Posts Tagged ‘critical care nursing’

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Critical Care Nursing in San Diego (or was it Las Vegas?)

May 20, 2015

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

I’ve written before about the American Association of Critical-Care Nurses (AACN) annual meeting, the National Teaching Institute (NTI). As a former critical care and emergency nurse, I’ve attended it almost annually. And I’m always amazed at how each year they step it up with new twists. One year, it was the helicopter and full MASH unit in the exhibit hall. Then AACN went to the TED talk style of keynote presentations. Last year, they had a contest for members to apply to be the guest co-master of ceremonies. So, what might possibly be a new twist in this year’s opening session?

I was sitting with leaders of the Canadian Critical Care Nurses Association, one of whom had never been to NTI before and had been told by her colleague that it would be unlike anything she had seen before. She couldn’t have been more on target—even by NTI standards. The session opened with a DJ and loud techno-rock music, followed by a very fit and energetic dance troupe and pop singers. Then, down from the ceiling came four acrobats and a bare-chested man spinning above the stage, along with a dozen or so men and women running up and down the aisles with large, lighted balls that the audience began batting around, all to the techno music. Was I really at a nursing meeting? Everyone was certainly awake and energized!

San Diego

San Diego

Awards. Pioneering Spirit awards were given to Paul Batalden (for his work with the Institute for Healthcare Improvement and at Dartmouth) and researcher Ann Rogers, and the Marguerite Rogers Kinney Award for a Distinguished Career was given to Joanne Disch (educator and former American Academy of Nursing president and AARP board chair). Some notable moments: Batalden said one piece of advice he would give is to “avoid working with jerks”; Disch received a rousing ovation when she told how she almost didn’t get into graduate school “because she partied too much as an undergraduate.”

‘Focus the flame.’ On a more serious note, AACN president Teri Lynn Kiss addressed the “growing community of exceptional nurses” (AACN membership is at a new record high of 104,000), speaking about her experiences over the past year as president, during which her theme, “Focus the Flame,” guided her work. Read the rest of this entry ?

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Addressing Alarm Fatigue in Nursing

March 2, 2015
by flattop341/via flickr

by flattop341/via flickr

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

“Will you please silence that alarm?!” The nurse is on the phone, and can’t reach the screaming cardiac monitor. It’s a normal request, considering that we’re working together in an ICU and the alarm has been ringing for awhile.

But her request for silencing the alarm isn’t issued to me; she’s talking to the unit clerk. Stuck in my patient’s room, I watch as this untrained staff member taps the flashing rectangle on the unit’s central monitor. Without having first been appropriately evaluated, the ringing disappears, along with the words “Multifocal PVCs.”

Later, the same unit clerk absentmindedly turns off a sounding alarm, without encouragement from a nurse. I’m floating today, and although I’ve just met her, I can’t help but ask, “Do you know what that alarm was saying? Was it accurate?”

She is clearly startled by my admonishment, but I persist. “A lot of the alarms around here do seem to be false, but what if this one wasn’t? Do you have the training to know the difference, and to report it?”

If looks could kill, the one that meets my gaze is certainly homicidal, but it’s paired with a grumbled promise to never touch the screen again. So maybe my point has stuck. Read the rest of this entry ?

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Why Don’t We Pay Attention to Oral Care in the ICU?

October 16, 2013

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

“Although meticulous oral care has been shown to reduce the risk of ventilator-associated pneumonia (VAP), oral care practices among critical care nurses remain inconsistent, with mouth care often perceived as a comfort measure rather than as a critical component of infection control.”

scanning electron micrograph of Pseudomonas aeruginosa bacteria, one several types that can cause VAP/CDC

Scanning electron micrograph of Pseudomonas aeruginosa, one of several bacteria types that can cause VAP/ CDC image

So begins one of our CE feature articles in the current issue of AJN. In “Mouth Care to Reduce Ventilator-Associated Pneumonia” (which you can read for free), the authors discuss why mouth care is so important among the interventions to reduce VAP—and why it is often not given a high priority among patient care procedures.

I have to confess that in my clinical days, mouth care was done almost as an afterthought. In our critical care unit, we were always diligent in monitoring vitals signs and IV fluids, suctioning, turning and positioning the patient, but oral care usually was a perfunctory task, completed with a few quick swipes with lemon-glycerine swabs.

Booker and colleagues explain why oral care deserves the careful attention we give to other measures. They also review the research on barriers to our providing this care. Many nurses are simply unaware of the connection between oral flora and subsequent development of VAP or the importance of addressing oral hygiene in the first few days after admission. This article is an eye-opener.

In addition, the authors include an evidence-based, step-by-step guide to providing oral care for intubated patients. Read the rest of this entry ?

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Delirium at the Hands of Nurses

September 11, 2013
by Augustin Ruiz, via Flickr

by Augustin Ruiz, via Flickr

Amanda Anderson, BSN, RN, CCRN, works as a nurse in New York City and is pursuing a master’s in administration from Hunter-Bellevue Scahool of Nursing at Hunter College. Her last post for this blog was “A Hurricane Sandy Bed Bath.”

Leo is young but I’ve cared for him in the ICU many times. It’s late, but he’s awake, talking, in a voice like Kermit the Frog’s. My eyes traverse the path between his, the patch of hair beneath his moving lips, and the newly healed trach site on his neck. He is too long for the bed frame that supports him—we’ve taken off the footboard, and his big feet stick out from the white blanket over his legs.

Tonight, Leo is stable, but this hasn’t always been the case; I’ve known him since the beginning, months and months ago. A long and nasty alcohol addiction led to a bad case of pancreatitis and multiple interventions to save his life. The saving is what I’m most familiar with—the sedated, unstable, intubated, tenuous Leo, not this chatty, relaxed, stable Leo.

Leo is my only patient tonight, a rarity in a busy urban hospital. The unit is empty and slow, not much care to give, nothing requiring immediate attention. So, I sit with him and talk about our common ground: what Leo survived.

It isn’t often that a MICU nurse gets a chance to hear the stories of a surviving patient. This isn’t because this one doesn’t care; it’s just that not all patients actually survive, or if they do, I don’t always see them when they’re able to talk about it. Leo asks a few questions of me, and then starts to tell me about his experience—the hallucinations that he remembers from when he was sick.

As this article summarizes, studies have found that posttraumatic stress disorder (PTSD) is common in patients after an ICU stay, attributed in some cases to high sedative use and related delirium, traumatic treatments such as intubation, and other factors. In a guy like Leo—close to seven-feet tall, outfitted with lines, drains, tubes, and monitors required to save his life—sedatives were a must. Read the rest of this entry ?

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On Its Own Terms: An ICU Nurse Considers Human Adaptability

May 30, 2013

By Marcy Phipps, RN, a regular writer for this blog. Her essay, “The Love Song of Frank,” was published in the May (2012) issue of AJN. Some of the patient’s identifying details in this post have been changed to protect privacy.

by ashraful kadir/ flickr

by ashraful kadir/ flickr

I caught an airing of The Shawshank Redemption the other day. It’s one of my favorite movies—full of irony and rich with messages of hope and perseverance.

There’s one line from the movie, in particular, that I love:

“Get busy living, or get busy dying.”

It’s one of my favorite movie quotes, and one that plagued me at work recently as I took care of a woman who’d suffered such a high-level fracture to her cervical spine that her injury was compared to an internal decapitation.

Her doctors had talked with her and her family at length about her injuries and prognosis, and although she’d initially indicated that she wanted to withdraw aggressive care, as time passed her directives became inconsistent—she’d tell her husband one thing, her medical team something else. On the day I was her nurse, she looked at me and very clearly mouthed the words “I don’t want to die,” then shut her eyes tight, ending our brief conversation as effectively as if she’d stood and left the room.

I think that most of the time, at least in the ICU where I work, people aren’t “getting busy” living or dying, but instead are taking very small steps in one direction or another, having been forced by illness or injury into a stillness that looks like limbo.

The more I considered exactly what my patient had said, the more significant it seemed that she hadn’t actually said she wanted to live, but that she didn’t want to die. I’ve come to interpret her words as an acknowledgment that the life terms she’d been left with were unacceptable—but that she’d take them, nonetheless.

She didn’t die. She’s been in our unit for some time, and neither she nor her family members discuss her directives anymore. I wonder if she’s at peace with her decision, although it may be too early to say. It’s not something I want to ask.

We pull her into the cardiac chair and position her in front of the windows. As I look past her I see the birds fly by and the summer clouds building into beautiful lofty thunderheads. I watch her devoted children tend to her during their visits; they bring her paintings and read her lips with ease.

And I know that if I were in her shoes, I’d grasp just as tightly to this life.

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The Nuts and Bolts of Fluid Therapy in Critically Ill Patients

May 1, 2013

By Maureen Shawn Kennedy, AJN editor-in-chief

Back in the day when I was a bedside nurse, hemodynamic monitoring was just coming into play, and then only in coronary care. In the ER, we relied on a combination of vital signs (pulse and BP), urine output, and central venous pressure (CVP) to guide fluid administration. Later, patients in need of close monitoring received arterial lines to monitor pulmonary arterial pressures; monitors and stopcocks were everywhere (and soon after, infections, but that’s another story . . . ).

But things are changing again, and the trend is toward less-invasive monitoring. In our May issue, we’re pleased to bring you a comprehensive CE article (worth 2.6 contact hours), “Using Functional Hemodynamic Indicators to Guide Fluid Therapy.” The author is Elizabeth Bridges, PhD, RN, CCNS, an associate professor in biobehavioral nursing and health systems at the University of Washington School of Nursing and a clinical nurse researcher at the University of Washington Medical Center in Seattle. Many critical care nurses will know her from her “standing room only” research sessions at the American Association of Critical Care Nurses National Teaching Institute (this year it will be in Boston, May 20–23), in my view one of the best annual national nursing meetings.

Here’s the article abstract:

Hemodynamic monitoring has traditionally relied on such static pressure measurements as pulmonary artery occlusion pressure and central venous pressure to guide fluid therapy. Over the past 15 years, however, there’s been a shift toward less invasive or noninvasive monitoring methods, which use “functional” hemodynamic indicators that reflect ventilator-induced changes in preload and thereby more accurately predict fluid responsiveness. The author reviews the physiologic principles underlying functional hemodynamic indicators, describes how the indicators are calculated, and discusses when and how to use them to guide fluid resuscitation in critically ill patients.


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Good Medicine

April 22, 2013

musichospitalroomBy Marcy Phipps, RN, a regular writer for this blog. Her essay, “The Love Song of Frank,” was published in the May (2012) issue of AJN.

Last week I saw something extraordinary.

I watched the music of Amy Winehouse soothe a patient who was recovering from a traumatic brain injury while suffering withdrawal symptoms from certain street drugs. He’d been irritable and restless all day, fidgeting and climbing out of bed, unable to rest and miserable in his persistent unease. He wasn’t interested in television, was too agitated to read, and the Celtic flute music supplied on the hospital relaxation station was useless to him as a diversion.

But when another nurse and I pulled an old stereo from behind the nurses’ station and played Amy Winehouse’s “Back to Black” at his bedside, his demeanor changed as suddenly as if we’d flipped a light switch. He leaned back into his pillow, sighed, and said, “That’s nice.”

For the next hour he barely moved.

Those familiar with Amy Winehouse’s music will know how completely at odds her vibe is with the atmosphere in a hospital—and perhaps that’s why her music mesmerized my patient, relieving his intractable agitation more effectively than any medication.

I often forget about complementary therapies—like music therapy—in the ICU. Prescribed medications are almost always the first intervention for pain and agitation, and yet complementary therapies are sometimes hugely effective adjuncts and easy to provide. I’ve seen fury stopped cold by the slow drawing of a wide-toothed comb through someone’s hair, seen someone instantly relax when provided pictures of a beloved pet, and have witnessed music provide relief more than once.

Small measures, perhaps, but sometimes little things matter a lot, and good medicine doesn’t always come from a vial.

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