Nursing Skills: NG Tubes!

NG tubes. Yes, they’re pretty gross. Anything going in or coming out of the nose is gross, have you seen the stuff that comes out when an NGT is put to suction? I’m talking rainbow secretions! All joking aside, if you think they are gross, just imagine how the patient feels. I put a NG tube in the other day and was struggling to get it around the sinuses, it isn’t a straight route y’know.

So advice for NG insertion:

• Explain EVERYTHING to the patient! Tell them it will be uncomfortable. Tell them you will be there for them. Tell them that it is crucial to swallow. Tell them you are going to try to do the procedure as quick as possible. REASSURANCE is key!
• Pre-medicate if necessary. This is controversial. My patient the other day got morphine sulfate IV before the procedure, this totally helped in chilling out her gag-reflex and made the process easier BUT, if your patient is prone to becoming sedated or unable to follow commands then lay off the meds – use your judgement.
• Measure correctly. Remember that it is nose to ear to xyphoid process – mark it with tape.
• Lube, lube and more lube! We need that tube to slide and it has a long way to go, so be liberal with that lube!
• Encourage your patient to sip water. The swallowing effect with assist you in moving the tube down the esophagus.
• Don’t give up in getting it down! There may be issues along the way so troubleshoot fast. If you cannot get it pass the sinuses, twist and manipulate the directing you are inserting the tube. Have the patient open their mouth to check for coiling in the back of the throat.
• Lastly, always check your placement. Use the piston to blow an air bubble in, listen at the xyphoid process with your stethoscope for the air bubble. Placement is also checked with a follow up CXR.

There are many reasons why an NG tube may be placed. There are reasons to suction, give meds, remove acid, or feeding – regardless they are not comfortable for the patient and careful consideration should be made for skin breakdown in the nares or insertion site.

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! 🙂

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.

NCLEX Success: Use Free Resources!!!

Being a student of any kind, well apart from some of those really rich Harvard prodigies, you probably know all about being on a budget, or to put it plainly – poor. Due to lack of funds due to all those lab fees, uniforms, strange looking nursing gadgets, your pocket is probably lacking the big bucks required to take one of those fancy NCLEX review courses. Hence, the advice I am about to crown you with – GOOGLE MAGIC BABY!

Yes, I passed the NCLEX-RN. And no, I did not pay for Kaplan or Hurst or any other claim-to-pass program. I knew that those courses were never an option because of the cost, so I gave myself a low budget and decided to use Google to help me. When Googling away, I found a plethora of material which was amazing! None of it cost $, and all of it so easy to access. The use of torrents is a controversial topic, but if you are guilt free about it then crack on! There are apps out there, as well as Saunders interactive test bank (very helpful resource), these can be purchased or with a little digging, found for free.

Kaplan Trainers. I see these are talked about a lot on the forums and people seem to freak out about the scores they get on them. I Googled them and found them posted on scribd.com. I printed a few and worked through them as a brain exercise. My best advise is not to focus on the scores! Scores don’t matter – learning matters. It really isn’t about the questions you get right, its about learning from the rationales on the ones you got wrong. Read ALL rationales, but make notes on the ones you get wrong – see if there is a trend, any topic that you are frequently getting wrong, which shows you where you need to put in some hard graft. Focus in on those weaknesses.

Practice, practice, practice! It’s all about banging out those questions.

So get those fingers Googling, and find out what’s free. There are some great Tumblr sites out there too. Below I will post some of the most helpful and intriguing sites I found!

http://rightatrium.tumblr.com/post/43568301576

http://www.scribd.com/doc/148347851/Nclex-Kaplan-Exam-1

http://www.scribd.com/doc/148349057/NCLEX-Kaplan-Exam-6

http://www.youtube.com/watch?v=HzqOkRnXBFw

http://mp3skull.com/mp3/hurst_review.html

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NCLEX Success

For all those who are embarking on their NCLEX – I feel for you!
I remember the relentless studying, the anxiety, and the need to use the bathroom every 2 minutes while in the waiting room before taking me test! Arghhhh! It was a momentous day in the life of a student. Overnight you become an RN, like a caterpillar to a butterfly…. Ok I’ll cut the crappy metaphors, we all know the torture! But do not despair, I hope to have helpful tip posts just for you NCLEXers.

This first tip is from my personal experience. Often times on the forum I saw people asking “what books did you use?”
So here is my list:

– Kaplan Strategies, Practice and Review
– Fluids & Electrolytes Made Incredibly Easy
– Prioritization, Delegation, and Assignment: Practice Exercisers for the NCLEX Exam – LaCharity

More Tips to Come! Good Luck!