Reflection Time…

So I’ve had a very busy month, and an array of patients with interesting stuff going on; but the most time consuming part of nursing doesn’t seem to be the charting – its the family members. Family members can be helpful, complex or just down right annoying. I’ve had all and in between over the last month. One stuck out to me though. He was the son of an elderly woman; he and his sister took turns in caring for her. One week she was with one family, next week with the other, like a child in the middle of a divorce or something. The patient and her two children were so happy though, it seemed that the sharing of caring had totally eliminated that air of burnout which is so common among caregivers.

I went in to check in on the patient and the son was there chatting with her. He said he had something to show me and pulled out his cell phone. He showed me a picture of the most beautiful beach sunrise, it was just idyllic. I told him how pretty it was and how much it made me want to go to the beach. He told me that he took that picture that very morning. I was amazed to think that something that beautiful had happened a few blocks from where I live but, I was so preoccupied I missed it. Sure I was at work, but I never even thought about the sunrise, I was focused on work/details/tasks. He told me that he makes a point of taking a picture every day of the sunrise, to remind him how lucky he is. I was so humbled by this, I understood what he meant, but I saw it as such a feat, that he would fit that moment into his daily life.

I reflected on this throughout my busy day. I thought about how many wonderful things happen everyday and I as so focused that I miss them. So consumed with work, the serious nature of nursing, and the responsibility that comes with it, somehow clouds our view of the small, wonderful things happening around us.

With this, I pass on my reflection to you the reader. Take one moment to reflect on the beautiful things that happen each day. You don’t have to be by the beach like me, but regardless, the sun still rises and falls everyday, giving us one more day to live our lives – that is something to be grateful for.

Nursing Skills: Starting a killer IV!

So students seem to think of IVs as the holy grail of nursing school, veteran nurses are still bummed out when they can’t get a stick, and there is always that one IV go-to person on the unit that can somehow find a vein that you never saw during the 30 minutes you spent combing those upper extremities! Ahhh the IV!

So some tips on getting that first stick golden IV! Firstly, get to know your IV catheter. My hospital just changed from the small catheters which have the needle safety cap on withdraw, but doesn’t have the valve so you have to hold pressure on the vein below the catheter while connecting the tail and flush – to now we have the huge long catheters with the button for needle retraction. Honestly they both have their pro’s and con’s, and I have found that both need a modification in getting the vein just right. So like I said, get to know the catheter; if you’re a student, roll up some gauze and practice getting the needle in at the right angle and gliding in the catheter with your index finger.

Before starting your IV, get prepared! Have extra IV catheters in case you don’t get the first stick or the vein blows. Set up your stuff, your IV lock and flush etc. I like to set up my tape too, because I still do chevron when I have time to secure the hub.

Check out the extremities before applying the the tourniquet, there is no point just throwing on the tourniquet above the elbow, look to see if you can see a clean vein before applying, this will make the process quicker.

Once you have your spot and tourniquet applied, tap the vein to get it to stand up. It will make it much clearer and easier to puncture.

Use your non-dominant hand to keep the area taught, this will reduce rolly veins from running or sinking away from you.

If you don’t get a good stick, don’t beat yourself up. Sometimes it happens and who knows the pt might end up with a PICC due to poor venous access anyhow!

Practice makes you better! If you are a student take every opportunity to watch or attempt an IV start. If you are a new nurse and still intimidated by IVs, tell your colleagues to let you know if they have a pt who needs an IV, let the charge nurse know you want to practice or assist them in starting IVs – they will be impressed by your eagerness to learn and guaranteed you will get better! Good luck and get sticking!

This is a decent video for students who want a start to finish visual on venipuncture!

Related articles

• Turning IV failures into successes (timesofisrael.com)
• IV tips: (emscapstone.com)

NCLEX Success: Test Day Advice Busters!

Ok so lets talk a little bit about that dreaded day. Most people are really nervous, they have itchy pants or just feel nauseous. Well that’s to be expected. When the day finally arrives you better be ready for it, although guaranteed you won’t feel ready! So now I’m going to tackle some of those test day cliches!

Things you’ve probably been told to do:

• Get a good nights sleep – well that is easier said than done. The likelihood is that you will toss and turn all night. The alternative is to take some melatonin or NyQuil the night before and have a family member or a friend AND an alarm clock set to wake you up. It’s true that a good nights sleep will help you, but don’t beat yourself up if you struggle to get some zzzz’s the night before.
• Eat a healthy meal the night before and a good breakfast the day of – This is dependent on what kind of eater you are. Do you binge eat under stress? Or do you lose your appetite? The fact is your mind is focused on the test, just eat whatever you want! One healthy meal isn’t going to help  you the night before. The day of, it is important to have something in your stomach, but if you are too nauseous then just stick to water.
• Don’t study the day of the test – Yeah, I was told that too; what a load of crap! My exam was at 2pm in the afternoon, and you’re damn right I studied before it. I didn’t go hardcore and freak out over the things I didn’t know. I simply went over the rationales of the mock test I took the day before. I felt like it got me in the groove without freaking me out. At the end of the day there will be questions that you just don’t know, but NCLEX know that, which is why they keep evaluating you with each question and will shut off when you have proved yourself.
• Aim to pass in 75 questions – This is a stupid notion; you should not expect or hope to be done in 75Q. Mentally prepare yourself to go the whole way. If you get to question 75 and it doesn’t shut off it doesn’t mean you failed – it means you still have to prove yourself, so take the challenge!!! Don’t freak out when questions 76 pops up, I had a friend that passed and it shut off after Q76. It is important to just take each question at a time, if you are clueless, then go with your gut and just pick one, you have to keep pace.
• You can always take it again – This isn’t a bad thing to keep in mind. We put a lot of pressure on ourselves; we don’t want to be the ones who fail, BUT, life is full of set backs and the fact that you can take it again if necessary should relieve some of that pressure. If you fail it doesn’t make you stupid, there are so many factors involved in taking the test, you just have to draw up a new study plan and start over.

You can do it, NCLEX isn’t a monster, just a bridge to cross! Best of luck to you!

Cardiac Tamponade

This has nothing to do with tampons in the heart ok! Just an FYI.

When blood or fluid accumulate in the sac which surrounds the heart it exerts pressure against the heart, making it harder for the heart to pump. As you can imagine, if the ventricles cannot fill fully or contract effectively then cardiac output decreases. Decrease cardiac output is not good news!

So how do you know if someone has this?

Well the symptoms are nothing unusual: chest pain, restlessness, quick shallow breathing, palpitations, pallor, tachycardia, weak peripheral pulses, pulsus paradoxical, distended neck veins, low BP… (do these all sound a little familiar? MI anyone?) Well causes of cardiac tamponade can be MI, Dissecting aortic aneurysm (thoracic), end-stage lung cancer, heart surgery, Pericarditis caused by bacterial or viral infections, or direct wounds to the heart.

How do we diagnose? Echocardiogram is the usual diagnostic tool, but MRI, CT, CXR or EKG can also highlight or confirm this.

Can you see the halo of fluid around the heart?

This is an emergency! The fluid must be drained to reduce damage to the myocardium and reestablish cardiac output.

Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac, the tissue that surrounds the heart. The patient will be hyperoxygenated, given fluids to maintain blood pressure. It is important to note that a pericardiocentesis may have to be repeated because cardiac tamponade can return. With fast treatment the outcome is usual good, without treatment death is immanent.

A pericardial draining tube may be placed during surgery to keep in place postop. The drainage will be measured every shift and documentation on the color, amount and consistency is very important! The tube will usually be removed slowly over the postop recovery weeks at the discretion of the cardiologist.

NCLEX Success: Remember your A-B-Cs!

Say it with me: AIRWAY, BREATHING, CIRCULATION!

If you have renewed CPR with AHA recently you’ll know that they have changed that to CAB from ABC, but for NCLEX you need to stick with the ABC.

So here comes that irritating priority question. You try to apply Maslow but all options are physiological, so there is nothing to eliminate. What do you do? You apply the ABCs.

Airway will always be the most important factor to take priority: anaphylaxis? Choking? So look for it, if it isn’t there, look for breathing, it could be simple like raising HOB to decrease dyspnea in a CHF pt – keep focused on the “B” until you can rule it out. If no luck at that point, move to circulation. Hemmorhage? Potential for bleed? Change in vitals (↑HR, ↓BP)?

Look at the big picture and apply all the ABCs and use them to lead you to the right answer! Priorities will always contain ABC/Maslow or combination! Use your question answering skills! 🙂

Nursing Skills: Reasons for Chest Tubes

So I thought I’d write about chest tubes this week because I had a patient with two chest tubes and was post removal of a pericardial tube also. Not only that, but a colleague had a young pt in his 20’s whose chest tube popped out on the same day! Needless to say I thought it would be a great topic to cover. I’ll break it into three postings

Firstly, chest tubes aren’t as scary as they appear: sure, they are stuck in someones chest but there are many different reasons for a chest tube so knowing a thorough background on your pt is very important.

The procedure for placing chest tubes is called a Thoracostomy.

Reasons for inserting a chest tube:

Pneumothorax: This is when air collects in the pleural space; can also be referred to as a “collapsed lung”. The air pressure in the pleural space does not allow the lung to reinflate.

Pneumothoraxes can occur after central line insertion, after chest surgery, after trauma to the chest, or after a traumatic airway intubation. It is very important to remember that if the air continues to collect in the chest, the pressure in that pocket can increase and push the whole mediastinum over to the other side – this is called a “tension pneumothorax”, and is  life-threatening.

 

 

 

 

 Hemothorax: This is is when blood fills/pools in the pleural space and reduces the area for lung expansion. This can happen due to trauma or surgery. There is a possibility of having a hemo-pneumothorax which means air and blood fill the cavity. Also there remains the risk for medialstinal shift “hemo-tension-thorax”, this would be an emergency.

 

 

 

 

 

Pleural Effusion: This is the accumulation of fluid in the pleural space. This can be caused by CHF, liver failure, kidney failure, peritoneal dialysis, pneumonia, lymphoma or breast cancer. Though most pleural effusions are caused by congestive heart failure, pneumonia, pulmonary embolism and malignancy.

 

 

 

 

 

 

 

 

 

 

 Empyema: This is when pus is the substance which fills the pleural space. This is clearly cause by infection, but the pressure of pus in the pleural space makes it difficult for pts to breathe freely, they will likely have fevers and chills, malaise and chest pain.

NCLEX Success: Maslow’s Hierarchy of Needs

Maslow is a great tool to narrowing down or answering NCLEX questions. Those pesky priority questions are the ones in which Maslow can lend a helping hand. Here is how you use the Maslow Strategy:

1. Look at the answer choices. Determine if the answer choices are both physiological and psychosocial, if they are – apply the Maslow strategy.
2. Now, eliminate all psychosocial answer choices.
3.  If the answer choice is physiological, don’t eliminate it. Maslow states that physiological needs must be met first. Although pain certainly has a physiological component, it is considered a psychosocial need on Nclex.

Laughter is Good Medicine!

 

Laughter really is the best medicine. The video above shows how a program which includes laughter into a dementia facility’s program can really affect levels of agitation seen in patients. I know in my own practice that I use humor to build a trusting relationship with my patients. When we laugh together, we are absolute agreement in that moment; I believe it is a vital component of fostering a rapport with my patients.

Sometimes when coming on shift I can sometimes tell when I have a grumpy one who isn’t going to “lighten up”. It doesn’t stop me trying. One patient once was very quite, stoic, indifferent. I had been lighthearted and chirpy with him in the morning, but it wasn’t until I put his sugar in his coffee and he asked for another one, when I replied, “another one? You have to be kidding me? So you’re not sweet enough?”. I big smile spread across his face and he started to chuckle. It was just a small comment, and it really made his day. After that he was so pleasant, he engaged in conversation with me, joked back at me – completely different. I crossed boundaries with that patient to where I wasn’t just another nurse coming to give him meds 3 times a day, I was a friend, I was someone he could speak to, I was interested in what he had to say.

As nurses we can often get wrapped up in task-managing, and forget that we are serving people! Maybe we need to stop and have a giggle with our patients; we might need it just as much as they need it.

The RN & CNA: The Modern Day Batman & Robin!!!!

Let’s face it, what would Batman be without his sidekick? Lonely, for starters.

RN’s and CNA’s relationships can be wonderful or tragic, but bottom line is – they need each other!

Similarities: They both deliver patient centered care. They both prioritize. They both respond to patient needs within their scope of practice. They both require excellent communication skills. They both know the patient better than the doctor! haha!

So why are there so many conflicts between the two? Some of the obstacles may be a clash of personalities, but at the end of the day, people management skills, good communication and teamwork are key.

How should a relationship be maintained between a CNA and RN – mutal respect. Yes, an RN can complete all the tasks a CNA can do; their scope of practice can overlap therefore, nurses need to remember that basic nursing tasks are not below them. If your CNA is extremely busy, and you as the RN have a little time on your hands or can shuffle tasks to give you a minute to help the CNA out, then that is the right action to take. A CNA appreciates when you notice that they need a hand and you jump right in. When is the last time as a RN that you completed a bed bath? Don’t lose touch of the essence of nursing! Connect with the patient, listen to their needs, and fulfill them no matter how simple they are.

CNA’s, it is important to stress to the RN that you need to receive report on the patients you are caring for. Although you do not provide advanced nursing care like the RN, there are things about the patient that are relevant to the nursing care you are provide. If the patient is NPO, if the patient has bleeding risk, aspiration risk, on a Tele monitor, incontinent, total care, etc. All these things are important for the CNA and nurse to communicate to one another. The CNA should feel comfortable letting the RN know if they sense a change in the patient’s LOC or changes in skin, swallowing ability or body fluids. These findings are important to the plan of care, the assessment data and possibly medical diagnosis. CNA’s just as much a part of the interdisciplinary team as the RN, Dr., Speech Pathologist, PT, Phlebotomists, X-ray Techs, and the list goes on. CNA’s need to feel valued, so as an RN encourage them to come to you with anything the observe regarding the patient.

So what do we know about working in harmony? Communication, respect, mindfulness, teamwork are all important ingredients. And remember, CNAs and RNs are cooler than Batman and Robin anyway… they’re the real superheroes!

A Little Self-Care…

So Nurses are renowned for caring for others, right? It is the essence as who were as individuals and professionals, but how to we maintain this lovely nature without becoming the crabby, unhelpful coworker in the corner?

SELF CARE

Self-care is something that is certainly more frequently discussed in hospitals and healthcare facilities. As she research into workplace abuse, horizontal violence and employee retention increases, it it beginning to be noticed by administrations and managers everywhere. Our environments and relationships with other members of the interdisciplinary team certainly reflects on our mood and overall job satisfaction, but how to we maintained centered in who we are as people? How to we keep that excitement for our profession alive? You got it, self care.

So self-care is something nurses struggle to find time for, yet it is such a vital component of personal well being. When was the last time you shut your phone off and went to do something you enjoy? If you can recall a time less that one week ago, you are doing great, if you can think of something longer than 1 month ago or not at all – you need an intervention!!!

Self care is all about the “ME” time. Some of you are moms and dads, or caregivers for family members, have multiple jobs and so much more…. but beneath the busy schedule there is just you. You may act like a superhero most of the time (lets face it, Superman’s got nothing on nurses!) but, everyone needs to have a little time to re-center and take a breather.

What ways can self-care be done?

A great option for self care is a healthy option. Running around that hospital unit might be exercise, but it doesn’t contribute to your self care. How about a walk along the beach or in a park? Trip to the salon? Nails or massage? (No acrylics though! hahah!) Is there something that you’ve always wanted to do but never had the time, such as salsa classes or yoga classes? Go and book that class! Force yourself to be accountable to attending one a week, so you are guaranteed that “me” time.

Cut the Crap! How about switching that lunchtime extra large coke for an extra large water? (Its so hard – need caffeine IV stat!) Think about your body, how can you help you? In a 12 hour shift, did you put out 30ml/hr? Huh? We don’t want kidney stones now do we?

There are so many options for self-care so do some soul searching and see what lifestyle change might be right for you. Nurse to nurse caring is so important, so make sure you encourage your nursing colleagues to do the same so we can have a HAPPY, HEALTHY workforce!

Related articles

• Burnout, Recovery and Work-Life Balance for Nurses (digitaldoorway.blogspot.com)
• On the nurse manifest project and creating change (nursemanifestblog.wordpress.com)