Posts Tagged ‘Nurses’

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Recent End-of-Life Care Links of Note, by Nurses and Others

April 13, 2015
nature's own tightrope/marie and alistair knock/flickr creative commons

nature’s own tightrope/marie and alistair knock/flickr creative commons

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

End-of-life care and decision making have been getting a lot of attention lately. The Institute of Medicine released a new report earlier this year, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life (available for free download as a PDF).

Nurses who write often write about end-of-life matters. A couple of recent examples:

On the Nurse Manifest Web site, a look at the realities and challenges of futile care in America. Here’s a quote:

“I am currently teaching a thanatology (study of death and dying) course for nurses that I designed . . . to support students to go deeply in their reflective process around death and dying, to explore the holistic needs of the dying, and to delve into the body of evidence around the science and politics of death and dying.”

Or read another nurse blogger’s less abstract take on the tricky emotional territory nurses face when a patient dies.

Elsewhere on the Web
Vox reporter Sarah Kliff collects five strong end-of-life essays that recently appeared in various sources.

And here’s something very practical that might catch on: according to a recent NPR story, a Honolulu hospital offers patients and their family members instructive videos on the sometimes gruesome realities of some end-of-life treatment options. Starting with the no-sugar-coating-it statement, “You’re being shown this video because you have an illness that cannot be cured,” these videos explain intubation, CPR, and the different care options available.

I really liked this piece because the physician admitted that he was ill prepared to talk to a patient running out of options who he had never met before. Then he remembered the counsel of other professionals to give patient-specific care (“What are your goals for your care?”).

And some recent coverage in AJN or on this blog
Joy Jacobson’s short end-of-life and palliative care overview from 2013. Read the rest of this entry ?

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More Than Competencies and Checklists: The Shadow Side of Nurse Orientation

March 30, 2015

‘Developing beneficial working relationships is part of a successful nursing orientation. If you’re lucky, your preceptor is explaining the nuances.’

Julianna Paradisi, RN, OCN, is an oncology nurse navigator and writes a monthly post for this blog. The illustration below is hers.

Paradisi_Illustration_ShadowI led the first patient I had contact with as a nurse navigator to the hospital restrooms—this was her most pressing concern at the time. Building on this success, I now have a small number of patients to navigate through their cancer journeys, under advisement of my preceptors.

During this early stage, I’ve become aware that, running parallel to my orientation, a shadow orientation is also occurring.

This umbral orientation doesn’t come, like its more tangible counterpart, with a sheath of paperwork with competencies to perform or checklists to mark off. But it’s just as real. Awareness of shadow orientation develops on an intuitive level. While this experience is difficult to describe in words, it feels familiar.

Shadow orientations happen to everyone. Nearly 30 years and several nursing jobs since that first one, I’m acutely aware of the importance of a good first impression. Fortunately, this particular orientation of mine is going smoothly, but here are some observations based on past experiences.

Shadow orientation is present when you meet a staff member who makes it known this is her desk, her chair, her phone—maybe not in words, but with a look and a click of her tongue as she makes a great show of finding somewhere else to sit, despite your offer to give up the seat.

It’s happening when a physician won’t speak to you directly about your patient, instead giving his orders to the charge nurse, because you’re new. When you question it, she explains, “It takes him a long time to trust new nurses.” But she does nothing to facilitate an introduction between you.

Another example: There’s much discussion about working relationships between nurses and physicians, but little is said about the interactions between nurses and ancillary staff, such as respiratory therapists, X-ray technicians, phlebotomists, or unit secretaries. Each play important roles in patient care, but negotiating workflow can be a source of friction, depending on the individual’s level of professionalism.

I’m only partially joking when I advise striving for a good working relationship with the unit secretary. She or he knows who to call for a vacant bed, the phone and fax numbers you need, and how to make the office machines work. Even now, I can manage a patient safely on a ventilator, but am nearly helpless when the copier machine doesn’t work.

Developing beneficial working relationships is part of a successful nursing orientation. If you’re lucky, your preceptor is explaining the nuances. Read the rest of this entry ?

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Workplace Conflict Engagement for Nurses: Consider the System

March 20, 2015

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

by Sachin Sandhu/Flickr

by Sachin Sandhu/Flickr

This month, Debra Gerardi writes about initial steps to managing workplace conflict as nurses. The quotes below are from her article in the March issue of AJN, “Conflict Engagement: A New Model for Nurses” (free until April 30, the article is one in an ongoing series on conflict).

Just as with most medical errors, there is usually not a single cause of workplace conflict—instead, a number of interrelated variables lead up to an event.

Sure, I was new to nursing, but I wasn’t new to work. My life as the child of small business owners had ingrained in me a certain sense of duty that I felt my colleague lacked. When you grow up with parents who make you pick up cigarette butts in their business parking lots, no work is below you, and there’s no time to complain. Maya wasn’t new to nursing, but she seemed, to me, new to the idea that work was to be done without a fight.

In my first months on the unit, I saw her complain much more than I saw her put her head down and plod through the tasks before her. Our unit was full of really sick patients, to be sure, and glitches like overflowing trash or equipment holdups too often set us back, forcing us to tend to jobs meant for others. But instead of voicing my frustration, I bit my lip and took on every task I came upon, judging my colleague for her unwillingness to silently do the same.

Maya and I soon clashed, probably because she picked up on the disapproval that I wore on my face. While I never told her that I interpreted her opposition to our daily workplace setbacks as laziness, our mutual frustration with each other became palpable. It never occurred to me to try to tell her how I felt; I had no desire to engage Maya in finding a solution. To me, she was the problem.

Effectively addressing conflict in complex systems requires an understanding of how systems function, and ultimately a shift in thinking toward a systems view of organizations.

One day, after a lunch room volley that publicly exposed our simmering conflict, Maya angrily pulled me into an empty patient room. My words to the group eating with us had implied that Maya was to blame for a slip-up, and although the incident hadn’t affected patient care, I’d made my feelings about her work ethic evident to all.

What Maya said to me that day shifted my narrow view of our conflict into one that encompassed our entire system, and changed my view of nursing work forever:

“It is clear we don’t like each other. We don’t need to like each other. We do, for the sake of our patients, need to respect each other. It’s dangerous to them if we don’t.” Read the rest of this entry ?

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Early Localized Prostate Cancer: Nurses Can Help Men Weigh Diagnostic, Treatment Options

March 18, 2015

By Jacob Molyneux, AJN senior editor

A new diagnosis of prostate cancer can be daunting. Nurses play an increasingly important role in helping men and their partners find their way through the maze of available information and choices. One of the two March CE feature articles in AJN, “Early Localized Prostate Cancer,” gives a thorough overview of tests and treatments.

The author, Anne Katz, is a certified sexuality counselor at CancerCare Manitoba, a clinical nurse specialist at the Manitoba Prostate Centre, and a faculty member in the College of Nursing at the University of Manitoba, Winnipeg, Canada, and Athabasca University, Alberta, Canada. She is also the editor of Oncology Nursing Forum. Writes Katz:

. . . as many as 233,000 men in the United States are diagnosed with prostate cancer each year, 60% of whom are ages 65 or older. Most diagnoses are low grade and localized . . . . Since low-grade, localized prostate cancer is slow growing and rarely lethal, even in the absence of intervention, it can be difficult for men to make treatment decisions after diagnosis—particularly if they do not understand the nuanced pathology results they receive and the potential for treatment to result in long-term adverse effects that can profoundly affect quality of life.

Pros_Cons_PSA_ScreeningThe article discusses options for intervention, potential adverse effects associated with each option, and, crucially, the nurse’s “role in helping men and their partners navigate the challenges of making treatment decisions that are appropriate in their particular circumstances.”

Read the rest of this entry ?

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Color-Coded Wristbands and Patient DNR Status: Can We Do Better?

March 16, 2015

In the Viewpoint column in the March issue of AJN, a staff nurse at an oncology center argues that we can improve our use of color-coded wristbands to communicate patient DNR status. There’s also a short podcast interview with the author below, in which she explains that her motivation for writing this article was “a near-miss” on her unit several years ago.

A lot of attention has been paid lately to the reasons why clinicians don’t follow end-of-life preferences in advance directives. Overaggressive care by some physicians is one reason, as is the vagueness of the language used in advance directives to express treatment preferences.

BlimaMarcus_ViewpointAuthor

Author Blima Marcus

Another major reason advance directives are ignored is lack of immediate access to a patient’s end-of-life preferences at critical moments, such as during a code. This month’s Viewpoint column, “Communicating Patient DNR Status Using Color-Coded Wristbands,” is by Blima Marcus, a doctoral student at the Hunter-Bellevue School of Nursing in New York City as well as an RN at the NYU Langone–Perlmutter Cancer Center. Marcus points out that a “patient’s choice of do-not-resuscitate (DNR) status is a major one, and communicating this status in the hospital is often the responsibility of nurses.”

However, she argues, paper and/or electronic chart documentation of patient end-of-life preferences isn’t always adequate, given clinical realities, and can leave “communication gaps that can lead to wrongful resuscitations and mistaken fatalities.” Read the rest of this entry ?

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The Delicate Dance for Stability

February 23, 2015

By Patricia O’Brien

Loïe Fuller sketched by Henri de Toulouse-Lautrec/via Wikimedia Commons

Loïe Fuller sketched by Henri de Toulouse-Lautrec/via Wikimedia Commons

In college I got a part-time job as a companion to an elderly widow named Fran, driving her around town and assisting with errands: post office, hairdresser, the market, her psychiatrist. The routine was set, and all was well for many months.

But one day, something unusual happened. Fran opened her door with a grand flourish, eyes shining. The television, radio, and blender were blasting. “Shall we go,” I asked, hurrying to turn off the noisy electronics.

“Fran,” I observed, “the blender’s empty.”

“Let’s not bother with tiresome details. I’m out of my head today,” she said, with purposeful excitement. At the pharmacy, this time, I took notice of the medication I picked up for her: lithium.

“What’s lithium for?” I asked, sliding into the car.

“A bipolar disorder. Not to worry. I’ve navigated these choppy seas half my life.”

We did errands. All the while, she acted like she was on the campaign trail for mayor, laughing, waving to friends, and smoking up a storm. At the market she hugged the meat manager, who was arranging Italian sausages. He looked confused, but smiled and told her there was a special on calf’s liver.

“I’ll take it all,” she declared, making a grand gesture with her newly acquired Cecil B. DeMille tendencies. Read the rest of this entry ?

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Measles 101: The Basics for Nurses

February 11, 2015

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

Measles rash/CDC

Measles rash/CDC

While debates about measles vaccination swirl around the current U.S. measles outbreak, most U.S. nurses have never actually seen the disease itself, and right now we are a lot more likely to encounter a case of measles than of Ebola virus disease. Here, then, is a measles primer.

Symptoms. Measles is an upper-respiratory infection with initial symptoms of fever, cough, runny nose, red and teary eyes, and (just before the rash appears) “Koplik spots” (tiny blue/white spots) on a reddened buccal mucosa. The maculopapular rash emerges a few days after these first symptoms appear (about 14 days after exposure), beginning at the hairline and slowly working its way down the rest of the body.

Infected people who are severely immunosuppressed may not have any rash at all. “Modified” measles, with a longer incubation period and sparse rash, can occur in infants who are partially protected by maternal antibodies and in people who receive immune globulin after exposure to measles.

Transmission. The virus spreads via respiratory droplets and aerosols, from the time symptoms begin until three to four days after the rash appears. (People who are immunosuppressed can shed virus and remain contagious for several weeks.) Measles is highly contagious, and more than 90% of exposed, nonimmune people will contract the disease. There is no known asymptomatic carrier state, and no nonhuman animal is known to carry or spread the virus. The virus survives for less than two hours in the air or on surfaces, and is rapidly inactivated by heat, light, acids, and disinfectants.

Isolation. When measles is suspected, airborne isolation is necessary. If negative pressure is not available, the patient should be placed in a room with the door closed. Only immune staff wearing N-95 masks should enter the room.

Diagnosis. The usual test for measles is serologic testing for immunoglobulin M (IgM) antibody; a positive test confirms the diagnosis. IgM is often evident as soon as the rash appears, and can be detected for about a month. A negative IgM test on a specimen taken within 72 hours of rash onset may be a false negative; the test should be repeated. Read the rest of this entry ?

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