One of those quirky nursing things

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

What is it? Here are some examples:

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

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

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

Posted: 3/23/2012 8:29:26 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety


One of those quirky nursing things

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

What is it? Here are some examples:

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

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

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

Posted: 2/23/2012 8:23:30 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety


The impact of SBAR

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

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

So what are these “far-reaching effects?”

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

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

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

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

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

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

Posted: 1/30/2012 7:23:58 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety


Calculating the mean arterial pressure (MAP)

MAP, or mean arterial pressure, is defined as the average pressure in a patient’s arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure (SBP). True MAP can only be determined by invasive monitoring and complex calculations; however it can also be calculated using a formula of the SBP and the diastolic blood pressure (DBP). 

To calculate a mean arterial pressure, double the diastolic blood pressure and add the sum to the systolic blood pressure. Then divide by 3. For example, if a patient’s blood pressure is 83 mm Hg/50 mm Hg, his MAP would be 61 mm Hg. Here are the steps for this calculation:

MAP = SBP + 2 (DBP)
                3

MAP = 83 +2 (50)
                3

MAP = 83 +100
             3

MAP = 183
           3

MAP = 61 mm HG

Another way to calculate the MAP is to first calculate the pulse pressure (subtract the DBP from the SBP) and divide that by 3, then add the DBP:

MAP = 1/3 (SBP – DBP) + DBP

MAP = 1/3 (83-50) + 50

MAP = 1/3 (33) + 50

MAP = 11 + 50

MAP = 61 mm Hg

There are several clinical situations in which it is especially important to monitor mean arterial pressure. In patients with sepsis, vasopressors are often titrated based on the MAP. In the guidelines of the Surviving Sepsis Campaign, it is recommended that mean arterial pressure (MAP) be maintained ≥ 65 mm Hg. Also, in patients with head injury or stroke, treatment may be dependent on the patient’s MAP. 

In what other clinical situations do you monitor MAP?  

References
Surviving Sepsis CampaignAccessed December 8, 2011. 
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition. Philadelpha: Wolters Kluwer Health/ Lippincott Williams & Wilkins.
 

More Reading & Resources
Focus On: Sepsis
Focus On: Stroke

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Posted: 12/8/2011 8:49:14 PM by Lisa Bonsall, MSN, RN, CRNP | with 17 comments

Categories: Patient Safety


When a patient or family member is a nurse

We’ve all been there...getting report when the oncoming shift finishes up and whispers to you that the patient’s family member is a nurse. How do you feel? What is your initial reaction? Do you change your approach to the patient? To the family?

It always made me a little nervous when a patient himself or a member of his family was a health care professional, especially when I was a new nurse. Would he be watching my every move, ready to pounce if I hesitated or didn’t have an answer to a question? Or would he be helpful, offering information and advocating for himself or his loved one?

There was one particular patient* that I cared for when the dynamic of a family member who was a nurse was particularly challenging. I don’t recall the specifics about the patient, only that he’d been transferred several times to different hospitals as a “challenge to wean” patient, meaning he was having difficulty weaning from the ventilator. His sister, a nurse, was his power of attorney and very involved with his care. The issue was that the patient appeared to be in severe pain from contractures and pressure ulcers. He was noncommunicative when he arrived at our hospital, but would have significant changes in vital signs and become diaphoretic and tense his muscles with nursing care. His sister requested that no analgesia or sedation be administered so as not to interfere with his ventilator weaning. 

The team caring for this patient was perplexed. We didn’t feel comfortable not treating his pain, but also were being influenced by the wishes of the patient’s sister. Our hospital’s ethics committee was consulted and a careful balancing act was employed to treat his pain adequately while allowing him to be awake enough to wean from the ventilator.

It was challenging to care for him. His sister would check medication doses and keep track of dosing intervals. It was a stressful time for the staff as we all worked together to provide the best care for the patient while being so closely observed. 

Of course this is only one example. More often, health care professionals who happen to “cross over” into the patient or family member role leave their scrubs or lab coat outside the door. In my next post, I’ll share my own experience being on the other end of the stethoscope. 

*Any identifying characteristics are purely coincidental. 

 

Posted: 8/23/2011 8:00:35 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety


The heat is on

how to treat heat-related illnesses for nurses

It has been incredibly hot here in the outskirts of Philadelphia as well as in the rest of the northeastern United States.  Last night, as my family and I walked out of an air-conditioned sporting event, I was amazed at the wall of heat and the hot “breeze” that greeted us. It was after 10 pm, shouldn’t it have cooled off by then?

I was reminded how dangerous the extreme heat can be. I coughed as I took a deep breath of that hot air. How would someone with lung disease handle this? I looked at my children, school-age now, but I flashed back to my twins who spent most of their first year of life on oxygen after their premature birth. I thought of my parents, not elderly, but dealing with a fair amount of chronic illness.

For those of you dealing with the extreme heat these days, I urge you to be safe and to check on those around you, especially the elderly and the very young. Remind your patients to be mindful of the heat. Take care of yourself - stay hydrated and cool. Here is the link to the CDC’s Tips for Preventing Heat-Related Illness. Also, Nursing2011 published a great article last year, Summer Emergencies, Can You Take The Heat?  It has information about preventing and treating heat-related illnesses, as well as drowning, insect stings, snake bites, and lightning injuries. 

Stay cool and be safe!

Posted: 7/23/2011 7:13:10 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety


Memories of a medication error

A recent study published in the Journal of Nursing Care Quality looks at medication errors from the perspective of nurses.  While the researchers sought information about reporting of errors, importance of technology in reducing errors, and current medication administration procedures, they also asked open-ended questions allowing nurses to share their own experiences with medication errors.

"Nurses were asked, "How did you feel when you made a medication error?" This question yielded somewhat surprising results. Many of the medication error incidents had occurred years before completion of the survey yet responses retained the emotions associated with it. Themes that emerged from these comments included concerns about patient harm; violation of trust; culpability, shame, and self-blame; loss of self-esteem and professional self-image; and an awareness that the system had failed them."

When I was a senior nursing student, I neglected to check a patient’s heart rate before giving him a dose of digoxin. I was devastated. As soon as I saw him swallow the pill, it hit me that I hadn’t taken his pulse. I panicked and grabbed his wrist. His pulse was 62; above the “Hold for heart rate less than 60” but not by much. I hadn’t thought about this incident for a long time, but now thinking back, I can remember this clinical day so vividly. My first concern, of course, was for the well-being of the patient and fortunately, his vital signs remained stable. My own feelings of self-doubt and failure, however, stayed with me for quite some time. How could I have forgotten something so important and yet so simple? 

Read the full text of When the 5 Rights Go Wrong: Medication Errors from the Nursing Perspective while it’s on our Recommended Reading list. Please share your own experiences and feelings by leaving a comment!

Posted: 6/7/2011 8:45:13 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety


8 rights of medication administration

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

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

 

Rights of Medication Administration

1. Right patient

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

2. Right medication

  • Check the medication label.
  • Check the order.

3. Right dose

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

4. Right route

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

5. Right time

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

6. Right documentation

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

7. Right reason

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

8. Right response

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

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


More Reading & Resources
Drug News
Clinical Nursing Resources
Three Ways to Minimize Your Risk of a Medication Error
 

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Posted: 5/27/2011 8:41:57 PM by Lisa Bonsall, MSN, RN, CRNP | with 31 comments

Categories: Patient Safety


Patient Safety

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

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

Posted: 3/7/2011 7:31:45 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety


And the winner is...

Just last month, two articles from our journals and one entire journal issue received prestigious Eddie & Ozzie Awards. Please allow me to offer my congratulations here and share this content with you.

In the B-to-B, healthcare/medical/nursing, single article category, Stop the disruption of anxiety (Nursing Made Incredibly Easy!, March/April 2010), by Kathryn Murphy DNS, APRN took the gold! This article shows how you, the nurse, are so vital in ensuring identification and proper treatment of anxiety disorders. You’ll find handy charts and illustrations that explain neurotransmitters and neurotransmission, and a great table of medications used to treat anxiety (includes adverse reactions and important nursing considerations). Here’s the link to the pdf if you prefer.

The silver award in this category went to Gathering pearls of knowledge for assessing older adults (Nursing2010, March 2010) by Peg Gray-Vickrey DNS, RN. In this article, the author not only describes variations with physical assessment, but she also offers insightful tips such as: “Never interpret confusion as a normal part of aging” and “Always expect the unexpected.” There are some great photographs in this article too! Again, if you prefer the pdf, you can find it here.

The March issue of Nursing2010 also earned a bronze award in the B-to-B, healthcare/medical/nursing, full-issue category, receiving high marks for editorial focus and presentation.

Congratulations to the authors, editors, and staff!

Posted: 2/13/2011 8:25:09 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety


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