Archive for August, 2011

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Hurricane Aftermath

August 29, 2011

Hurricane Irene, by D. Fletcher via Flickr

By Shawn Kennedy, MA, RN, AJN editor-in-chief

Well, Hurricane Irene has come and gone in the northeast United States. While it certainly destroyed property, downed power lines, and caused flooding, many are thinking that we escaped the worst, since Irene morphed from a hurricane into a tropical storm when it made landfall in Long Island, New York.

This is not to diminish the tragedy that it caused—in loss of life (CNN reports 25 Irene-related deaths)  and destruction of property.  And I sympathize with those who experienced flooding or lost power. Cooking, showering, and basic daily activities become major challenges and require ingenuity, creativity, and sometimes a touch of genius. While initially this merely seems inconvenient, after a few days it’s exhausting. I’m sure there will be many households without power for weeks, judging from some local news reports.

An important potential health hazard that wasn’t covered in depth on the news is walking or wading in flood waters in shorts and bare feet or flip-flops. Flood waters often contain contaminants from storm drains and sewers, including raw sewage (as one news reporter discovered only after he was covered in it). Debris, sharp objects, and even power lines may be hidden underwater, as well as ditches or drains (47-year-old postal worker Ronald Dawkins, from Orange, New Jersey, was killed when he tried to wade through rising water to a postal facility where he worked and stepped into a hidden drainage creek).

The Centers for Disease Control and Prevention offers a guide to preventing illness after a disaster and also has information for how to stay safe while cleaning up after flooding. Check it out and spread the word.

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Patient Privacy and Company Policy: What Nurses Should Know About Social Media

August 26, 2011

Should you be able to have an online discussion about hospital policies that aren’t working or are unfair? What if the point of your discussion is to improve working conditions or to troubleshoot and not to cast an uncomplimentary light on your employer? Right now, the answer is “good question.”

If you’re a nurse or health care worker of any sort, if you sometimes use one or more of the many available social media options (Facebook, blogging, Twitter, etc.), if you’re worried about what it’s OK for you to do or say online, if you have a job or are thinking of looking for one, we strongly suggest you take a look at this month’s iNurse column in AJN (quoted above).

In it, Megen Duffy, RN, aka blogger Not Nurse Ratched, considers such issues as the following:

  • hospital social media policies (always read them; some are surprisingly restrictive)
  • HIPAA and potential issues raised by blogging about aspects of work
  • the ways your social media history may be mined by HR departments at prospective employers
  • the reasons why she strongly believes that social media isn’t going away and has many potential benefits, despite various well-publicized pitfalls—and why nurses need to let their input be known so that social media policies will be sane and balanced

And, since this is social media, we hope you’ll let us know your thoughts, in the form of comments. Maybe Megen will even weigh in, if you really get her attention.—Jacob Molyneux, senior editor

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Killing Traditional Nursing Duties #1

August 24, 2011

By Shawn Kennedy, MA, RN, AJN editor-in-chief

We recently had a lot of feedback to a question we posted on our Facebook page: “We know old habits die hard and nursing has a lot of them. What old habits do you think we should kill? NPO after midnight? Routine temps on every patient?”

We got several good responses:

- Waking patients up at 4am for blood drawing, routine vital signs

- Measuring intake and output on every patient

- Taking routine temps

- Giving dorsogluteal IM injections

- Doing a skin prep for an IV by swabbing the site in a circular motion, inside to out (some manufacturers of products are instructing that skin prep be done by a scrubbing motion)

- Enemas before childbirth

- Double documenting

- Rushing to give medications right on time (which makes one prone to error)

- NPO after midnight

Choosing from the above, we then asked this: “Survey question #1: Do you routinely wake patients up at night to check their vital signs? If not, when would you?”

This question received many comments, from “Of course not” and “only when necessary” to “If a doc orders q 4 vs and you don’t do it and something happens to the patient, that would not be good for you AT ALL.” Also this: “Orders are orders which we must follow.”

Commenters cited several stories of recent postoperative patients (who, I agree, should have vital signs frequently monitored) who could have suffered grave consequences had the nurse not woken them to check their vital signs or level of consciousness. I do like what one response noted—“critical thinking.” This is key, regardless of what the physician order may be—if the physician order is “q4h” but a patient’s condition may warrant more frequent checks, we would all hope the nurse wouldn’t stick to q4h.

Of course, for those working in ICUs or in postanesthesia units, the answer is simple: the patients are there precisely because they need close monitoring. As one responder indicated, “If you don’t check, you don’t know. I don’t want to be that nurse!”

Our next question was this: “When you give IM injections, what site do you most often use: dorsogluteal (upper outer quadrant of buttocks), ventrogluteal (lateral hip), or deltoid (upper arm)? Why?” Weigh in here or on our Facebook page.

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The Perception Treadmill: Has Nursing’s Status Really Gone Anywhere?

August 22, 2011
a Treadmill

Treadmill/Image via Wikipedia

By Margaret Gallagher, BSN, RN. Margaret is a cardiovascular nurse currently working in Georgia. Her last post for this blog was “Return on Investment: A Mother Makes Her Wishes Clear.”

Usually, it’s nice to share stories among friends you haven’t worked with in a while. However, I haven’t been able to let go of one such recent conversation.*

“You want to know what really burns me?” asked Lisa, a long-time nurse, as I sipped my coffee. “The rumors had been going around for a while that the residents get an incentive if the patients’ coag levels stay within therapeutic range. You know that John and I go way back; I decided to just flat out ask him.”

I listened attentively, expecting that Lisa and John’s friendship wouldn’t keep the attending MD from laughing her out of the ICU for this one.

Lisa glowed like an electric oven coil. “John told me it was true, and with a straight face! How dare they! All the residents do is click on ‘heparin protocol’ in the computer when the patient’s admitted. We draw the labs, follow the protocols, and titrate the drip around the clock until the patient is transferred, but they get the bonus. Does that stink or what?”

I couldn’t help but think back to my very first code. It was three states away and nearly three decades ago. For those who’ve never worked in a teaching hospital, July is when the interns, residents, and fellows promote up to their next year’s tasks. In our surgical step-down unit, that meant that the intern paged to the code had been employed as a doctor for all of 36 hours. He appeared, breathless from the stairs, at the code already in progress. Turning to Penny, the charge nurse, he gasped, “I’ve never done this before.”

Penny calmly handed him the chart, open to the orders pages, and her pen. “Write down everything I say as a list,” she replied. Penny ran the code from start to finish, successfully resuscitating the patient. The intern thanked us, signed “his” orders, and left the unit (with her pen). Read the rest of this entry ?

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When Do You Know You’re Really a Nurse?

August 18, 2011

There’s an imaginary line that one crosses when becoming a nurse. This line divides the floundering nursing student from the confident and experienced nurse. After four months of nursing, I found myself wondering where it could be found so I could cross it. Everybody around me already accepted me as a bright and talented nurse, yet I had doubts. I could manage patient care assignments calmly and efficiently, but I sensed that nursing wasn’t as superficial as checking off items on a list. Sooner or later, I’d face a more complex situation, with no instructor nearby to give me confidence.

That’s the first paragraph of the August Reflections column, “The Letter,” which was written by Melanie Patterson, a mental health supervising RN at a hospital in the Pacific Northwest. It’s about making the extra effort for a patient who might otherwise have been forgotten in his isolation.

Was there a moment, an event, a time when you began to feel confident in whatever your nursing role might be?—JM, senior editor

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Thoughts After an INANE Editors Conference

August 16, 2011

By Shawn Kennedy, AJN editor-in-chief—I just returned from 10 days out of the office, a long time for me. The first three days were in San Francisco at the annual conference of the International Academy of Nursing Editors (or INANE), a group that steadfastly declares itself a non-organization, with no officers, no dues, and no bylaws.

Begun almost 30 years ago, the group depends on the goodwill of its 200+ members, who volunteer for Web site operation, take turns organizing the annual meeting, and contribute when needed to support small expenses like mailings, Web site fees, etc.

It’s simple and it works. This year’s conference covered things editors of nursing journals find interesting—copyright, impact factor, ethics, and the like (see INANE’s blog, From the Editor’s Pen—“Cherry Ames” blogged from the conference!), plus a lot of great networking. (Full disclosure: the conference was sponsored by the specialty nursing journals of Lippincott Williams & Wilkins, AJN’s publisher.)

I’m always struck by the breadth and variety of nursing knowledge among the members of this group—there’s everything from skin and wound care and infusion practices to broader topics like oncology and home health. (Not to mention a few broad-based journals, like AJN, that cover all of nursing.) The editors of these journals are passionate about meeting the needs of their readers—for some association journals, this means meeting members’ needs while also trying to gain nonmember readers. It might seem easy to figure out what those needs are, but it’s not. Read the rest of this entry ?

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Compassion for Those Among Us: Recent Poems in ‘Art of Nursing’

August 12, 2011

By Sylvia Foley, AJN senior editor

Faded rose texture, by Calsidyrose via Flickr

In Carolyn Scarbrough’s poem “A Rose By Any Other Name” (Art of Nursing, August), a nurse sees an “opaque rose, unfurling” on a CT scan of an infant’s brain. Recognizing this as “evidence of violent acts,” she knows the outcome will almost certainly be tragic. Yet when she looks from the scan to the exhausted young father, another memory shifts her thoughts from “trauma to love.” With each reading, this poem reveals more about the intertwining of outrage and compassion. (Art of Nursing is always free online—just click through to the PDF file.)

“I try / to meditate on emptiness, // receive the next lungful, ignore / my prattling mind,” says the narrator of Risa Denenberg’s poem “Three-Part Breath” (Art of Nursing, July). The poem’s title refers to a yoga breathing practice, one built on trust; as the yoga teacher says, “There will always be // another inhalation.” Read the rest of this entry ?

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Return on Investment: A Nurse’s Mother Makes Her Wishes Clear

August 10, 2011

By Margaret Gallagher, BSN, RN. Margaret is a cardiovascular nurse currently working in Georgia. This is her first post for this blog.

Fly Away / jenny.nash712, via Flickr

My parents believed it was their obligation to educate their children. My sister and I both walked out with a college diploma and no debt. Susan went to a state university for her pharmacy degree, but I fell in love with a private nursing school. So my mother spent her inheritance on her own alma mater’s archrival because it was where I wanted to go. Mom got what she paid for, however, as I graduated with a BSN that has done more than just keep the roof over my head.

Shortly after I passed my boards, I planned a trip to visit my parents. I got report for my last shift, then walked in on a shouting match. My patient lay comatose between his two adult sons. Awareness of my presence brought a thick silence, followed by the younger son muttering an “excuse me” as he bulldozed his way out. After a pause, the remaining son searched my face as he began to speak.

“The doctors just told us today that Dad’s never going to get better than this. They asked us how far we wanted them to go.” He bit his lip. “I’m the oldest, so it will fall on me. But I don’t know what to tell them. I never heard him say how he felt. Dad never liked to talk about that sort of thing. I don’t know what to do.”

His eyes drifted to his father’s face, then back to mine. He blinked back the tears, “I only know that, no matter what I decide, I will never know if it was the right choice.”

I knew that this would haunt him for the rest of his life. I don’t remember what I told him. I do remember the voice in my head telling me not to ever have to utter those words.

It’s been a quarter century, but I can still see my parents, sitting at the kitchen table that next afternoon. I told them about my patient’s son. I mentioned that I knew they didn’t like to talk about that sort of thing either. I promised I’d never bring it up again if they would just tell me what they would or wouldn’t want if I ever had to be asked. Read the rest of this entry ?

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We’re Not Going to Lie to You

August 8, 2011

By D'Arcy Norman, via Flickr

By Marcy Phipps, RN, whose essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

“Hgb 4.1,” the lab tech said, and we jumped as though someone had fired a starter pistol. While one nurse called the on-call trauma doctor, the rest of us mobilized in preparation for the interventions we anticipated.

The “critical results” call wasn’t a surprise. The teenager’s pelvis had been crushed when he was run over by a delivery truck. His blood pressure was holding fairly steady, but we didn’t put much faith in that. In cases of hemorrhagic shock, young patients tend to compensate until the very last second, and we knew that.

His heart rate was soaring and his color was terrible. In the 15 minutes since he’d been wheeled into the unit, flat and flaccid on a stretcher, he’d gone from barely arousable to completely nonresponsive. Aside from his shallow, even respirations, he looked strikingly dead.

A good nursing team functions like a choreographed troupe, and we were at our best that day, moving with staccato precision. Massive transfusions can do wonders; still, it was amazing how quickly he improved. He lost the gray-white pallor and his heart rate stabilized. Then his lashes fluttered and he opened his eyes.

He regarded us working over him for several minutes. The air of urgency remained, and the gravity of his condition was no secret.

“This is bad, isn’t it?” he asked.

And it wasn’t a time for platitudes.

“We’re not going to lie to you.” We told him. “It is bad. You’re in rough shape, but you’ve got a good team here . . . ”

He nodded as he closed his eyes.

His dad, planted on a nearby chair after he’d swooned, pale and sick with his own shock, perked up as well. Heartened to see his son awake, he shakily got to his feet and came to the bedside to plant a cautious kiss on his son’s forehead. They spoke softly to each other, oblivious to us and what was going on around them.

Watching them grasp that fragile moment felt like witnessing a miracle. It’s stuck with me, reminding me, at least for now, of the things that are really important. I’d been irritable that day, worried about completing a school assignment on time, annoyed that it looked like I’d be getting out late, planning my next day off. Those things seemed petty and small, cast in the light of life and death.

I’m lucky; nursing affords me a front-row seat to glimpses of the things that are most important. It reminds me to pay attention to life and the people I love, and to hold tight to the fleeting moments that are right in front of me.

The best part? The teenager lived.

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Fecal Impaction and Dementia: Knowing What to Look For Could Save Lives

August 4, 2011

By Amy M. Collins, associate editor

Photo by Sevda Cordier-Dirikoc / GE Healthcare, via Flickr*

Last October, I wrote a blog post about my grandmother, who is 85 and suffering from the first stages of Alzheimer’s disease, and about the failure of many providers to assess and treat the underlying cause of a sudden and extreme acceleration of her dementia symptoms (mania, agitation, and violence, along with nonstop, nonsensical talking).

The post generated a slew of comments on both the blog and Facebook, with over 20 nurses suggesting the probable cause for her symptoms to be fecal impaction or urinary tract infection. They were right. But several physicians and specialists had been shockingly wrong, diagnosing her with everything from closet alcoholism to VERY-late-onset bipolar disorder.

My grandmother did, in fact, have a severe fecal impaction, finally diagnosed—after several weeks of family turmoil—by a nurse in an ED. She was treated, and within a few weeks her symptoms slowly dissipated. I’m happy to say that she’s now back to her sweet and gentle self, with no memory of the episodes she herself would have deemed crazy.

Although her Alzheimer’s symptoms are still heartbreaking (she recently introduced me to a fellow assisted-living resident as her ‘special friend’ instead of her granddaughter), she isn’t agitated, hallucinating, accusing people of stealing, or showing other signs of the previous mania. At a recent family visit, she spoke of her plans to attend a luau at her facility, and requested a grass skirt!

Chronic constipation in the elderly isn’t a rare occurrence, especially in patients with dementia, but unfortunately the outcome may not always be as favorable as in the case of my grandmother. Our August CE by Leah Craft and Joseph A. Prahlow, “From Fecal Impaction to Colon Perforation,” describes the case of a woman in her 70s, nonverbal and suffering from Alzheimer’s disease, who developed a fecal impaction and eventually died. Read the rest of this entry ?

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