Posts Tagged ‘critical care nursing’

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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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Unanticipated Codes

February 20, 2013

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Love Song of Frank,” was published in the May (2012) issue of AJN. She currently has an essay appearing in The Examined Life Journal.

Code cart/courtesy of author

Code cart/courtesy of author

My mentor once told me that there are almost never unanticipated cardiac arrests in the ICU. I’ve found this to be true. Certain indicators, like laboratory abnormalities or particular cardiac rhythms, can foretell a Code, and sometimes subtle signs trigger an instinctual foreboding that I’ve learned never to ignore.

The conviction that a Code Blue can be anticipated provides a sense of security; if the arrest is anticipated, then it may be preventable. And when it’s inevitable, at least anticipation allows for preparation. I strongly believe this. And yet this weekend my patient coded and I was caught completely off guard.

I had just remarked to one of my colleagues that my petite, elderly Chinese patient (some identifying details have been changed) was looking so much better than she had when I’d admitted her earlier that day from the floor—she’d been in respiratory distress, in a hypertensive crisis, and in need of immediate dialysis. All of the various specialty consultants had seen her and collaborated and I’d had the thought that Ms. M’s day would end very well, that it would be one of those nursing shifts where I’d see a metamorphosis from dire straits and distress to comfort.

My shift was nearly over and I was standing at Ms. M’s bedside, monitoring her breathing, which had very suddenly become irregular. I was slightly distracted by her husband, who was standing at my shoulder and very upset. He was speaking in a heavily accented staccato that left me blinking, with a vague impression that he was angry at his children. Exactly why, I never did discern—for as he spoke, his wife took one last ragged breath, her eyes rolled upwards, and her EKG began registering electrical activity with no matching pulse to be found.

The respiratory therapist managed the airway while I started chest compressions. The rest of the Code team showed up; everything went as it should. Ms. M survived, intubated but responding. Mr. M, as a witness to what must have felt like mayhem, was traumatized. And I was rattled far more than usual—and more than I like to admit. I can only surmise that my stress response was related to my lack of anticipation in this case, for not only did I not see the arrest coming, I’d thought Mrs. M’s condition was moving in the totally opposite direction.

I discussed the situation with a good friend who happens to be a chaplain. I told her, not quite rationally, that I wanted to participate in a thousand completely unanticipated cardiac arrests in the hope that repetition would dull my emotional reactions, leaving automation and efficiency without distress. Perhaps then, I told her, I wouldn’t be as aware of family members while doing chest compressions and wouldn’t go home feeling like I’d watched a car accident play out in slow motion.

I also told her I wouldn’t be writing a post about this, as I felt my response was overdramatic. I was too experienced to be this shaken.

But she urged me otherwise, reminding me that nursing is not for the faint of heart, that years of experience don’t make certain difficult aspects of it any easier, and that it’s always good to write and to share.

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The Kiss: Hope in the ICU

June 4, 2012

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Love Song of Frank,” was published in the May issue of AJN.

by limegreeen9, via flickr creative commons

I always look forward to interdisciplinary rounds. I’ve worked with most of the team members for years and enjoy the differing perspectives and collaboration. Today is no exception; I know my patient very well, as he’s been in the ICU for months. As the interdisciplinary team moves through the ICU like a small mingling mob, pausing at each room for a brief nursing report and lingering for discussion, I stand in anticipation, ready to present my patient’s case.

My report, though, is politely cut short by the medical director.

“What’s changed?” he wants to know.

And I feel pressed to produce some crumb of improvement. 

“Well…” I say. “He kisses his wife. His GCS* remains eight, but he kisses his wife.”

A few people smile, and I hear a few chuckles.

“It’s a reflex!” I hear someone say as they move away.

I know, of course, how little the kisses mean from a medical standpoint. His initial injury was neurologic, and his neuro status is quite compromised, but stable. His cardiovascular, gastrointestinal, and genitourinary systems are stable, as well. It’s respiratory insufficiency that keeps him in the unit. Puckering his lips in response to his wife leaning towards him is not significant and likely doesn’t change where he is or where he’s going.

And yet . . . his wife, Linda, crosses town every day on a city bus to come and see him. She calls us en route, and we slide him into a cardiac chair before she arrives. She spends hours with him, rubbing hospital-grade lotion into his hands and feet as she chats with him about the details of the life she’s navigating without him. She works each of his joints in turn, counting the repetitions to the beat of country music. She’s made his ICU room homey, even hanging a vanilla scented, tree-shaped air freshener from his IV pole, which I find particularly touching.

I sit, charting, and watch them out of the corner of my eye. I’m distracted by the beauty of Linda’s devotion. There’s a quality to her interactions with her husband that feels rare and that I find difficult to describe. 

I love it that he kisses his wife. The act itself may hold no medical significance, nor does it signify romantic love. But what I sense in them is more profound than romance, and because of that the simple kiss seems deep and intrinsic.

Perhaps, in that way, it is a reflex, after all.

*GCS refers to the patient’s level of consciousness, as measured by the Glasgow Coma Scale (range: 3–15)

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Critical Care 2012: An Educational Extravaganza

May 29, 2012

By Maureen Shawn Kennedy, AJN editor-in-chief

So, for the 12th or 13th time (I’ve lost count), I attended the National Teaching Institute of the American Association of Critical-Care Nurses (the “other” AACN organization, not to be confused with the American Association of Colleges of Nursing) in Orlando last week. And as usual it was impressive—approximately 6,000 attendees, and rows and rows of exhibitors. There were two helicopters, a bus, and an ambulance in the exhibit hall, as well as two-story booths and classrooms. While there were some recruiters looking for staff, they were overshadowed by monitoring companies, bed and equipment manufacturers, and pharmaceutical companies.

Some highlights:

Left to right: Outgoing AACN president Mary Stahl and incoming president for 2013, Kathryn Roberts.

Kudos to the AACN for its creativity in making general sessions lively and interesting. This year, the organization held open auditions for a member to assist as “MC” for the general sessions (or “super sessions”). It was a tie, and attendees were treated to two of their own in action, hamming it up and enjoying the spotlight.

The TED-talk presentation style used by both AACN president  Mary Stahl and president-elect Kathryn Roberts was refreshing—and unique for nursing meetings.

I interviewed both presidents—click the link to listen to the podcast (it may take a minute to load). The 2013 president, Kathryn Roberts, MSN, RN, CNS, CCRN, CCNS, is a clinical nurse specialist in the pediatric ICU at The Children’s Hospital of Philadelphia; she chose “dare to” as her theme for the year.

My favorite session, hands down, was Elizabeth Bridges’ “Critical Care Studies You Should Know About,” in which she pulled apart recent research and evaluated it in the context of other studies. She is the only person I know who can have 500+ people laughing and learning statistical analysis. (After hearing her speak last year, I approached her to do a column for AJN. Her column, Critical Analysis: Critical Care, debuted earlier this year with “Central Venous Pressure Monitoring: What’s the Evidence?”free until June 12. And she’s working on two more.)

The engaging super session featuring Robyn Benincasa—a firefighter, world class adventure racer (think Survivor and The Amazing Race combined), and motivational speaker—illustrated what one could achieve with team support, leadership, and perseverance. (Of course, being in superb shape for firefighting, endurance biking, and mountain climbing doesn’t hurt either.)

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Nurses Week: Comparing Notes on Matters of the Heart

May 9, 2012

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Love Song of Frank,” was published in the May issue of AJN.

Image courtesy of Wikemedia Commons

Earlier this week I took care of a man who nearly coded, rather unexpectedly. I was standing next to his bed when his heart rate slowed suddenly and significantly, with one extraordinarily long pause between beats.

A pause doesn’t have to be extraordinarily long to feel like it is, especially when you’re standing next to someone, palpating their pulse while watching the monitor. In this case, in this five-second pause that felt like minutes, I’d dropped the bed rail, shouted out to my team, and was ready to start chest compressions when his heart beat again. His symptomatic bradycardia was treated accordingly; there were no chest compressions, and it was no code.

I had lunch with a good nurse-friend of mine who works in a nearby hospital. I was telling her how “bradycardia with a five-second pause” feels a lot like asystole, when you’re standing next to your patient, and she was telling me that her hospital had sort of cancelled Nurses Week this year. Instead of the traditional week of silly games, superlative awards, and physician-sponsored lunches, and then a later “Hospital Week,” her facility was having a combined “Team Member Week.”

“It feels like we’ve lost recognition,” my friend said. “We don’t feel appreciated, and we’re angry.”

I definitely see her point. Although Nurses Week festivities can seem campy sometimes, it’s the sentiment behind them that matters, and merging Nurses Week into an “everybody” celebration seems like a poor administrative move. I’m not sure I’d want to work for a hospital that didn’t specifically honor and recognize its nurses.

My friend and I agreed—whether in the case of marked bradycardia with a long pause, or in the exchange of Nurses Week for “Team Member Week,” the rhetoric doesn’t mitigate the reality, nor does it soften the reaction.

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Critical Care: Where’s the Evidence for Central Venous Pressure Monitoring?

January 13, 2012

Editor’s note: This post is by Anne Dabrow Woods, MSN, RN, CRNP, who is AJN‘s publisher and chief nurse and publisher of Wolters Kluwer Health Medical Research. It was originally published on the blog of Lippincott’s Evidence-Based Practice Network.

I read with interest the article Central Venous Pressure Monitoring: Where’s the Evidence?” (purchase required for nonsubscribers) in the January issue of AJN. It’s part of a series called Critical Analysis, Critical Care, which will appraise the evidence regarding common critical care practices. So much of what we do in nursing is not based on evidence but on how we have always done things in practice—or on research that was not credible.

This article looks at the evidence supporting the use of central venous pressure (CVP) monitoring alone to guide treatment decisions for patients. According to the article, a 2008 systematic review by Marik and colleagues concluded that CVP is not an accurate indicator of intravascular volume, nor is it an accurate predictor of fluid responsiveness (whether a patient will respond to a fluid bolus with an increase in stroke volume). The authors of the AJN article critically appraised the evidence and determined the following:

  • The relationship between intravascular volume and CVP is a weak relationship and clinicians should not use CVP to estimate a patient’s intravascular volume.
  • The absolute CVP value or a change in CVP should not be used to predict a change in the stroke volume or cardiac index.
  • There is not an absolute CVP value that can be used to determine what the next step of treatment should be, be it a fluid bolus or the use of a vasoactive medication.

In brief, the evidence tells us that we can’t base treatment decisions on just one hemodynamic indice. The clinician needs to look at the entire hemodynamic picture, including, for example, heart rate, blood pressure, mean arterial pressure, and urine output, when determining the best treatment option for the patient.

References
Kupchik, N. & Bridges, E., 2012. Central venous pressure monitoring: what’s the evidence? American Journal of Nursing. 112 (1).

Marik, P. et al. 2008. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 134(1).

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