Lippincott Announces a Donation Campaign to the American Red Cross

In a time following numerous natural disasters and the deadliest mass shooting in modern U.S. history, healthcare professionals are reminded how vitally important emergency preparedness protocols are in times of crisis. However, the rippling side effects continue after the initial impact of traumatic incidents. Crises of this size and scale can trigger post-traumatic stress disorder (PTSD) among anyone who experiences or witnesses the traumatic event. In the wake of these recent events, Lippincott is offering a PTSD continuing education (CE) collection for $1.00 until 12/31/2017. All proceeds from this collection will be donated to the American Red Cross.

Recognizing PTSD Symptoms
Nurses are in the position to make an impact in times of crisis beyond providing acute patient care. In the aftermath, recognizing the signs of post-traumatic stress disorder (PTSD) is critically important. Managing PTSD in patients and, at times, amongst peers requires nurses to stay in-the-know on what classifies as PTSD and how they can deliver care. The National Institutes for Mental Health identifies four diagnostic criteria for PTSD (National Institute of Mental Health, 2016):

  1. At least one re-experiencing symptom (flashbacks, bad dreams, frightening thoughts)
  2. At least one avoidance symptom (staying away from places that are reminders of the trauma, avoiding related thoughts and feelings)
  3. At least two arousal and reactivity symptoms (startling easily, feeling tense, sleeping difficulty, angry outbursts)
  4. At least two cognition and mood symptoms (trouble remembering key features of the trauma, negative thoughts about self or the world, guilt or blame, loss of interest in enjoyable activities)

Continuing Education
It is imperative for nurses to perpetually learn and prepare for crises of this nature in an effort to provide optimal patient care and patient outcomes. Lippincott offers an array of free journal articles and resources that can be found here to help nurses be prepared to exercise their training in an unpremeditated situation and successfully recognize and manage PTSD in patients and peers.

                                                                More Reading & Resources
                                                              Focus On: Post-Traumatic Stress Disorder


Posted: 10/20/2017 10:31:07 AM by Lindsey Lynch | with 8 comments

Categories: Diseases & Conditions

Plunging Forward in the Aftermath of the Las Vegas Tragedy

Las Vegas is different this week. And that’s no surprise. This city has been shocked by the largest mass shooting in modern U.S. history. Some of us were here that day; some of us flew in on Monday. All of us are safe. All of us are deeply saddened. All of us want to do something to help.

Nursing Management Congress 2017, our annual conference for nurse leaders, is taking place this week at The Mirage Casino & Resort. Conference staff and attendees came to Las Vegas to continue our tradition. And while it’s been a different mood here this week, we will not let the actions of one person stop us from learning, networking, and supporting one another. We’re nurses. We are here and we are here to help.

What we’ve been doing

Upon arrival here, our conference chairperson, Pamela Hunt, BS, MSN, RN, NE-BC, immediately contacted University Medical Center to see how our large group of nurse leaders could best serve their network. Because of the overwhelming response from local businesses and volunteers, our services have not been required on-site. Like many all over the world, we have been thinking and praying for the victims and their families, and all the first responders and health care providers.
 “We are truly saddened and heartbroken at the recent events and tragedy in Las Vegas. While we continue to hold the victims and families in our thoughts and prayers – we are a resilient and dedicated group of nursing professionals who have gathered for a week of learning, education and networking. Our goal is to remain committed to providing strategies for improving the quality and cost-effectiveness of care delivery as nursing best practices. And no one will take that from us.”
-Pamela Hunt, BS, MSN, RN, NE-BC, Nursing Management Congress2017 Chairperson

NMC-Dr-Cheatham.JPGIn a sad coincidence, the topic of the keynote address was Orlando Active Shooter: Lessons Learned.  We all listened closely to this sobering presentation from Michael L. Cheatham, MD, FACS, FCCM, Chief Surgical Quality Officer, Orlando Regional Medical Center. Dr. Cheatham emphasized the importance of preparation and drills, focusing on being ready when, not if, the next mass casualty occurs.

Here are some things other things I learned:
  • There have been 273 mass casualty events this year as a result of gun violence.
  • During a mass casualty event, the Health Insurance Portability and Accountability Act (HIPAA) allows sharing of names and conditions to identify victims.
  • While we know gun violence is a public health crisis, the Dickey Amendment prohibits the use of federal funds to study this issue.
  • Stop the Bleed is an initiative to train the public how to help in a bleeding emergency. 
 In coordination with the Mirage Casino & Resort, a blood drive was organized to be held here at the conference. We are proud of the nurse leaders who are lining up to contribute to this cause! As nurses, we know how important it is to have an adequate supply of blood products for a typical shift. I can only imagine the number of units of blood that have been transfused at UMC over the past several days.
NMC-Blood-Drive.JPG NMC-Heroes-Thank-you.JPG   

What you can do

Thousands of people attended the outdoor concert on Sunday, October 1, 2017. There were also many witnesses including hotel guests, entertainers, and employees in the tourism industry  During a cab ride from the airport to Nursing Management Congress, Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN, Executive Director, Continuing Education, listened to her taxi driver share her experience driving many frightened concert-goers away from Mandalay Bay. The driver kept repeating “I was in shock.”.

Unlike many other mass casualty events that had a local impact, the survivors and witnesses who were tourists in Las Vegas will be heading home to their communities around the U.S. They may present to your health system, clinic, or office for health care in the coming months. They may experience post-traumatic stress disorder (PTSD). Will you be able to recognize it?
The National Institutes for Mental Health identifies four diagnostic criteria for PTSD (National Institute of Mental Health, 2016):
  1. At least one re-experiencing symptom (flashbacks, bad dreams, frightening thoughts)
  2. At least one avoidance symptom (staying away from places that are reminders of the trauma, avoiding related thoughts and feelings)
  3. At least two arousal and reactivity symptoms (startling easily, feeling tense, sleeping difficulty, angry outbursts)
  4. At least two cognition and mood symptoms (trouble remembering key features of the trauma, negative thoughts about self or the world, guilt or blame, loss of interest in enjoyable activities)
It is critical for all of us to be prepared both for the occurrence of mass casualty events and for the care of patients who are affected as a result. Recognize the importance of preparation and drills. Make sure your institution has a Hospital Incident Command Center. Ask questions. Get involved. Be prepared.
National Institute of Mental Health. (2016, February). Post-Traumatic Stress Disorder. Retrieved from National Institute of Mental Health:
Lisa Bonsall, MSN, RN, CRNP
Senior Clinical Editor, Lippincott
Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Executive Director, Continuing Education


Posted: 10/5/2017 8:20:27 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments


Inspired Nurses Calendar 2017: I’m Just Like You

Lippincott is partnering with Lippincott Solutions to bring you an inspired nurse’s story every month. Here is September’s nurse story, “I’m Just Like You.”
September-2017.jpgI’m Just Like You
Angela Townsend, BSN, RN
Home Health
When I was 17, I was diagnosed with Type 1 Diabetes. It was at that moment when I decided to become a nurse. I've found that my own personal experience having a chronic illness has not only increased my understanding and passion for teaching others with diabetes, it has allowed me an empathy towards my patients that I never thought possible. I teach my patients about their illnesses and let them know, "hey, I have to do this too." It has made my experience as a nurse in an ever-changing world of medicine, so much more rewarding!
To see all 2016-2017 stories or to share an inspiring story of your own about being a nurse, or how you were inspired by another, and enter to win prizes, visit  Be sure to check our blog every month for a new inspired nurse’s story.



Posted: 9/27/2017 8:01:04 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Inspiration

What is sepsis? What the public needs to know

sepsis-is-a-medical-emergency-(2).PNGSepsis is a medical emergency. It is a complication of the body’s response to an infection that can lead to life threatening tissue damage, organ failure and death (CDC, 2017). By increasing awareness of the early signs and symptoms of sepsis and risk factors for developing sepsis, we could improve survival and decrease complications. Like many life-threatening conditions, time is of the essence. Early detection and treatment of sepsis is the cornerstone of managing this medical emergency. According to the most recent data from 2013, sepsis was the most expensive condition treated in US hospitals accounting for $23.7 billion, or 6.2% of aggregate cost for all hospitalizations (Torio & Moore, 2016). To increase awareness and improve outcomes related to sepsis, we summarized key teaching points to communicate with patients and the public about this medical emergency. 

Here are the top 10 things to teach patients and the public about sepsis:

  1. Any type of infection can lead to sepsis. The four most common are lung, urinary tract, GI tract, and skin infections (CDC, 2017). 
  2. Sepsis begins outside the hospital in 80% of those affected (CDC, 2017).
  3. Sepsis affects approximately one million people in the US annually (NIH, 2017); patients hospitalized with sepsis are eight times more likely to die during hospitalization (Hall et al. 2011). 
  4. Sepsis is the result of an abnormal inflammatory response that the body has to an infection. The overwhelming inflammatory reaction is what leads to the symptoms of sepsis and the associated organ failures.
  5. Risk factors for developing sepsis are age (those older than 65 and those under one-year old [CDC, 2017] are highest at risk); weakened immune systems due to medication or disease; and chronic illness, such as diabetes or COPD.
  6. Early signs and symptoms of sepsis include fever, chills, fast heartbeat, confusion, shortness of breath, rapid breathing or severe pain (with no obvious cause).
  7. There are no specific diagnostic tests for sepsis. Diagnosis is based on clinical examination which is why it is critical to seek prompt medical attention if there is any concern for sepsis.  
  8. Taking measures to prevent infection, such as hand washing, vaccinations, and smoking cessation (since chronic lung disease is a risk factor), can help prevent infections that could lead to sepsis.
  9. There are likely genetic components and other biological factors that make some people more susceptible to developing sepsis in response to an infection. Ongoing research continues to help us understand sepsis and the optimal treatment supporting the goal to improve early diagnosis and improve outcomes. 
  10. Seek medical attention if you have an infection and any signs or symptoms of sepsis. Early identification and treatment are critical in improving survival and reducing complications.
Improving public awareness of sepsis can save lives. By educating patients and the public, you can make a difference by encouraging someone to seek treatment for this medical emergency that can potentially be overlooked and mistaken for other less threatening illness. Are there any other important items you routinely educate your patients and families about to improve awareness of sepsis? If so, please share your expertise with us.

Centers for Disease Control and Prevention (CDC). Sepsis Questions and Answers. Updated April 13, 2017. Accessed August 21, 2017.  
Hall, M.J., Williams, S.N, DeFrances, C.J, & Golosinkiy, A. (2011). Inpatient Care for Septicemia or Sepsis: A Challenge for Patients and Hospital. NCHS Data Brief No. 62, June 2011. Centers for Disease Control and Prevention (CDC). Accessed August 22, 2017.
Torio, C.M. & Moore, B.J. (2016). National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013. Statistical Brief #204. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. May 2016. Accessed August 20, 2017
National Institutes of Health (NIH): National Institute of General Medical Sciences. Sepsis Fact Sheet. Updated January 2017. Accessed August 22, 2017.

Posted: 9/19/2017 10:39:22 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Diseases & Conditions

Take an Ethical Stance!

This blonobc-logo-300.pngg is the second in the series, Nurses on Boards: Building a Healthier America. Wolters Kluwer is a Founding Strategic Partner of the Nurses on Boards Coalition

In this turbulent era in healthcare, we are all called to be cognizant of our input and its potential impact on our society and nursing, specifically in inner cities, rural America, suburban America, U.S. territories, and internationally. Sharing your input on important decisions often requires taking an ethical stance. The decision-making lenses that we use are impacted by our personal and professional core values, experiences, backgrounds, and preparedness. The American Nurses Association Code of Ethics and Nurses on Boards Coalition’s Board Core Competencies may serve as a guide as you take a stance for building a healthier America. 

10 Key considerations in ethical decision-making for a positive outcome:

  1. Do your homework on the topic.
  2. Be objective; consider all perspectives before drawing your own conclusions.
  3. Maintain curiosity and an eagerness to explore all relevant ideas and approaches.
  4. Seek out the perspective of all stakeholders; listen with an open mind.
  5. Consider the social determinants of health.
  6. Express empathy; consider the implications of the decision on others.
  7. Provide evidence-based rationale to substantiate your position.
  8. Strive for the best possible outcomes for the benefit of all.
  9. Communicate your position with clarity, and be succinct.
  10. Engage in reflective practice.

According to Pam Rudisill, DNP, RN, MSN, NEA-BC, FAAN, Senior Vice President and Chief Nursing Officer at Community Health Systems (CHS) in Tennessee, AONE, Past President, "Nurse leaders are faced with challenges and opportunities every day that impact patient outcomes and quality of life for patients and their families. It is a moral imperative of the profession that our collective thoughts and actions model the highest ethical standards. The same principles chief nurse executives use in everyday practice are applicable to service on a board. The Code of Ethics developed by the American Nurses Association serves as a guide to assure nursing responsibilities are consistent with quality of care and ethical decision making.

Call to Action:
Your role and confidence as a nurse leader in taking an ethical stance is critical as you serve or aspire to serve on a board. We hope our column serves as a reflective tool to strengthen your ethical influence when serving on boards and in other leadership roles.
American Nurses Association (2015). Code of Ethics.
International Council of Nursing (2012). The ICN Code of Ethics for Nurses. Geneva, Switzerland.

Nurses on Boards Coalition (2017). Board Core Competencies.
M. Lindell Joseph, PhD, RN, AONE Board of Directors and The University of Iowa College of Nursing
Laurie Benson, BSN, Executive Director, Nurses on Board Coalition      

For more information or comments contact us: and



Posted: 9/17/2017 9:28:21 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Leadership

Sepsis: What nurses need to know

sepsis-(2).pngSepsis is a life-threatening, medical emergency affecting approximately one million persons annually in the United States (NIH, 2017). Patients hospitalized with sepsis are eight times more likely to die during hospitalization (Hall et al., 2011). As nurses, we are in a position to directly impact sepsis-related morbidity and mortality. Early identification and treatment are the cornerstone of sepsis management. We are on the frontline in the care of the hospitalized patient. Being cognizant of the subtle clinical changes indicative of impending clinical decline is critical for timely interventions and avoidance of poor clinical outcomes. 

In 2016, “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” was published (Singer et al., 2016). As nurses, there are several key points from this publication that we should be familiar with. First, the terminology related to sepsis has changed, but the basis of the definition of sepsis has not. Sepsis is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection;” the term severe sepsis has been eliminated; and septic shock is defined as a “subset of sepsis in which underlying circulatory, cellular and metabolic abnormalities are profound enough to substantially increase mortality” (Singer et al., 2016). Clinically, those in septic shock have been given the standard fluid resuscitation (30 mL/kg) with refractory hypotension/hypo-perfusion requiring vasoactive medications to maintain a mean arterial pressure (MAP) > 65 mmHg. Furthermore, Systemic Inflammatory Response Syndrome (SIRS) is no longer part of “sepsis” terminology. Previously, sepsis was considered SIRS with an infectious etiology.

As with many medical conditions that we see on a regular basis, there are continual advances in the understanding of disease, both from a medical and scientific perspective. With these advances come changes to best practice recommendations. It is essential that nurses stay well-informed on these changes. Below is a summary of recommendations based on the most recent literature on sepsis with a focus on what is most pertinent to our practice as nurses.

Tips for nurses taking care of patients with sepsis

Recommendation: Administer 30 mL/kg crystalloids within three hours of confirmed or suspected sepsis or sepsis related hypo-perfusion.
  • Tip: Crystalloids refer to IV fluids with a balanced electrolyte composition, such as normal saline or lactated ringers solution (as opposed to colloids, such as albumin or hetastarch).
  • Tip: This initial fluid bolus is often referred to as a fluid challenge.
  • Tip: In those patients diagnosed with sepsis, the nurse plays a critical role in monitoring appropriate administration of fluids as the patient transitions between levels of care (i.e. ED to floor, floor to ICU).
Recommendation: Measure lactate level; if elevated (>2 mmol/L), ensure that a repeat level is obtained within 6 hours.
  • Tip: Lactate (or lactic acid) is a byproduct of glycolysis in anaerobic metabolism.
  • Tip: In the septic patient, think of elevated lactate as a sign of tissue hypo-perfusion.
Recommendation: Obtain two or more sets of blood cultures prior to the administration of antibiotics; at least one set should be peripheral, the other from a vascular access device, if present.
  • Tip: Bacteremia is common in patients with sepsis; collecting cultures prior to administration of antibiotics gives us the best chance of identifying the correct organism before antibiotics have a chance to affect the growth of pathogens.
  • Tip: A “set” of blood cultures is collected in 2 separate bottles, one anaerobic culture bottle and one aerobic culture bottle.
Recommendation: Administer broad spectrum antibiotics (covering gram-positive and gram-negative organisms) within one hour of diagnosis or in those with high clinical suspicion for sepsis or septic shock.
  • Tip: Controlling the source of infection, either with antibiotics or intervention for those infections amenable (wound drainage, debridement, removal of potentially infected device, cholecystectomy), is the foundation of treating patients with sepsis or septic shock.
  • Tip: Failure to control source of infection could lead to persisting or worsening sepsis or septic shock and inability to stabilize your patient.
  • Tip: If a patient is not getting better, think “Do we have adequate source control?”
Recommendation: Administer vasoactive medications if a patient remains hypotensive or if lactate remains elevated following the initial fluid challenge. Vasoactive medications should be titrated to a mean arterial pressure (MAP) of > 65 mmHg.
  • Tip: Norepinephrine (Levophed) is typically the first vasopressor that is initiated. This is typically started at 2-5 mcg/min and titrated to a MAP > 65 mmHg.
  • Tip: The second vasoactive medication added is typically vasopressin at 0.03 U/min. This medication does NOT get titrated and can be added in attempt to decrease the dose of norepinephrine.
Recommendation: In taking care of a patient with sepsis, it is imperative to re-assess hemodynamics, volume status and tissue perfusion regularly.
  • Tip: Frequently re-assess blood pressure, heart rate, respiratory rate, temperature, urine output, and oxygen saturation.
  • Tip: Dynamic measurements such as passive leg raising (PLR) are recommended to assess for fluid responsiveness. PLR mimics endogenous volume expansion (equivalent to an approximate 300 mL fluid bolus) and can be thought of as a preload challenge. It is used to predict if a patient will respond to additional fluid bolus. ​Follow these steps to perform PLR (Mikkelsen et al., 2016):
    • Position the patient in the semi-recumbent position with the head and torso elevated at 45 degrees.
    • Obtain a baseline measurement.
    • Lower the patient's upper body and head to the horizontal position and raise and hold the legs at 45 degrees for one minute.
    • Obtain subsequent measurement.
    • The expected response to this maneuver in those that are fluid responsive is a 10% or greater increase in cardiac output (CO). Although not considered a validated measure, we often use blood pressure as a surrogate marker of CO in evaluating response to the PLR.
Recommendation: In patients in the ED or admitted to the general hospital floor with infection, use the quick sequential organ failure assessment (qSOFA) to identify patients at risk for clinical decline and sepsis-related organ dysfunction (Singer et al., 2016). The presence of any two of the qSOFA criteria should prompt further evaluation. 
  • Tip: qSOFA
    • Respiratory rate > 22 breaths/min
    • Altered mental status
    • Systolic blood pressure of 100 mmHg or less
    • If your patient has 2 of these criteria, be concerned for sepsis.
  • Tip: It is important to know your patient’s baseline when possible. Be aware of other variables that could potentially affect qSOFA score (dementia, baseline low systolic blood pressure [SBP]). Alternately, if your patient’s SBP is typically in the 200s and now it’s 140 with no other explanation, this should prompt further evaluation.
  • Tip: The qSOFA was derived from the sequential organ failure assessment (SOFA), a tool that numerically quantifies the number and severity of organs failed (Hall et al., 2009). The SOFA score allows us to predict prognosis and severity of illness in those patients with sepsis.
Remember, sepsis is a medical emergency and should be treated as one. Early identification and management of sepsis improves patient outcomes.

Nurses have the capacity to make a difference both clinically and system-wide. Actively participate in hospital-wide performance improvement programs and share your experiences and expertise. You can have a global impact on how we manage sepsis and septic shock in the future.
Hall, M.J., Williams, S.N, DeFrances, C.J, & Golosinkiy, A. (2011). Inpatient Care for Septicemia or Sepsis: A Challenge for Patients and Hospital. NCHS Data Brief No. 62, June 2011. Centers for Disease Control and Prevention (CDC). Accessed August 22, 2017.
Jones, A. E., Trzeciak, S., & Kline, J. A. (2009). The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Critical Care Medicine37(5), 1649–1654. Accessed September 6, 2017.
National Institutes of Health (NIH): National Institute of General Medical Sciences. Sepsis Fact Sheet. Updated January 2017. Accessed August 22, 2017.
Mikkelsen, M.E., Gajeski, D.F., & Johnson, N.J. (2016). Novel tools for hemodynamic monitoring in critically ill patients with shock. UpToDate. Last updated December 20, 2016. Accessed September 6, 2017.
Singer M, Deutschman CS, Seymour CW, et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).

Posted: 9/13/2017 10:07:02 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Diseases & Conditions

Top 10 Things Advanced Practice Nurses Need to Know about the Updated Guidelines for Management of Sepsis and Septic Shock

TOP-TEN-THINGS-APNS-NEED-TO-KNOW-ABOUT-NEW-SEPSIS-GUIDELINES_300.pngThe Surviving Sepsis Campaign (SSC) is the leading organization responsible for educating healthcare professionals on the most current scientific evidence on the timely and appropriate treatment of sepsis. This ultimately allows us to positively impact sepsis-related morbidity and mortality.

Over the past year and a half there have been several major updates to best practices in the field of sepsis. In 2016, Singer, et al., published “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” which provided updated definitions and clinical criteria for Sepsis and Septic Shock with the elimination of the terms severe sepsis and SIRS. The new terminology defines sepsis as life threatening organ dysfunction caused by a dysregulated host response to infection and septic shock as a subset of sepsis in which underlying circular and cellular/metabolic abnormalities are profound enough to substantially increased mortality (Singer et al. 2016). Clinically, the septic shock subset are those patients with refractory hypotension despite adequate fluid resuscitation requiring vasoactive medications to maintain a mean arterial pressure (MAP) > 65 mmHg.

In March 2017, the Surviving Sepsis Campaign (SSC) published updated guidelines on the management of Sepsis and Septic Shock. This document, titled “Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016” provides updated recommendations to the version published in 2012 and includes 93 statements on early management of sepsis and septic shock. A major difference evident in the new guidelines is a movement from protocolized management to a more individualized, “patient-centered” approach guided by dynamic variables and ongoing evaluation of clinical response to treatment (DeBaker & Dorman, 2017).

As the scientific and medical community’s understanding of sepsis and the pathobiology driving this life-threatening condition grows, it is essential that the APN stays abreast of changes to management based on the most up-to-date information.

Below is a summary of the recent SSC guidelines (Rhodes, et al., 2017) with a focus on material most pertinent to our practice as APNs.
  1. Initial Resuscitation
    1. Fluids
      1. Begin fluid resuscitation with crystalloid fluids immediately for sepsis-induced hypo-perfusion. Ideally, aim for at least 30 mL/kg completed within the first 3 hours from time of diagnosis.
        • Crystalloids are the fluid of choice for initial fluid resuscitation.
        • Recommendations against hydroxyethyl starches or bicarbonate therapy as an agent to improve hemodynamics or reduce vasopressor requirement.
      2. Following initial resuscitation, hemodynamic assessment should be used to guide further fluid administration using invasive and non-invasive measures.
        • Include clinical exam and evaluation of available physiologic variables including heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output.
      3. Evaluate fluid responsiveness by the following means:
        • Dynamic variables:
          • Passive leg raise
          • Pulse or stroke volume variations induced by mechanical ventilation
        • Lactate clearance
      4. Discontinue fluid administration if response is no longer beneficial.
      5. Target a mean arterial pressure (MAP) of 65 mmHg in those with septic shock.
    2. Vasoactive Medications
      1. Initial vasoactive medication of choice should be norepinephrine.
      2. Consider the addition of vasopressin (at 0.03 units/min) or epinephrine to reach target MAP or to decrease the dose of norepinephrine.
      3. Consider arterial catheter placement for the monitoring of blood pressure in those requiring the use of vasoactive medications.
    3. In the absence of response or if clinical assessment does not lead to clear diagnosis, consider evaluation for other types of shock (DeBaker & Dorman, 2017).
  2. Diagnosis/Source Control – obtain both as soon as possible with early antibiotic therapy.
    1. Goal to identify or exclude anatomic source requiring emergent intervention as soon as possible; this includes removal of intravascular access if possible source of infection.
    2. Obtain at least two sets of blood cultures prior to initiation of antibiotics in all patients with suspected sepsis or septic shock if it will not delay initiation of treatment.  
  3. Antibiotic therapy
    1. Initiate one or more empiric broad-spectrum antibiotics as early as possible and within 1 hour (maximum) of recognition of sepsis or septic shock to cover all suspected pathogens.
    2. Evaluate daily for potential de-escalation/narrowing of antibiotics based on pathogen identification and clinical improvement.  
    3. Limit combination therapy (double coverage) to patients with septic shock.
    4. Do not continue antibiotics for severe inflammatory states (i.e. systemic inflammatory response syndrome [SIRS]) with no infectious etiology.
    5. Duration of antibiotic treatment should be 7-10 days.
      • Extend for slow clinical response, undrainable foci, staph aureus, or neutropenia.
      • Shorten course for quick clinical response, adequate source-controlled, GU/UTI or simple pyelonephritis.
    6. Consider procalcitonin measurement to support de-escalation of antibiotics in patients with sepsis and to support discontinuation of antibiotics in those who ultimately have limited clinical evidence of bacterial infection.
      • Although there is low quality of evidence and a weak recommendation by the SSC, many institutions have adopted use of this biomarker in the management of sepsis.
  4. Blood products
    1. Limit red blood cell transfusions to those patients with hemoglobin concentration < 7 g/dL. Consider higher threshold in select clinical populations (i.e. acute hemorrhage/ongoing active bleeding, acute coronary syndrome with ischemia, symptomatic anemia).  
  5. Mechanical ventilation
    1. In all mechanically ventilated patients with sepsis:
      1. Utilize lower tidal volume strategy using predicted body weight.
      2. HOB 30-45 degrees.
      3. Spontaneous breathing trials in those ready for weaning.
      4. Minimize sedation and set targets for titration end points.
    2. In patients with sepsis-induced acute respiratory distress syndrome (ARDS):
      1. Target tidal volume = 6 mL/kg
      2. Upper limit goal for plateau pressures of 30 cm H20
      3. Higher PEEP strategy
      4. Recruitment maneuvers for those with sepsis-induced severe-ARDS and refractory hypoxemia  
      5. Consider prone positioning if paO2/FiO2 ratio < 150.
      6. Conservative fluid strategy
  6. Glucose Control
    1. Begin an insulin administration protocol for patients with sepsis and two consecutive blood glucose readings > 180 mg/dL.
    2. Target glucose ≤ 180 mg/dL, rather than upper limit ≤ 110 mg/dL
  7. Nutrition
    1. Begin early enteral nutrition rather than parenteral nutrition or combination in critically ill patients with sepsis or septic shock (Rhodes et al. 2017).
    2. If early enteral feeds are not possible, begin IV dextrose and advance enteral feeds as tolerated rather than initiating parenteral nutrition during the first seven days of critical illness. This may include trophic or hypocaloric feedings and advance as tolerated.
    3. Gastric residual volumes should only be considered when there is enteral feeding intolerance or high risk of aspiration, rather than routinely.
  8. Stress Ulcer prophylaxis
    1. Begin in those patients with sepsis and septic shock AND risk factors for gastrointestinal bleeding; may use either proton pump inhibitor or histamine-2 blocker.
  9. VTE prophylaxis
    1. Initiate pharmacologic prophylaxis unless contraindicated. Rhodes et al. (2017) recommends LMWH rather than UFH in absence of contraindications to LMWH, in combination with mechanical prophylaxis in absence of contraindications.
  10. Communication
    1. Discuss goals of care and prognosis with patients and family as early as feasible, incorporating end-of-life planning and palliative care principles, when appropriate.
De Backer, D. and Dorman, T. (2017). Surviving Sepsis Guidelines. A Continuous Move Towards Better Care of Patients With Sepsis. The Journal of the American Medical Association, 317(8).
Rhodes, M.B., Evans, L.E., Alhazzani, W, et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3).
Singer M, Deutschman CS, Seymour CW, et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).


Posted: 9/8/2017 12:04:17 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Diseases & Conditions

Collaboration, communication, cooperation

Nurse Wubbels…If you haven’t heard, seen, or read this story, here is a link to The Washington Post article, which includes the video. Briefly, nurse Alex Wubbels was arrested after refusing to allow a detective to obtain a blood sample from an unconscious patient. And here are the details:
  • The detective didn’t have a warrant and the patient was not under arrest.
  • Consent could not be obtained because the patient was unconscious.
  • Nurse Wubbels followed hospital policy – and the law – by refusing the blood draw.
  • Nurse Wubbels acted professionally and responsibly, by confirming policy with her supervisor.
  • Nurse Wubbels was threatened, assaulted, and arrested.
My initial reactions were anger and shock, and these feelings still come to the surface when I read the story and watch the video. After more time has passed and I’ve given it more thought, three words come to mind: collaboration, communication, and cooperation. Here’s why…

My experiences with law enforcement at the bedside have always been positive. If there was a patient in our unit who was under arrest, the officers and nurses depended on each other to share information with each other that was necessary and within the law. Oftentimes, if a patient was restrained or combative, the officers were a calming presence for all the hospital staff; we felt safe. I think (hope) that the officers knew, we were providing care to a patient and would uphold the highest level of care, no matter who that patient was.

I don’t know anything about training of law enforcement, but I know how much emphasis is placed on communication during a nurse’s education! We focus on verbal and nonverbal cues, learn strategies to get the information we need, and practice our communication skills from those very first semesters of nursing school. It’s an important part of our job and I must give a shoutout to nurse Wubbels for maintaining professionalism despite being bullied.

team.pngI think of cooperation, not in the sense of doing what one is told, but to take this unfortunate incident and work together to learn from it. As nurses, we are obligated to our patients. Who are police officers obligated to? Is it the public? Is it the law? Nurse Wubbels put the patient first, while risking her own well-being and safety. The detective in this case did not demonstrate duty to the public, nor the law. It is that cooperation that is missing here – respectfully working together to meet the goals of our chosen professions and to serve the people who depend on us.

We’ve all got a job to do – and to do it well, we must work together.
*At the time of this writing, two members of law enforcement are on administrative leave, and an investigation is underway.


Posted: 9/5/2017 2:16:20 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

Sepsis: Learning from the past to improve patient outcomes

As many of you know, I am a practicing acute care/critical care nurse practitioner in a hospital in the Philadelphia area. Recently I was called to a rapid response on a medical floor. The patient was an elderly gentleman who was admitted for a urinary tract infection the day prior and now had a temperature of 103° F, a systolic blood pressure of 80/50 mm Hg (normally 130/72), a respiratory rate of 26/min and has gone from being awake, alert and oriented to being lethargic. This scene plays out every day in our healthcare system; so how did the nurse know to call for the rapid response team to come evaluate the patient? She used the qSOFA (Quick Sequential Organ Failure Assessment) tool which identifies patients who are at risk for a poor outcome. Based on the nurse’s quick, critical thinking, the patient was evaluated and the diagnosis was changed to septic shock secondary to a urinary tract infection and he was transferred to the critical care unit for management and he survived. The nurse was the hero in this situation because she recognized this patient was in septic shock.  

Sepsis, learning from the past
Sepsis is thought to occur in 750,000 people in the U.S. each year and it’s one of the leading causes of mortality and critical illness worldwide (Angus, 2013; Dieter-Lessnau, 2015). Sepsis is not a new diagnosis but, the guidelines on how to best recognize and manage it have been refined over the years as we learn more about this devastating diagnosis. In 2016, the definition of sepsis was changed to better reflect new knowledge on the pathophysiology of sepsis. For years, we have used the Systematic Inflammatory Response Syndrome (SIRS) criteria to identify patients with sepsis; however, new research has determined that the SIRS criteria was unhelpful because a SIRS response occurs with many other conditions and does not indicate dysregulation as once thought (Singer, et al., 2016; Rhodes, et al., 2017).

A new sepsis definition
As a result, a new definition of sepsis was established and was described in The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3) in 2016 (Singer, et al., 2016). In 2017, The Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock were published (Rhodes, et al., 2017).  Sepsis is now defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer, et al., 2016; Rhodes, et al., 2017).  Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality (Singer, et al., 2016; Rhodes, et al., 2017). The term ‘severe sepsis’ has been eliminated from the definitions.

Early recognition is key
We know that early recognition of a patient with sepsis and septic shock is the first step in sepsis management. What tools are available to nurses to identify a patient who is likely to have a poor outcome due to organ dysfunction potentially related to sepsis? New definitions and guidelines have identified two tools that can be used by healthcare professionals to help identify a patient at risk for poor outcomes.

The qSOFA tool is a resource to be used outside of a critical care unit, such as in the emergency department or a medical/surgical unit, or primary care/urgent care, to identify these types of patients.

The qSOFA tool looks at 3 variables:
  • Respiratory rate greater than or equal to 22/min
  • Altered mentation
  • Systolic blood pressure less than or equal to 100 mm Hg (Singer, et al., 2016; Rhodes, et al., 2017).
The SOFA tool is used with critical care patients to identify a higher risk of patient mortality. Any change in 2 points or greater is equal to a higher risk of mortality. The variables evaluated in the SOFA tool are:
  • Respirations
  • Coagulation
  • Liver function
  • Cardiovascular system
  • Central nervous system
  • Renal system
Post-Sepsis Syndrome Reality
Patients who live through an experience of sepsis often have post-sepsis syndrome and exhibit long-term physical, psychological, and cognitive disabilities which result in health and social implications (Iwashyna, 2010). It is imperative that nurses recognize this syndrome and educate their patients and their families and other members of the support network, about this condition.

Sepsis-Alliance-SAM-Support-Badges-(2).pngNurses, you are an integral part of the interdisciplinary team
Without a doubt, nurses are key in sepsis early recognition, management and education because you are with the patient 24 hours a day. Having access to the latest evidence-based clinical practice guidelines and using them for clinical decision support is crucial to improving patient outcomes. Sepsis Alliance has an assortment of valuable resources for healthcare professionals and patients on sepsis. Wolters Kluwer is proud to partner with Sepsis Alliance to improve knowledge on this devastating, but preventable, condition.  
Angus, D. C. (2013). Severe sepsis and septic shock. New England Journal of Medicine, 840-851.
Dieter-Lessnau, K. (2015, Oct. 8). Distributive shock. Retrieved July 20, 2016 from Medscape:
Iwashyna, T., et al. (2010). Long-term cognitive impairment and functional disability among survivors of sepsis. JAMA,304(16):1787-1794.
Rhodes, M.B., Evans, L.E., Alhazzani, W., et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3).
Singer M., Deutschman, C.S., Seymour C.W., et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).




Posted: 8/31/2017 5:39:49 AM by Lisa Bonsall, MSN, RN, CRNP | with 5 comments

Categories: Diseases & Conditions

Using the art and science of nursing to fight the opioid crisis

emergency.jpgEvery day we see it in the news and in our emergency departments, a person overdosing on prescription or street drugs. Every day, 90 Americans die due to an opioid overdose and in 2015, 33,000 lives were lost (Rudd, et al., 2016).  Age, gender, socioeconomic class, it doesn’t matter; opioid overdose has become a crisis that causes heartache for not only the overdose victim, but their loved ones too. Some victims are lucky; they receive naloxone and are revived, but too often they just repeat the behavior that landed them in trouble in the first place. So why are we, as one of the most developed nations in the world, in this predicament? What can we do as a country and as nurses to change this precarious course?  

We’ve all seen patients in pain and know it’s real. But, something happened over the past 20 years. Somehow, we thought patients should be pain free no matter what the cause, and we even considered it a 5th vital sign, although it was never meant to be considered that way (Morone & Weiner, 2013).  Let’s think about that for a minute. It’s completely unrealistic that after surgery or an injury, a person won’t experience pain; in fact, pain gives us information that something maybe wrong. We should have been focusing on decreasing pain, not totally alleviating it.  

With the availability of tablet formulations  growing in the 1990’s, the number of opioid prescriptions and the length of time they were prescribed grew. When their prescriptions ran out, many turned to less costly street drugs like heroin; in fact, 80% of patients who use heroin today used prescription opioids first (Muhuri, et al., 2013). Many people can access prescription opioids by using a family member’s or friend’s medication or buying them on the street. Today 21% to 29% of patients prescribed opioids for chronic pain misuse them and 8% to 12% of these people will develop an opioid use disorder (Vowles, et al., 2015; Muhuri, et al., 2013; Cicero, et al., 2014; Carlson et al., 2016). 

The federal government is trying to alleviate this crisis. The Department of Health and Human Services is working to improve access to drug treatment programs, promote the use of overdose-reversing drugs (such as naloxone), and improve public health surveillance. The National Institutes of Health has devoted funding for research on innovative pain management and addiction treatment. 

Nurses are an integral part of the interdisciplinary team fighting the opioid crisis. For those of us who prescribe opioids, before writing the prescription, we must now check the Prescription Drug Monitoring Program Database to investigate the patient’s opioid prescription history. We must advocate for and practice responsible prescribing of opioids; we do not want any organization dictating our prescription practices. We need to encourage patients to seek treatment for opioid addiction and help them find those resources. We need to teach patients how to properly dispose of their used opioid medications.

Nursing is both an art and a science, and using those principles can help guide our pain management practice through:
  • Educating patients that reducing pain, not completely alleviating it, is often the goal.
  • Evaluating and managing the patient’s anxiety through relaxation techniques.
  • Using correct patient positioning.
  • Using ice or heat when appropriate.
  • Using compression and elevation for sprains or strains.
  • Encouraging rest.
  • Using acupuncture, meditation, and other alternative or naturopathic techniques.
When we do administer an opioid medication to a patient, we need to consider: is this the right drug for the right level and right type of pain? Would an alternative drug such as acetaminophen, ibuprofen, gabapentin or something else be more appropriate?

The opioid crisis has brought too much heartache to this country. As nurses, we must recognize we are integral to assessing and managing pain appropriately, be able to identify patients who need addiction therapy and help them gain access to those resources, and we must be a voice for responsible prescribing. Together with the interdisciplinary team, we can help to alleviate the opioid crisis; we owe it to our patients!
Rudd RA, Seth P, David F, Scholl L. (2016). Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016;65. doi:10.15585/mmwr.mm655051e1.
Morone NE, Weiner DK. (2013). Pain as the fifth vital sign: exposing the vital need for pain education. Clin Ther. 2013;35(11):1728-1732. doi:10.1016/j.clinthera.2013.10.001.
Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. (2015). Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576. doi:10.1097/01.j.pain.0000460357.01998.f1.
Muhuri PK, Gfroerer JC, Davies MC. (2013). Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBHSQ Data Rev. August 2013.
Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. (2014). The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366.
Carlson RG, Nahhas RW, Martins SS, Daniulaityte R. (2016). Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study. Drug Alcohol Depend. 2016;160:127-134. doi:10.1016/j.drugalcdep.2015.12.026.
Chief Nurse, Wolters Kluwer



Posted: 8/30/2017 4:52:14 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

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