Archive for the ‘practice tips’ Category

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How Good Are Your CPR Skills? Research Shows Monthly Practice Is Crucial

May 11, 2012

A nurse practices CPR on a voice advisory manikin. Photo courtesy of Laerdal Medical.

By Maureen Shawn Kennedy, AJN editor-in-chief

Most of you are probably aware of the AHA’s revised CPR guidelines that were issued in 2010. They include a major change in the resuscitation sequence—which now begins with chest compressions rather than ventilation—and emphasize the importance of achieving adequate compression of the chest—“at least two inches (5 cm)”—to achieve adequate blood flow. (You can see a video by the AHA demonstrating the new guidelines here.)  This change is especially important in light of recent research on CPR skills.

In 2011, Marilyn H. Oermann and colleagues conducted research with nursing students to determine how often one needs to practice CPR skills to maintain competence. 

As she explains in an article in the May issue of AJN, students who practiced briefly each month not only maintained their skills, but improved them significantly by the end of 12 months.

In comparison, the skills of those who only  had an initial training session deteriorated after three months; by 12 months, few could perform CPR adequately, especially in terms of achieving adequate depth for chest compressions. And although these were students, Oermann describes studies showing similar results with paramedics, non-ICU nurses, and nurse anesthetists. 

Most hospitals and agencies only require an annual review or demonstration of skills to be recertified in CPR; few, I bet, measure the depth of compressions. Sounds like it’s time to revisit this practice.

You can hear Oermann discuss her article in a podcast with Jo Haag, director of global training, ECC Programs, AHA, and Vanderbilt nursing professor Mary Fran Hazinski, a clinical specialist in pediatric critical care at Monroe Carell Jr. Children’s Hospital at Vanderbilt and a senior science editor at the AHA.

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Addressing Traumatic Injury in Older Adults

November 18, 2011

By Sylvia Foley, AJN senior editor

Frank Jones, age 83, arrives at a local trauma center after falling down a flight of stairs in his home. Initially diagnosed with two fractured ribs, a fractured ulna, and a fractured tibia, he’s admitted to the ICU.  At first, things seem to go well—his electrolytes and bloodwork appear to be within normal limits, and his vital signs are stable. But the next day he becomes increasingly unstable. What’s going on?

Stairs by spivvo, via Flickr

Trauma is currently the seventh leading cause of death in older adults—and older adults are more likely to suffer complications and die than are younger ones. But as author Christine Cutugno points out in this month’s CE, “The ‘Graying’ of Trauma Care: Addressing Traumatic Injury in Older Adults,” advanced age isn’t a predictor of trauma outcome. Many trauma-related complications are preventable.

What guides current care? While standards of care for geriatric patients and for trauma patients exist, as yet none have been specifically developed for and tested in geriatric trauma patients. Until that happens, Cutugno writes, “nurses will need to be guided by measures known to prevent iatrogenic complications in other patient populations.”

To that end, Cutugno first reviews common mechanisms of traumatic injury in older adults and discusses the effects of aging and comorbidities. She points out that older adults usually have poorer physiologic reserves and are less able to maintain homeostasis. Their compensatory responses may be inadequate. The drugs taken to manage many comorbidities can mask warning signs. In short, it can be challenging for nurses to recognize when a geriatric trauma patient is in trouble. Read the rest of this entry ?

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Killing Traditional Nursing Duties #2

September 6, 2011
This 2006 image depicted an adolescent female ...

Image courtesy of CDC

Editor’s note: In early August, on our Facebook page, we asked if there were “old nursing habits” that should be killed off. We received a lot of feedback, which we described in a blog post, “Killing Traditional Nursing Duties #1.” We’re back now with feedback from our second question: “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?”

Hands down, the deltoid injection site was preferred for intramuscular (IM) injections, especially for immunizations and if the patient was an adult. (“People don’t have to drop their drawers” was my favorite reason cited.) A few of those who favored that site noted that, if they didn’t use the deltoid (because of the volume of the injection), they would then go to the ventrogluteal site. One person preferred the vastas lateralis (the outer middle third of the thigh), which wasn’t listed as a choice, but is certainly a site that’s used, especially in infants. And several respondents said they prefer the dorsogluteal site. Reasons given were “more comfort” and “more muscle.”

This is actually contrary to current evidence and teaching, which is that the preferred site is the ventrogluteal site. As noted in an article we did in February 2010, evidence indicates we should avoid the dorsogluteal site because “it poses unnecessary and unacceptable risks of injury to the superior gluteal artery and sciatic nerve.” Also, the traditional dorsogluteal site, especially in obese
individuals, may have excess subcutaneous fat that can reduce the chances of having the medication injected into the muscle.

And it’s not just a few nurses who continue using the traditional dorsogluteal site—a recent Canadian study (see our report on the results) showed that only 14% of hospital nurses use the recommended ventrogluteal site. So, for those of you who still prefer the dorsogluteal site, think again.

Our new question is this: “Does your institution routinely follow ‘NPO after midnight’ for preoperative patients?” Give your feedback here or on our Facebook page.—Shawn Kennedy, editor-in-chief

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Caring for Suicidal Children in the ED

September 1, 2011

By Sylvia Foley, AJN senior editor

Emergency lights #5, by DrStarbuck via Flickr

Suicidal children and adolescents are often first seen in EDs. At Children’s Hospital Boston (CHB) recently, a boy we’ll call J.J. was one of them. Still in elementary school, he had just started a new school year. J.J. has Asperger’s syndrome (a disorder on the autism spectrum), and new situations are difficult for him. His classmates were teasing him, and it was escalating: one boy reportedly threatened to kill J.J. for being “weird.” Despite efforts by J.J.’s parents and the school to address the situation, J.J. became increasingly depressed and fearful. As September CE authors Alexis Schmid and colleagues explain,

On the morning of the ED visit, as the family members were starting their day, J.J. had gone into the kitchen, found a butcher knife, and held it to his throat. His mother walked in and saw him. Although J.J. willingly surrendered the knife to her, she said she was “rattled to the core.”

Schmid was the ED nurse on J.J.’s case that day (all three authors work at CHB). In “Care of the Suicidal Pediatric Patient in the ED: A Case Study,” the authors describe the course of J.J.’s care and what they did to keep J.J., his family, and the hospital staff safe as the day progressed. Read the rest of this entry ?

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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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‘A True Art’: Strategies for Feeding Patients with Dementia

April 1, 2011

By Sylvia Foley, AJN senior editor

The fork and the spoon, by Jordan Fischer via Flickr

Feeding difficulties in people with dementia are common, but the way such difficulties manifest can vary widely, and there is no single, one-size-fits-all solution. Nurse researchers Chia-Chi Chang and Beverly L. Roberts open their April CE article, “Strategies for Feeding Patients with Dementia,” with some disturbing statistics that make clear the scope of the problem:

People with dementia constitute roughly 25% of hospital patients ages 65 and older and 47% of nursing home residents. And more than half of them lose some ability to feed themselves, which puts them at high risk for inadequate food intake and malnutrition. Patients who are unable to eat independently must rely on caregivers to assist them . . . Unfortunately, caregivers may be unable to identify the various types of feeding problems that accompany dementia or unaware of the feeding practices required to address them.

In an earlier literature review published in the Journal of Clinical Nursing, Chang and Roberts evaluated three tools used to assess feeding difficulties in people with dementia, then created a conceptual model depicting such difficulties, contributing factors, and outcomes. Now, in this CE article, the authors take their work a step further. Read the rest of this entry ?

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Saving ‘Mimi’: How Nurses Can Combat Human Trafficking in the USA

February 1, 2011

By Sylvia Foley, AJN senior editor

Never to lie . . . by flickrohit, via Flickr

Picture this: “Mimi,” an 18-year-old Brazilian girl who speaks little English, arrives in your ED with injuries sustained in a beating. She’s accompanied by an older man who refuses to leave her side and who intercepts and answers questions directed at Mimi. The ED physicians and nurses treat Mimi’s injuries and release her back to this man’s care. Maybe you feel uneasy, but what can you do? Maybe the man really is her uncle; maybe he’s just being overprotective.

In fact, Mimi is a victim of human trafficking, and the man who brought her to the hospital is both her pimp and her trafficker. And you and your colleagues just missed a chance to intervene on her behalf. Unfortunately, you’re not alone. In “The Role of the Nurse in Combating Human Trafficking,” a February CE feature, author Donna Sabella notes that clinicians who encounter victims of human trafficking often don’t realize it, and many such chances to intervene are lost. Sabella, a nursing professor active in helping such victims, hopes to change this. Read the rest of this entry ?

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Why Do Needlestick Injuries Still Haunt Us 10 Years after Protective Legislation?

November 8, 2010

By Shawn Kennedy, AJN interim editor-in-chief

By ad-vantage / Vanessa Agressti, via Flickr

In 2008, a survey by the American Nurses Association (ANA) indicated that 64% of nurses reported a needlestick injury. That startling figure was reported by Marla Weston, CEO of the ANA,  in her opening remarks last week when the ANA relaunched “Safe Needles Save Lives,” its campaign for use of safe needles in the workplace. The campaign originally launched ten years ago and was instrumental in passage of Public Law 106-430, the Needlestick Safety and Prevention Act, which requires employers to “identify, evaluate, and make use of effective safer medical devices.” And while there have been inroads towards use of safer needle systems, the 2008 data show that much needs to be done. 

Speaking from experience. Karen Daley, the ANA president, has long been a leader in advocating for safer needle systems. She sustained a needlestick injury while working in the ER a decade ago and contracted hepatitis and HIV infection. Her home state, Massachusetts, has been in the forefront of legislation. According to Angela Laramie from the Massachusetts Department of Public Health, all hospitals in Massachusetts are mandated to use sharps injury prevention devices, maintain a log of any injuries, and submit an annual report to the state. Yet, state data show an average of 3,000 needlestick injuries yearly—and more than half of these are with devices that lack safe needle systems.

Why does this continue? Why can hospitals, clinics, and other workplaces that use sharps continue to not invest in safe devices when they are available and when, by law, their use is mandated? Nurses, does your workplace protect you from needlestick injuries?

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When Delirium Is Mistaken for Dementia

September 23, 2010

We hope you had a chance to read “No Country for Old Women,” yesterday’s moving post by AJN associate editor Amy Collins, in which she described the failure of multiple providers to assess and treat the underlying cause of her grandmother’s rapid acceleration of already existent dementia symptoms (or what were assumed to be dementia symptoms).

It so happens that several years ago we ran an article on a frequently undiagnosed condition in older adults; the article was called “Delirium Superimposed on Dementia.” Maybe this is why two of our nurse editors were able to point Amy in the right diagnostic direction as to possible hidden causes of her grandmother’s crisis. Here’s an excerpt from that article:

A systematic review . . . found that prevalence rates of delirium in people with dementia ranged from 22% among older adults who lived in the community to 89% in hospitalized patients . . .  It’s more difficult to recognize delirium in people with dementia than in those without because of overlapping symptoms, difficulty in ascertaining baseline mental status and the acuteness of symptoms, and the tendency to attribute symptoms of delirium to a worsening of dementia symptoms.4 Yet early recognition is essential in order to determine and treat underlying causes; institute interventions to maintain safety; [and] restore prior cognitive function and improve short- and long-term outcomes.

The article gives a useful algorithm for recognizing as well as managing this condition. There’s also a video which discusses the condition and shows a nurse working with an actual patient (you have to enter your e-mail address to get to it). Reading Amy’s account of her grandmother’s experience, one can’t help wondering if any of the physicians who assessed her had ever even heard of this condition, or knew to look for it. With older patients more and more the norm in hospitals, it’s time for nurses to lead the way in educating others about this condition so it no longer goes unnoticed. As the authors point out, “acuteness, fluctuation, inattention, and altered level of consciousness are not normal in people with dementia, and their presence should trigger further assessment and treatment.”—JM, senior editor/blog editor

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An Evidence-Based Look at the ‘Unvoiced Symptom’: Fecal Incontinence

September 7, 2010

Public toilet by Looking Glass / Fernando de Sousa, via Flickr

First, a confession: initially the subject of this month’s CE, fecal incontinence, seemed so daunting that we considered lighter titles (“Don’t Pooh-Pooh Fecal Incontinence,” for one). But we decided against going that route, because we didn’t want to minimize the condition’s importance or its life-altering effects. Indeed, fecal incontinence has been called the “unvoiced symptom,” one so embarrassing that sufferers often fail to tell their health care providers about it—and one that many providers never ask about.

Fecal incontinence has been defined as the “involuntary loss of liquid or solid stool that is a social or hygienic problem.” As authors Donna Zimmaro Bliss and Christine Norton report, possible causes include cognitive or physical disability, impaired sensory or motor function, poor coordination of defecation processes, and loose stool consistency; in some cases the cause may be multifactorial or idiopathic. Although studies of nursing home residents have found prevalence rates of more than 40%, the condition is by no means limited to elderly or disabled people.

Quality-of-life issues. Bliss and Norton provide an overview of fecal incontinence and describe what the research thus far has revealed about its impact on patients’ quality of life. Read the rest of this entry ?

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