important to remember that we are all human beings first and in times of crisis, we all need compassionate care and a kind ear. 

Posted: 9/8/2011 5:56:11 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


Headlines from the ADA

The American Diabetes Association's 71st Scientific Sessions took place at the end of June and several headlines have come across our newsfeed. Here are some highlights that you might be interested in:

Access more information from this meeting, including video highlights, webcasts of select presentations, and links to abstracts, at DiabetesPro: Professional Resources Online.

Posted: 7/8/2011 6:14:31 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


American Heart Month

February is American Heart Month! Here are some links to resources about heart disease and the campaign:

...and some patient education tools from our journals:

Help spread the word! Have more resources to share? Please do so by leaving a comment! Thanks!

 

Posted: 2/1/2011 1:52:21 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


The Ugly Duckling

A good portion of my time as clinical editor is spent reading journals, blogs, articles, news, and anything else having to do with nurses, impacting nurses, or written by nurses. Last evening, while perusing a stack of journals, I learned something new - something important that I thought would be good to share. It’s a technique to use when assessing someone’s skin.

I’ve learned, relearned, and reviewed the ABCDEs of melanoma many times, as I’m sure many of you have as well. Remember Asymmetry, Border irregularity or bleeding, Color, Diameter, and Evolving or changing? In the January/February issue of Nursing Made Incredibly Easy!, I learned an additional technique to use in conjunction with the ABCDEs, called the “ugly duckling” approach. This approach encourages you to look at a person’s general mole appearance and pattern while being alert for any “outlier” lesions which look or feel different than the other moles or that change over time.

Here are some examples shared by the authors:

  • In a patient with a dominant mole pattern with slight variation in size, the ugly duckling might be clearly darker and larger than all the other moles.
  • When there are two predominant patterns, one of larger moles and the other of smaller, darker moles, the ugly duckling could be small and lack pigmentation.
  • When there’s only one lesion on the back that is changing, symptomatic, or deemed atypical.

Here’s the link to the pdf of the article: Caring for a patient with malignant melanoma - great information, great photos, and great illustrations to help you understand the “ugly duckling” approach. So, next time you are assessing a patient's skin, or even your own, remember to look for any "ugly ducklings" around.

Posted: 1/20/2011 4:14:41 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


My preemie story

My preemie story began about 10 years ago. Pregnant with my first child, I watched as friends and family progressed through their own pregnancies without incident. I had planned to do the same. Sometimes plans change...

At my 20 week OB visit I was feeling pretty good. Then came some surprising news - twins? A little panic, a little excitement, and we were on our way to confirm with ultrasound. Yes, twins! The babies looked fine and we shared the news and changed some of our plans. I worked less, we stepped up the house search, and bought a few more of, well, of just about everything!

Then….29 weeks. My blood pressure sharply rose, hands and feet swelled, and I didn’t feel well at all. Bedrest was ordered and within 24 hours, I was experiencing pretty bad back pain. My OB had me meet her at the hospital just “to check me out” since a big snow storm was forecast. Good news…I was not contracting and had not dilated at all. The bad news came a bit later when lab results revealed I had developed HELLP syndrome. All I remember hearing is “You are going to have your babies today.”

HELLP is a syndrome of pregnancy identified by the presence of hemolysis, elevated liver enzymes, and low platelets (less than 150,000/mm3.) It occurs in 0.5 to 0.9% of all pregnancies and in 10-20% of cases of women with severe preeclampsia. It can also develop without changes in blood pressure. Signs and symptoms include headache, nausea and vomiting, upper abdominal pain, and vision changes. Serious complications can include DIC, hemorrhage, renal failure, and ARDS.  Treatment consists of corticosteroids, magnesium sulfate, and delivery.

So, my twin sons were born at 29 weeks by stat cesarean section. We experienced the roller coaster ride of the NICU for 2 months. I spent most of that time in a daze as we navigated our way through many of the preemie complications - NEC, IVH, sepsis, aspiration, ROP, PDA, A’s & B’s, and then some - a whole lot of abbreviations and acronyms that I had never heard of as an adult ICU nurse. Sure I knew the effects of dopamine, but administration through an umbilical vein? Never did it.

The story did not end there in the NICU however, as most parents of preemies are well aware. My sons came home on cardiac monitors, oxygen, and several medications. Growth was slow and development delayed. Lots of therapists, evaluations, pediatrician visits, and emergency room visits ensued. We remained isolated for 2 years for fear of RSV and handwashing became an obsession. It was a tough journey and I am lucky to report now that my boys have caught up to their peers. They are in fourth grade, do well in school, and play sports and video games just like their buddies.

We are lucky. Not every preemie catches up. Not every preemie goes to school. Not every preemie can feed themselves. Or talk. Or walk. Not every preemie survives. We are so lucky.

November is Prematurity Awareness Month. Did you know that one in eight babies is born prematurely? That more newborns die from prematurity than any other cause? And that the effects of prematurity can last a lifetime?

I hope sharing my own story can help raise awareness. As nurses, patient education is a top priority. Please remind women that while pregnancy is a natural process, no pregnancy is without risk. Tell women to listen to their bodies. No one else knows how they feel. Back pain is typically not a sign of preeclampsia and HELLP. I am lucky. My boys are lucky.

References
The HELLP Syndrome: Clinical Issues and Management: A Review
The March of Dimes
Emergency Care for Patients with HELLP Syndrome

Posted: 11/17/2010 4:20:00 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


New ways to manage pain

For those of us caring for patients, pain management is always an issue. I rarely see patients in my practice who aren't experiencing some sort of pain issue. Unfortunately, many times what I use to manage pain doesn't work for every patient.

I was glad to see in the latest issue of Nursing2010, an article addressing some of the new advances in pain management. Yvonne D"Arcy, MS, RN, CRNP, CNS does a great job discussing some of the recently developed drug delivery systems and applications for pain control. Her article, "An update on new pain medications," in the Controlling Pain column in the Nursing2010 November issue reviews topical NSAIDS, double-action oral medications that have both opioid and non-opioid activity in one drug, and a new extended release medication, Embeda, which is a combination of an extended release morphine and has a core of naltrexone, an opioid reversal agent that is activated if the drug is crushed, chewed, or dissolved. Quite a nice little abuse deterrent built right into the drug. The article also discusses a new capsaicin patch used to treat intractable pain from postherpetic neuralgia.

Without a doubt, this article will give you some new ideas to help manage your patients' pain. 

Posted by Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC

Posted: 11/5/2010 5:41:57 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


ABC is now CAB

Wow - big changes announced today by the American Heart Association! Based on recent studies demonstrating the priority of adequate circulation in saving cardiac arrest victims, chest compressions are now the first step in cardiopulmonary resuscitation (CPR). The rate of chest compressions should be 100 per minute, with a depth of at least 2 inches in adults and children and 1.5 inches in infants.

Exceptions to the new guidelines include newborns and those with primary respiratory arrest. In these victims, the steps should remain airway management, followed by rescue breathing, and then chest compressions.

Here are some helpful links with more about these changes:

Also, here are links to the abstracts from the supporting studies:

Posted: 10/18/2010 6:54:17 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


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