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As Sepsis Awareness Increases and Guidelines Change, Timing Remains Crucial

October 6, 2014

By Amanda Anderson, a critical care nurse and graduate student in New York City who is currently doing a graduate placement at AJN two days a week.

stopwatch/wikimedia commons

stopwatch/wikimedia commons

September was Sepsis Awareness Month, but the urgency of the issue didn’t disappear when the month ended. I still remember my first day in the medical intensive care unit (MICU) I’d soon call home. I was shadowing the charge nurse, and an admission had just come in from the ED.

“Here, we need a CVP setup.” A crinkly bag of normal saline and a matching package containing something evidently important were shoved into my hands—a medical football passed to the only open player.

Very quickly, I would learn what a CVP, or central venous pressure, was and to monitor it. I would learn all about sepsis, and septic shock, and the treatment of its devastating process. Multiple organ dysfunction syndrome (MODS) was a primer for my care in this unit, and on my first day off of orientation, I was entrusted with one of its full-blown victims: Septic shock from pneumonia, causing respiratory, renal, and heart failure. Learning to spike a bag of saline for a CVP transducer was just my first step into the vast and complicated land of sepsis management.

This was 2007. Sometimes, as in all hospitals, care was delayed and septic patients sat without timely treatment for hours. Back then, we tubed people, snowed people, and flooded people. Now, after two updates to the Surviving Sepsis Campaign’s guidelines, we sometimes tube them, and sometimes we don’t. We use a lot less sedation, and a lot less fluid.

If you’re not familiar with them, it’s a good time to review the updated guidelines. The Surviving Sepsis Campaign Web site offers everything from exhaustive articles to handy cheat-sheets on how to handle patients from the ED who have sepsis in a manner that complies with updated guidelines. Timely sepsis recognition doesn’t just depend on ED nurses or those in the ICU; every nurse needs to know what to look for, as demonstrated by the case in this AJN article, “Recognizing Sepsis in the Adult Patient” (free until November 1).

Timing remains crucial. In the new guidelines, you’ll find a lot of the same treatment goals and procedures, but a lot more stress on rapid recognition and on doing things quickly and in the right order. Timing is so central that the campaign bundled its guidelines into time segments: 3-hour bundle and 6-hour bundle.

For example, within the first three hours, practitioners must draw blood cultures, determine lactate level, hang broad-spectrum antibiotics, and begin fluid resuscitation with a crystalloid. By the time six hours have passed, 30ml/kg of normal saline must be completed, and if the patient’s mean arterial pressure and urine output don’t meet certain parameters, vasopressor infusion (norepinephrine first, please!) must be started.

Close attention to the effectiveness of these basic measures—diagnosis, antibiotics, resuscitation, and stabilization—is key. Other more complex treatment measures such as mechanical ventilation and renal replacement therapy are addressed, but the focus remains on timing and simplicity in care.

 

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10 Good Things About Being an Older Nurse

October 3, 2014

Alice Facente, MSN, RN, is a community health education nurse in Connecticut. Her Reflections essays, “At Her Mercy” and “The Dirtiest House in Town,” were published, respectively, in the August 2009 and January 2010 issues of AJN.

Puddle Reflection/by joiseyshowaa, via Flickr

Puddle Reflection/by joiseyshowaa, via Flickr

I recently passed a professional career milestone: 40 years since I’d graduated from nursing school. When I began my career, nurses still wore white starched caps and white uniforms. I don’t know how we accomplished everything we did with those impractical caps perched on our heads. The shocking realization that four decades had so quickly passed forced me to think about all of the benefits of being a mature, experienced nurse. Right off the top of my head, I thought of 10 things (and yes, these are generalizations and exceptions exist).

1. Older nurses are often more empathetic. Chances are that in the last several decades every older nurse has been a patient, undergone surgery, become a parent and possibly a grandparent, encountered personal financial challenges, experienced the death of a close friend or family member, and much more.
2. Death is not so frightening. Nurses have cared for people at all stages of the life cycle and know that, with planning and preparation, the end of one’s life can be peaceful and dignified.
3. We are not easily fooled. There is not too much that we haven’t seen or heard in 40 years.
4. Computer crashes don’t bother us. In fact, who do they turn to when they have to chart using the “old fashioned” pen and paper method?
5. We have X-ray vision. Years of experience have fine-tuned our assessment skills.
6. We have accumulated simple “tricks of the trade” like the heel-drop test for appendicitis or checking conjunctiva pallor for anemia. Read the rest of this entry »

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Unbalanced: The Art of Changing Nursing Roles

October 1, 2014
Bull and Monkey/ graphite, charcoal, acrylic on vellum/by julianna paradisi

Bull and Monkey/graphite, charcoal, acrylic on vellum/by julianna paradisi

Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology.

The culture shock experienced by new nurses making the transition from student to professional is well documented. Less well documented is the culture shock seasoned nurses face when changing jobs. Not all nurses are the same. Neither are all nursing jobs.

Working in an unfamiliar setting means being the new guy. You may have been in the top 10 of your nursing class for grades and clinical excellence. Or you may have held a position of leadership in your previous unit. In your new job, you are unknown and unproven.

For nurses changing jobs from high-acuity areas—ICU or bone marrow transplant, say—to an ambulatory clinic, the stress is twofold.

First, there’s a period of grieving the loss of hard-won skills and certifications that are not applicable in the new role.

Then there’s the shock that your skills and experiences did not prepare you for the outpatient setting. Often, the first realization is that high-acuity patients have central lines, so a nurse migrating from such a practice area may not have strong peripheral IV skills.

By contrast, placing peripheral IV’s is something outpatient infusion nurses do all day long; IV placement skills are learned over time through practice. The nurse experienced in high-acuity patient care is suddenly a beginner, often needing the help of coworkers to insert IV’s in patients. The inability to consistently start a peripheral IV is frustrating for the nurse and for coworkers, not to mention the patient.

I’ve been thinking a lot about how it feels to be new at a job, because of the changes at mine (see earlier post, “The ACA and Me: A Dispatch from the Trenches”). Although my job is basically the same job that it was, the oncology piece has greatly expanded, and I’ve worked hard to become familiar with numerous chemotherapy regimens. Read the rest of this entry »

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AJN in October: Getting Inpatients Walking, Calciphylaxis, Nurses and Hurricane Sandy, More

September 30, 2014

AJN1014.Cover.OnlineAJN’s October issue is now available on our Web site. Here’s a selection of what not to miss.

Calciphylaxis is most often seen in patients with end-stage renal disease. “Calciphylaxis: An Unusual Case with an Unusual Outcome” describes the rare case of a patient diagnosed with calciphylaxis with normal renal function, and how the nursing staff helped develop and implement an intensive treatment plan that led to the patient’s full recovery. This CE feature offers 2.5 CE credits to those who take the test that follows the article. To further explore the topic, listen to a podcast interview with the author (this and other podcasts are accessible via the Behind the Article page on our Web site or, if you’re in our iPad app, by tapping the icon on the first page of the article).

The adverse effects of bed rest. Prolonged periods of immobility can have adverse effects for patients, such as functional decline and increased risk of falls. “A Mobility Program for an Inpatient Acute Care Medical Unit” describes how an evidence-based quality improvement project devised for and put to use on a general medical unit helped mitigate the adverse effects of bed rest. This CE feature offers 2 CE credits to those who take the test that follows the article. Read the rest of this entry »

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If You Want to Write, Do It (and Skip the ‘Weaseling Qualifiers’)

September 26, 2014
Photo by mezone, via Flickr.

Photo by mezone, via Flickr.

Are you one of those people—nurse or otherwise—who daydreams about writing (a personal essay about a formative experience, an article about a quality improvement project you took part in, a blog post about some aspect of nursing) but can’t seem to find the proper way to get started?

Since the weekend is coming and the October issue of AJN is now live on our Web site, it seems a good time to draw attention to “On Writing: Just Do It,” the editorial by Shawn Kennedy, AJN‘s editor-in-chief. Kennedy points out the one idea common to most writing advice: you have to start somewhere. You have to do it, and learn from doing it, and then keep doing it. Or, as she puts it:

One key to becoming a good writer—or a good anything—is persistence.

But the editorial also gives a range of other excellent tips from Kennedy and several experts in the field, and quotes writing advice found in AJN issues through the decades. My favorite bit is from a 1977 editorial by former AJN editor Thelma Schorr:

“[the writer] will use the active voice and not shirk his [or her] responsibility by introducing a statement with such weaseling qualifiers as ‘It is considered that…’ or ‘It is generally believed that…’”

What a great word: “weaseling.” It’s about as far as you can get from the jargon that afflicts so much academic writing. So if you’ve got some free time this weekend, take 15 minutes and see what happens. Netflix will wait.—Jacob Molyneux, senior editor

 

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What Our Readers Had to Say About RN Staffing in Nursing Homes

September 24, 2014

By Maureen Shawn Kennedy, AJN editor-in-chief

nursing homeEarlier this month, AJN’s managing editor Amy Collins wrote a post about nursing homes, basing her discussion on a New York Times article by Paula Span at the paper’s New Old Age blog that examined efforts to address the inadequate number of registered nurses (RNs) in nursing homes. While federal regulations for agencies that receive Medicare or Medicaid require 24-hour nursing services, they only require an RN to be on site for eight hours daily. According to Span, 11.4% of nursing homes did not meet this requirement.

Collins found confirmation of this information in her own experiences visiting her grandmother in nursing homes:

“There always seems to be a lack of staff—and with so many residents these days suffering from varying levels of dementia and memory problems, staff are needed more than ever.”

We linked to the blog post on our Facebook page and received a tremendous number of comments on both sites. While both Span and Collins emphasized that increases in all levels of nursing personnel are needed, some LPNs responded to our post to assert that they too have valuable skills, as well as extensive experience, in this setting—and that a broader underlying problem is inadequate staffing tied to corporate cost-cutting.

Few people would argue with these assertions. Most LPNs do the best work they can despite impossible patient ratios. Most LPNs are assigned too many patients. Even so, there’s also a real need to increase the number of RNs in nursing homes. We know from research (and you can find links to some of the studies in Span’s article) that there are fewer adverse events when RNs are managing care. Many comments on Facebook and this blog drive the message home. Here’s a sampling:

“Having two large medication passes in one shift gives any nurse with 15 to 25 patients no opportunity to do what RNs do: assess, diagnose, plan, intervene, and evaluate. I don’t’ care how good you are…”

“Insurers are not recognizing that the ‘usual’ patient is different from years ago and requires a much higher level of care.”

“’Skilled nursing’ is a euphemism for ‘med-surg floor.’”

“The problem isn’t that RNs don’t want to work in LTC it’s that the LTC industry as a whole is an inhospitable environment for anyone to work in, nurse or otherwise…The industry is already so rootbound with rules and regulations that it is virtually impossible to function reasonably in this setting.”

“Nursing homes are no longer ‘rest homes’ but individual, sub-acute hospitals. Post-op orthopedic, cardiac, stroke care, along with rehab and wound care, bring with them outlandish amounts of regulations and paperwork. Add to that corporate financial officers who dictate the number of nurses and aides that can work each shift, no matter the acuity of care needed, and you have the recipe for what you find in nursing homes today…. A previous nurse mentioned 46 patients and one nurse on night shift. Of those 46, how many had orders for medications that required ‘30 minutes before (or after) meals,’ multiple insulins (long and short acting), multiple eye drops (administer individually with a wait between), multiple inhalers (also with waits)? Medicating ONE individual might mean 5–6 personal contacts! All of these must be recorded on the medication record and many must be documented on the patient’s chart.”

“Another unspoken issue is that nursing homes are not seen as a desirable workplace by young nurses or by high quality administrators. Lower pay and little room for advancement does not attract the best and brightest. Administrators walk a financial tight rope to keep the place profitable by keeping staffing at a minimum, which also does not lead to innovation or satisfied workers.”

Read the rest of this entry »

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The Underlying Connection Is Nursing

September 22, 2014
Angel sculpture on grave marker

photo by author

Marcy Phipps, BSN, RN, CCRN, ATCN, TNCC, an ICU nurse who recently took up flight nursing, is an occasional contributor to this blog.

I recently experienced a series of events that seemed interconnected and orchestrated.

It started with my usual morning run. I was jogging out of my neighborhood, already sweating in the summer heat and absorbed—coincidentally—in an audio podcast about trauma care, when I came upon a man sprawled in the middle of a usually very busy thoroughfare. His motorcycle, badly damaged, was lying on its side next to a car with a crumpled door panel. The accident had clearly just occurred—traffic hadn’t yet backed up and no sirens could be heard heralding imminent assistance.

I had the weird sensation that I’d been running to the accident all along. I held his C-spine and monitored his neuro status while an off-duty paramedic managed the scene. Unexpectedly, a cardiologist I sometimes work with emerged from a nearby café and held his fingers to the man’s radial pulse, and then several more off-duty paramedics arrived.

It seemed fortuitous to me at the time—not the accident, of course, but the proximity of medical personnel who were so quickly available. And I had the impression that, despite not having worn a helmet, the motorcycle rider would be okay. He was talking to me, after all, and I didn’t see any obvious deformities or signs of severe injury.

About a week later, with the motorcyclist (and a shred of doubt) in the back of my mind, I glanced through the obituary section of the local paper. I should say that I almost never read the newspaper. When I do, I don’t look at the obituaries. And yet, on this rare occasion, I saw that not only had the motorcyclist succumbed to his injuries several days after his accident, but also that a patient with whom I’d developed a friendship several years ago had died, and that his memorial service was the following day. Read the rest of this entry »

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