Archive for the ‘practice tips’ Category


What Advice Would You Give a New Nursing Student? Our Readers Respond…

April 9, 2014

KarenRoushBy Karen Roush, MSN, RN, FNP-C, AJN clinical managing editor

My daughter Kim is starting nursing school next month, so last week I asked AJN’s Facebook followers for the best piece of advice I could give her. The response was overwhelming: over 600 people offered wisdom, encouragement, and tips for success. I went through and read them all and the following is an attempt to synthesize the advice.

Of course, with so many responses, there were many valuable pieces of advice I had to leave out, from the practical to the profound, such as:

sit in the front of class, stick to your principles, invest in good shoes, choose clinicals that push you out of your comfort zone, be early for everything, celebrate the small victories, get a really good stethoscope up front, believe in yourself, pick the hardest patient you can at clinical, audiorecord the lectures, be truthful and committed to your work, eat healthy, get to know your instructors, coffee and chocolate!

And finally: look into the eyes of your patients and be sure they know you care. Every patient, every time.

(Oh, and not to leave out the lighthearted—Don’t hold your nose in clinicals. The teachers frown on that.)

Below are five areas of advice that stood out:

1) “Take a good picture of your friends and family and put it on your desk, because that’s all you’ll be seeing of them for the next two years.” There were many variations on the idea that nursing school “takes 100% dedication.” You need to warn your family and friends that they won’t be seeing you for a while, get rid of your TV, sleep when you can, learn good time management, and be prepared to spend Saturday nights with your books . . .

2) “Study, study, study, and study some more.” Respect the quantity and degree of difficulty of the material you will have to learn. There were a lot of ideas about how to optimize your studying—chief among them was to get in a study group and to study NCLEX questions from the beginning. Others were to read ahead, not procrastinate, use flashcards, attend practice and review sessions, and have a study partner or buddy system. Having a study buddy, though, is only a small part of the importance of friendships with your fellow students . . . Read the rest of this entry ?


Chronic, Common, Hidden: Helping Patients With Urinary or Fecal Incontinence

January 13, 2014
Article illustration by Gingermoth. All rights reserved.

Article illustration by Gingermoth. All rights reserved.

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

Urinary and fecal incontinence are not the kinds of health topics widely discussed—people may compare notes about knee or hip replacements or their cholesterol levels, but you’ll find few people talking about leaking urine or feces. Even at medical and nursing conferences—unless one happens to be at a conference specifically dealing with those issues—you might be hard-pressed to find the topic on a program agenda.

But these are common problems—a 1995 report in the CDC’s MMWR estimated that 15%–30% of adults over age 60 suffer from urinary incontinence. (And that was 10 years ago. No doubt that number is higher by now, given the higher numbers of people who are over 60.) Fecal incontinence occurs in about one in 12 adults—in a 2009 report, that was 18 million people.

It’s the kind of problem that can drastically change the quality of life for those who have it, due to their fear of having an “accident” in public. Think about it: no extended excursions unless there are facilities all along the way (this can rule out many outdoor activities like golf, trips to the beach, or hiking); timed meals and beverages to reduce the chance of leaking, or even foregoing them altogether. It isolates people unnecessarily, and may contribute to further decline.

Our CE article this month, “Self-Management of Urinary and Fecal Incontinence,” examines self-management concepts and provides strategies to enable nurses to to help people self-manage their incontinence. Here’s the article overview:

Widely used by patients to control symptoms of chronic conditions such as diabetes, asthma, and arthritis, self-management can also help patients with urinary or fecal incontinence. The authors discuss the principles of self-management, the behaviors and skills self-managing patients need to acquire, and the nurse’s role in reinforcing their use. They then describe strategies that can be incorporated within the framework of self-management to control urinary, fecal, or dual incontinence. Read the rest of this entry ?


What Ever Happened to a Good History?

January 10, 2014
ky olsen/via Flickr

ky olsen/via Flickr

By Karen Roush, MS, RN, FNP, clinical managing editor

What ever happened to a good history? We were taught as NP students that the history portion of the exam was as important as the physical. In fact, in most cases it’s what you learn in the history—from asking the right questions and really listening to the patient’s answers—that gives you the information you need to figure out what is going on. The physical findings either support what you’re thinking or lead you to ask more specific questions.

A good history isn’t just listening to the patient’s answers to your questions; it’s listening to all the information they offer. Take for example, the middle-aged construction worker who takes his lunch hour to come in to the clinic complaining of a cold. He lists the usual symptoms, cough, fatigue, a little shortness of breath, and then as you’re starting the exam he casually mentions that he hasn’t been to a doctor in 15 years.

Someone who’s managed to stay out of a doctor’s office for 15 years and now shows up, on his lunch hour, because of a simple cold? So, you ask some more questions and learn about some chest pressure he attributes to the coughing he’s been doing and about his father’s death at 58 of a heart attack. And you realize it’s not a cough that has brought him in; it’s something more that doesn’t fit a neat checklist of symptoms. An ECG shows some nonspecific changes—nothing dramatic—but knowing what you do based on the history, you start an IV, give him an aspirin to chew, a little nitro, call an ambulance, and he’s off to the ED. Later you learn that he was immediately sent to a regional care center and into surgery for a triple bypass.

True story.

Any good NP can tell you their own version of this story. It was just something the patient said, or the way they said it, that heightened their alertness and led them to a diagnosis that could so easily have been missed.

But taking a good history is a skill that is in danger of getting lost in this age of computer checklist care. (That and eye contact, but we’ll save that for another blog post!) Two recent visits I made to clinics, one for primary care and one for urgent care, found me looking at the backs of nurses’ heads as they ran through standardized lists of questions, dutifully clicking them off a checklist on the computer. The provider at the urgent care center took a look at the answers and then proceeded, silently, with the exam. This may seem extreme, but unfortunately it or something very much like it is too often the norm. Read the rest of this entry ?


Drilling into Bone: A Nurse’s Guide to Intraosseous Vascular Access

October 31, 2013

By Sylvia Foley, AJN senior editor

An example of a pediatric manual intraosseous needle insertion. Used by permission.

An example of a manual pediatric intraosseous needle insertion. Reprinted with permission from King C, et al. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2007.

In this month’s CE Emergency feature, “Intraosseous Vascular Access for Alert Patients,” authors Stacy Hunsaker and Darren Hillis  describe this scenario: a three-year-old girl arrives in the ED after three days of fever, vomiting, and diarrhea. She needs fluids urgently, but efforts to establish IV access have been unsuccessful. Now she’s on the verge of decompensated shock. The team is about to try an alternative route—intraosseous (IO) vascular access—but there are concerns: “Could such access be attempted on a patient who wasn’t unconscious? Would the parents understand why a hole was going to be drilled into the bone of their child’s leg?” The team must decide whether and how to proceed.

If this child were your patient, would you know what to do? If you aren’t sure, you are not alone. In this article, Hunsaker and Hillis provide some answers. Here’s a short summary. Read the rest of this entry ?


AJN’s November Issue: Voices of New RNs, Intraosseous Vascular Access, Measuring Dyspnea, Coccidiodomycosis, More

October 25, 2013

AJN1113 Cover OnlineAJN’s November issue is now available on our Web site. Here’s a selection of what not to miss.

New RNs. Hospitals invest in orientation or residency programs for newly licensed nurses, but turnover rates for first-year nurses remain relatively high. This month’s original research article, “Hearing the Voices of Newly Licensed RNs: The Transition to Practice,” looks at the orientation experience of new nurses in order to explore how institutions can best transition new nurses from an academic to a clinical setting. If you’re reading AJN on your iPad, you can listen to a podcast interview with the author by clicking on the podcast icon on the first page of the article. The podcast is also available on our Web site.

Starting an IV. Nurses are often faced with the challenge of starting an IV line in a patient who is dehydrated, has suffered trauma, or is in shock. This month’s Emergency CE feature, “Intraosseous Vascular Access for Alert Patients,” describes how nurses can use this fast, safe, and effective route for delivering fluids and medications when IV access fails. Earn 2.1 CE credits by reading this article and taking the test that follows. Don’t miss the video demonstration of the placement of an intraosseous  (IO) needle in the proximal tibia using an IO access power driver (click on the video icon on the first page of the article if you’re using your iPad, or click here).

Measuring dyspnea. Though many studies show that dyspnea is an important indicator of adverse outcomes, including death, little is known about its general prevalence in hospitalized patients. “Routine Dyspnea Assessment on Unit Admission” describes a nurse-led pilot study that sought to test the feasibility of measuring dyspnea as part of the initial patient assessment performed by nurses in a large urban hospital. You can earn 2.4 CE credits by reading this article and taking the test that follows. Read the rest of this entry ?


AJN’s October Issue: Reducing VAP, Decreasing Patient Agitation, Bedbugs, Helping Transgender Kids, More

September 30, 2013

AJN1013.Cover.OnlineAJN‘s October issue is now available on our Web site. Here’s a selection of what not to miss.

Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections and a leading cause of death in ICUs. The authors of “Mouth Care to Reduce Ventilator-Associated Pneumonia” discuss the importance of oral care in infection control and offer an evidence-based, step-by-step guide to providing optimal mouth care for intubated patients. You can earn 2.3 CE credits with this article. If you’re reading AJN on your iPad, you can listen to a podcast interview with the author by clicking on the podcast icon on the first page of the article. The podcast is also available on our Web site.

The stress of hospitalization can lead to anxiety or agitation, especially in patients with psychiatric or cognitive disorders, putting them at increased risk for falls and self-harm.Decreasing Patient Agitation Using Individualized Therapeutic Activities” describes a nurse-led quality improvement project that reduced agitation in patients suffering from cognitive impairment, delirium, and other behavior-altering conditions who were receiving continuous observation on a nonpsychiatric unit. Earn 2.4 CE credits by reading this article and taking the test that follows. Don’t miss the podcast interview with the author (click on the podcast icon on the first page of the article if you’re using your iPad, or visit our podcasts page).

Increasing patient satisfaction has become a critical goal for hospitals in the U.S. “Nursing Staff Innovations Result in Improved Patient Satisfaction” describes how nurses at one facility implemented and tested a variety of care practices to improve patients’ hospital experience and outcomes. Read the rest of this entry ?


AJN’s September Issue: Care of Incarcerated Pregnant Women, Gun Violence, Pressure Ulcer Guidelines, More

September 3, 2013

AJN0913.Cover.OnlineAJN‘’s September issue is now available on our Web site. Here’s a selection of what not to miss.

Loneliness may be linked to multiple chronic illnesses, decline in positive health practices, and increased risk of death, as described in this  month’s original research article, “Loneliness and Quality of Life in Chronically Ill Rural Older Adults.” Data from the pilot study described in the article suggest that nurses’ assessment and management of loneliness in this population is vital. You can earn 2.5 CE credits with this article. If you’re reading AJN on your iPad, you can listen to a podcast interview with the author by clicking on the podcast icon on the first page of the article. The podcast is also available on our Web site.

In 2004, only 54% of incarcerated pregnant women received some type of pregnancy care, and the quality of that care varied widely. Pregnant women in prisons face other risks, such as poor nutrition and heavy workloads, and often are required to be shackled during labor, despite laws to the contrary. These practices, as well as implications for nursing practice, policy, and research, are discussed in this month’s CE feature, “Care of Pregnant Women in the Criminal Justice System.” Earn 2.5 CE credits by reading this article and taking the test that follows it. Don’t miss the podcast interview with the author (click on the podcast icon on the first page of the article if you’re using your iPad, or visit our podcasts page). Read the rest of this entry ?


Trailblazing: The Value of Positive Deviance in Nursing

August 1, 2013
Illustration by Janet Hamlin.

Illustration by Janet Hamlin.

By Sylvia Foley, AJN senior editor

The word deviant tends to have a negative connotation, suggesting something aberrant or harmful. But deviance simply means a departure from the expected or usual way of doing things—and there are times when being able and willing to do so is crucial. Indeed, some have called this trailblazing.

In “Exploring the Concept and Use of Positive Deviance in Nursing,” an August CE, author Jodie Gary points out that “the clinical setting contains an infinite assortment of situations” in which applicable pro­fessional standards might be unavailable or unrealistic; at such times, “nurses might have to react creatively” in order to provide optimal patient care. This article provides an in-depth, evidence-based look at positive deviance in nursing.

Overview: Positive deviance involves an intentional act of breaking the rules in order to serve the greater good. For nurses, the rightness or wrongness of such actions will be judged by other people who are in charge of rules enforcement; but the decision to engage in positive deviance lies solely with the nurse. There is no uniform or consistent definition of positive deviance. This article uses the Walker and Avant method of concept analysis to explore and identify the essence of the term positive deviance in the nursing practice environment, provide a better understanding of the concept, and clarify its meaning for the nursing pro­fession. In turn this led to an operational definition: positive deviance is intentional and honorable behavior that departs or differs from an established norm; contains elements of innovation, creativity, adaptability, or a combination thereof; and involves risk for the nurse. The concept of positive deviance is useful, offer­ing nurses a basis for decision making when the normal, expected actions collide with the nurse’s view of the right thing to do.

Gary further argues for the importance of accurate documentation. “Nurses who are positive deviants may be generating new knowledge on the fly,” she writes. “We need to be able to access that knowledge. It’s essential, then, that nurses have a way to safely report the deviations they make for the sake of pa­tients. The true cause-and-effect relationships between care and outcomes cannot be known otherwise.”

To learn more, read the article, which is free online, and listen to our podcast with the author. If you’ve used positive deviance in your practice or know nurses who have, we’d love to hear your stories and thoughts in the comments.


How Military Service Affects Veterans’ Health: What All Nurses Need to Know

July 3, 2013

By Sylvia Foley, AJN senior editor

Photo (c) Associated Press

Photo (c) Associated Press

“The war tried to kill us in the spring,” says John Bartle, the narrator of The Yellow Birds, Kevin Powers’s acclaimed novel about two U.S. soldiers serving in Iraq. “I know now that everything that will ever matter in my life began then.” The same might be said by many war veterans. The effects of military service, especially on veterans’ health, vary greatly and can be lasting. And with most veterans seeking care through non-VA channels, it’s imperative that civilian nurses have some knowledge of the health issues veterans face.

In this month’s CE, “Enhancing Veteran-Centered Care: A Guide for Nurses in Non-VA Settings,” authors Barbara Johnson and colleagues describe a wide range of veterans’ health concerns and provide guidance for civilian nurses caring for these patients.

Overview: There are currently 22.5 million living U.S. military veterans, and this number is expected to increase dramatically as military personnel return from Iraq and Afghanistan. Although honorably discharged veterans may qualify for health care through the U.S. Department of Veterans Affairs (VA), only about 25% of all veterans take advantage of this benefit; a majority seek services in non-VA settings. It’s imperative for nurses in all civilian care settings to understand the impact that military service has on veterans’ health. This article provides an overview of veterans’ unique health care issues, focusing particularly on traumatic brain injury, polytrauma, hazardous exposures, chronic pain, posttraumatic stress disorder, military sexual trauma, substance use disorders, suicide, and homelessness. Evidence-based assessment tools and treatment guidelines for these health issues are discussed. A resource table provides telephone numbers and Web sites offering tools, educational materials, and veteran services. A second table provides detailed veteran-centered health assessment and screening questions.

Johnson and colleagues also discuss the roles of military culture and “veteran identity,” which continue to affect veterans even after they have transitioned back to civilian life. The authors conclude with three general suggestions:

  • Ask every adult patient whether she or he has served in the military.
  • If the answer is yes, take time to listen to the patient’s story.
  • Incorporate the patient’s military experiences and health concerns into the medical record.

To learn more, read the article, which is free online, and listen to our podcast with the lead author. If you’ve cared for veterans, please consider sharing your experiences with us in the comments.

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AJN’s July Issue: Caring for Veterans, Managing IBS, Reducing Readmission Rates, More

June 28, 2013

AJN0713.Cover.OnlineAJN’s July issue is now available on our Web site. Here’s a selection of what not to miss.

On our cover this month, U.S. Air Force first lieutenant Georganne Hassell is photographed during a presence patrol in Qalat City in southern Afghanistan. According to a 2011 U.S. Department of Veterans Affairs report, America’s Women Veterans: Military Service History and VA Benefit Utilization Statistics, by 2035, women will make up 15% of all living U.S. veterans. For more on the health issues of women troops and women veterans, see this month’s editorial.

And for an overview of how to recognize and assess veterans’ unique health care issues, such as posttraumatic stress disorder (PTSD), military sexual trauma, chronic pain, and traumatic brain injury, see our continuing education (CE) feature “Enhancing Veteran-Centered Care: A Guide for Nurses in Non-VA Settings.” This article, which also lists useful resources offering tools, educational materials, and veteran services, can earn you 3.1 CE credits. If you’re reading AJN on your iPad, you can listen to a podcast interview with the authors by clicking on the podcast icon on the first page of the article. The podcast is also available on our Web site.

The prevalence of irritable bowel syndrome (IBS) is estimated to be around 5% to 10% in North American, and it is diagnosed more often in people under the age of 50. No single drug effectively relieves all IBS symptoms. “Managing Irritable Bowel Syndrome” reviews current approaches to treatment, including medications, diet, and more, and discusses the implications for nurses. This article can earn you 2.5 CE credits.

Almost 20% of Medicare patients are readmitted to hospitals within 30 days of being discharged, and the estimated cost is more than $2.6 billion per year or over $1,000 per readmission. Read this month’s Cultivating Quality article, “A Project to Reengineer Discharges Reduces 30-Day Readmission Rates,” to learn how a Texas hospital decreased its readmission rates by implementing a set of 11 interventions developed by researchers.

There is plenty more in this issue, including an article by nurse ethicist Doug Olsen that considers the ethical obligations and challenges nurses face in treating patients who continue self-destructive practices, and our latest edge runner Profile, which highlights the work of Barbara Daly, PhD, RN, FAAN, who developed the first special care unit in the country. Stop by and have a look, and tell us what you think on Facebook, or here on our blog.
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