Posts Tagged ‘ICU’

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Noise in the ICU: Terminology, Health Effects, Reduction Strategies, and What We Don’t Know

May 16, 2014

By Jacob Molyneux, AJN senior editor

Noise isolation headphones to use in loud environments

via Wikimedia Commons

I woke up this morning, as I do every morning now, to the sound of pile driving at a large construction site a block and half away on the Gowanus Canal. It shakes the earth and reminds me of the forges of evil Sauron in one of the Lord of the Rings movies. I once had a dog lose a good bit of hair when there was a pile driver for several months in the lot behind another apartment in Brooklyn.

The negative physical and emotional effects of excessive noise get an occasional mention lately in health reporting, but in New York City or along the remotest forest lane, the forces of quiet can seem to be in rapid retreat before an army of leaf blowers, all-terrain vehicles, diabolically amped-up motorcycles, huge TV sets, garbage trucks, helicopters, and the like.

Lest I sound like a total crank (I do have useful noise-cancelling headphones plus an Android app that offers such choices as white noise, brown noise, burbling creek, steady rain, crickets, and soothing wave sounds), there’s a reason for the preamble. Florence Nightingale herself called unnecessary noise “the most cruel absence of care which can be inflicted either on sick or well,” as is pointed out by the University of Washington researchers who wrote the latest installment of our column Critical Analysis, Critical Care.

“Noise in the ICU” looks at current research about the health effects of noise in the ICU, provides useful definitions of the terminology used when talking about sound levels, and considers strategies for reducing noise, as well as what still needs more study. The article will be free for a month (until June 15), so give it a look and see if it gets you thinking. After all, to quote the article again, “Studies have found that sound levels in the ICU continue to exceed WHO recommendations.”

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When the Preceptor’s Attitude Is a New Nurse’s Biggest Challenge

March 12, 2014

FirstPreceptorIllustrationHere’s the start of “My First Preceptor,” the Reflections essay in the March issue of AJN.

“Manage your day,” she told me, not for the first time, as if it had been my fault that one patient crashed yesterday just as my second one returned from surgery with a new set of orders. I could not be in two places at once, keeping track of two critical patients, making sure each one received the care she needed at the moment she needed it.

A new critical care nurse has a lot to worry about. It’s easy to feel overwhelmed, even when you’re actually doing a pretty good job. A preceptor can play a crucial role in helping a new nurse find her or his footing. As one might expect, however, some good nurses are not good preceptors. In this essay, the author describes her struggles to deal with the time pressures of her new job, along with her preceptor’s constant admonitions and disapproval.

This fraught nurse–preceptor relationship reaches a crisis point against a backdrop of life and death struggles. I won’t try to summarize what happens in the essay, since different readers may interpret it differently, depending on experience and temperament. But it’s definitely worth a read.—Jacob Molyneux, senior editor

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Preventing Delirium, The Luxury of Time, Things We Get Right, More: Nursing Blog Roundup

March 7, 2014

By Jacob Molyneux, senior editor

Here are a few recent posts of interest at various nursing blogs:

karindalziel/ via Flickr Creative Commons

karindalziel/ via Flickr Creative Commons

In the throes of nursing school: An intriguing little pastiche of a poem (does it qualify as a ‘found word’ poem?) can be found at a newish blog, adrienne, {student} nurse, in a short post called anatomy of a bath. In another post, she makes the following observations: “In nursing school, you are not driving the train…You absolutely must keep telling yourself that there is nothing wrong with you.”

Preventing delirium in the ICU: At the INQRI blog (the blog of the Interdisciplinary Nursing Quality Research Institute), a post summarizes some recent research on implementing a “bundle” of practices to increase mobility and reduce sedation in the ICU, all in order to prevent patient delirium, which is known to have many short- and long-term negative effects.

The luxury of time. At Love and Ladybits, the author gets a tantalizing glimpse of the quality of care she’d be able to provide if she had more time to spend with each patient. Of course, this “alternative reality” can’t last, but perhaps it can serve as a touchstone of sorts during more hectic times.

The past is present. At Head Nurse, there’s a somewhat rueful post about an unexpected encounter, years later, with the author’s least favorite nursing professor (“Everybody has one of those instructors–the ones whose classes make you yearn for the sweet release of death, or at least a nice case of vascular dementia”). Read the rest of this entry ?

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Not Compatible With Nursing

February 5, 2014

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.

photo 1-1

Photo by the author

“His family knows this is not a survivable injury, right?”

This question, posed to me in the doorway of my patient’s room by a trauma surgeon I regard as brilliant, caught me off guard.

“No,” I said. “They don’t know that.”

He frowned at me, mumbled something about false hopes, then moved away to continue his rounds.

This wasn’t the only physician who’d expressed a strong opinion regarding my patient’s mortality—a consultant had deemed his injuries “not compatible with life.” But I’d been caring for this man, as a 1:1 assignment because of his high acuity, for every shift for weeks. It seemed obvious to me that my patient’s continued presence in the ICU—and his relative stability on that particular day—directly opposed the dire predictions. The man’s family did not see his situation as hopeless, and neither did I.

And yet days after the surgeon uttered those words, my patient suffered a complication and became so unstable that for hours he teetered between life and death. The resuscitation effort was massive—and no one mentioned survivability. No one behaved like there was even a shred of futility in bringing to bear the full force of medical interventions. I never left his bedside, determined that, if my patient were to die, it would not be for a lack of vigilance and intervention on the part of his nurse. 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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Something Like Grace

July 22, 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.

ViewFromPlaneWindowMark was in town to be the best man in an old friend’s wedding—on a vacation, of sorts—when the unthinkable happened and he was involved in a horrendous traffic accident. He was ejected from his rental car. His injuries were severe and life threatening.

Mark’s family was halfway across the country. Getting to Mark quickly seemed impossible. But this is where the story takes a turn:

Mark’s family found a flight leaving that morning from their local airport, with the exact number of available seats that they needed. As they bought the tickets, they explained the nature of their emergency. They got to the airport in the nick of time. While checking in, they were approached by an airline employee who asked if they’d already arranged a rental car. They told him that they hadn’t—they hadn’t even stopped to get their clothes.

They didn’t know it at the time, but the employee who’d approached them was the pilot of the plane. He’d learned of the family emergency and held the plane for them. He knew how serious Mark’s accident had been, as he’d happened to drive right past the accident scene on his way to the airport before the first leg of the flight.

When the plane landed, the pilot requested that Mark’s family be given priority in leaving the plane, then he followed them and drove them to the hospital. Amazingly, Mark’s entire family reached the hospital before he’d even come out of the operating room.

Mark’s dad told me this story while Mark, dozing in his ICU bed, chimed in occasionally with a word or two. It gave me chills—as his nurse, I’d read the operative reports and seen the scans; I knew how critical his injuries had been, how easily things could have gone much differently.

The American Nurses Association definition of nursing includes “alleviation of suffering through the diagnosis and treatment of human response.” All too often, especially in the trauma ICU, people are responding to unexpected tragedy and loss with shock and pain, and alleviation of suffering is not always possible or realistic.

In Mark’s case, I was reminded of the flip side of suffering, where the love and bonds of family, good medicine, and the unsolicited kindness of strangers come together to paint a beautiful picture of the human experience.

It’s nursing that affords me this view. I feel fortunate to be a member of a profession that I love.

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Get the Job Done

July 8, 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.

Dietetics class for nurses, 1918/Cornell University Library/via Flickr

Nursing students, 1918/Cornell University Library/via Flickr

I remember being a new nurse and having an order to place a Foley catheter in a female patient.

I was filled with dread. Urinary catheter placement was the only skill I’d failed in nursing school (I’d contaminated my sterile field), and placing a catheter in this patient was sure to be a challenge, as she was obese and unable to cooperate. It was not a one-person job, even for a far more experienced nurse.

When I asked a coworker for help, she sighed and said, “I don’t have time. This isn’t nursing school, you know. You just do the best you can and get the job done.”

Oddly, as clearly as I remember the situation and the nurse’s response, I don’t recall the outcome of the task—only my feelings of incompetence and the impression of a complete lack of support. I can only hope that my patient didn’t suffer any consequences of my inexperience, because I’m sure I did what my coworker advised—there’s no doubt I got the job done.

I precept new nurses frequently, and sometimes I hear the echo of that long ago nurse’s response in my mind. Just last week, as I gathered supplies and prepared to place a nasogastric tube in a patient, I asked the student nurse I was working with if she’d placed an NG tube before.

“Only in skills lab,” she said.

I remember well the wooden model we used in nursing school to practice placing NG tubes and the ease with which the tubing slid along the hard tunnel and into the stomach of the faceless form. And I remember, as well, how unprepared I was to perform that skill in reality.

We were rushed; our patient was quite sick, and there were many things to do and little time left in our shift.

“This isn’t nursing school,” I wanted to say. In that moment, I wanted proficiency and efficiency; I didn’t want to teach.

But I bit my tongue, saying instead, “Okay, it’s going to feel like this, and then like this,” describing the angles she’d encounter during insertion, trying to break down the sensory and motor aspects that have become automatic to me.

And we got the job done—or rather, she did.

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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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When Nurse-Patient Boundaries Blur, in Fact or Fiction

March 15, 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.

Courtesy of the author

Courtesy of the author

Professional boundaries, as defined by the National Council of State Boards of Nursing (NCSBN), are “the spaces between the nurse’s power and the patient’s vulnerability.” The NCSBN describes the nurse–patient relationship as a continuum, with “too little care provider involvement” at one end and “too much care provider involvement” on the other.

The ideal therapeutic nurse–patient relationship lies in the middle, with “no definite lines separating the zone of helpfulness from the ends of the continuum.” I don’t love the indeterminate nature of that definition, but I understand it.

Some time ago, I was surprised by a friendship that developed between a patient and me. It was an unusual circumstance, in that the patient was in the ICU for a very long time for chronic problems that didn’t affect his mental capacity. I was his nurse many times, and through idle chatter during routine care we discovered not only a shared appreciation of literature in general, but a fondness for many of the same authors and books. I started thinking of books I’d bring him, hoping to augment the tedium of his hospital stay. At some point, I started thinking of him as a friend.

This had never happened to me before, probably because I work in a trauma ICU and the majority of my patients are intubated, sedated, or mentally altered for a variety of reasons. I’ve become friendly with patients’ family members, but have never developed much of a relationship with an ICU patient.

Although I don’t believe any boundary was crossed with this particular patient—and I never specifically thought about it in those terms—a personal red flag went up when I realized I thought of him as a friend. While this may or may not make sense to nurses in other specialties, to me it just felt strange, and I was relieved when my assignment changed and I was no longer his nurse.

Perhaps that same red flag is to blame for my dislike of Hemingway’s 1929 novel, A Farewell to Arms. Set in Italy during World War One, the classic novel has been lauded as a chronicle of self-discovery, full of passion and turmoil. Yet I found myself so put off by the main character’s love affair with his nurse, Catherine, that the book was ruined for me.

There’s no question of whether or not boundaries were crossed, no shadowy area in Hemingway’s continuum, as the relationship only blossoms after Frederic Henry is injured and Catherine becomes his nurse. There’s no ambiguity about the sexual aspect of their relationship, the nature of the banter they exchange while she’s caring for him, or the motives behind her selection of shifts—she stays on the night shift to spend more personal time with her patient. And Hemingway clearly acknowledges the existence, and transgression, of those boundaries—the characters take much care to keep their relationship a secret from the hospital staff.

But it’s literature, of course, and not life—it’s romanticized and dramatic, set in a foreign country . . . in a war. I know this, and I regret having felt so much prudish disdain over the actions of the characters that I couldn’t enjoy the book. But I couldn’t help it.

I suppose the sanctity of the nurse–patient relationship feels too important to play with, even in fiction. Boundary lines are boundary lines, after all, and when it comes to nursing, such blurring of them bothers me.

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