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.

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)

EKG: Hypokalemia vs Hyperkalemia

So you should already know that potassium (K+) is VERY important in our bodies. From the action of K+ in the depolarization and repolarization which takes place in the heart, you can imagine that if there is too little, or too much potassium, then the effects will be present in the heart muscle.

HYPOkalemia

Hypo –  meaning; less, not enough, below normal levels. Therefore, here we are talking about not enough potassium. Below is an EKG, and from my last posting where you became familiar with a normal EKG, you should be able to notice there are things about this EKG that are abnormal (If you noticed that, then well done!)

You can see that the U wave is really big, or in medical terms; prominent U waves are present. The T wave on the other hand is said to be “inverted” or the opposite direction that it should be, it can be flattened also. So just looking at this portion we can see that the REpolarization phase is definitely going to be affected by these changes.

I like to think of hypokalemia as making everything more depressed. A depressed person, moves slower, things take longer for them to do, they are disorganized and one thing runs into another.

Other things that can be seen in Hypokalemia in the EKG: the ST segment can be depressed (below the flat baseline), the PR interval can be prolonged (longer that should be) as well as the QT interval (due to the merging of T and U waves) and the P wave can get taller and longer.

Hypokalemia is serious because it can develop into life threatening arrhythmia such as Torsades de Pointe, Ventricular Tachycardia, Ventricular Fibrillation.

HYPERkalemia

This is the opposite, HYPER: too much, more than baseline, overload. Too much is just as dangerous and not enough, and as you can see from the strip below, the EKG will show you signs of high K+.

P waves here in this strip is missing; you might see small to no P waves, coupled with spiked T waves. Look at the T waves here, they are as tall as the QRS complex! In severe hyperkalemia, the QRS complex can widen also.

So as with hypokalemia, I like to think use little story concepts to remember the differences. So I like to think of hyperkalemia as an ADHD child: the T waves are hyper and the P waves are playing hide-&-go-seek. Repolarization period here is affected by surplus potassium by causing a faster repolarization period, and reducing the response of sodium channels in the myocardium; therefore slowing conduction around the heart and reducing the P wave in the strip.

So how can we tell when someone is hyperkalemic? Think: Blood test (straight forward, check K+ level), ABG (metabolic acidosis), hx renal disease (reduces elimination of K+), Addison’s disease, severe burns (mass K+ being released for cells/cell-lysis?), Digoxin toxicity.

What to know about potassium:

Potassium is mostly found inside the cells.

The normal range for potassium is 3.5-5.0 mEq/L

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.

“Don’t Take It Personally!” Famous Last Words!

How many times have your colleagues or bosses told you “don’t take it personally”, when someone has treated you wrongly. Being a new nurse I hear it all the time. My first phone call to a Dr. I was yelled at for no reason, I was told – don’t take it personally. My first phone call to healthcare surrogate for consent, I was yelled at, I was told – don’t take it personally! There gets to a point where you kind of do take it personally! No one wants to be yelled at, especially with no just cause, if there ever could be for that behavior. 

It is less about taking it personally for me, it’s more about the damper it puts on my workflow and mood. It leaves you feeling a little downtrodden which is never nice, especially when you are new and trying to get into your groove. So what is it about the nurse that makes us such easy targets for hostility?

We are sandwiched between the physician and the patient, which means were are often the messenger that get the bullet from one side or the other. Aside from this angle, we meet hostility from within or at a horizontal level, with coworkers being unsupportive of one another. There is often hostility which comes down the chain, from administration it trickles down to charge nurses and then staff. How to we reduce this hostility? And with this constant bombardment, how do we not take this personally?!

I suppose one key is to ensure you maintain a high level of self-esteem. You are a great nurse and no-one can make you feel otherwise. Secondly if you have someone who you consider a mentor, then go talk with them about it, but avoid gossiping about the event with others on the unit, it will only make the situation worse or you feel worse. Lastly, after work you must decompress, however you choose to do that; spending time with loved ones, yoga, exercising, taking a hot bath – whatever. Always recenter yourself and let no-one or any situation take away your light!

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This is a great visual of the sx seen with Hyperthyroidism!