Critical Mass Nursing

Atrial Fibrillation...The Irregularity Of It All

leslie — Fri, 12 Oct 2007 09:22:35 GMT

I think the funniest thing I ever heard our current President's father say was in response to a common arrthymia encountered in nursing today, atrial fibrillation. I cannot remember the exact circumstances of the address, whether it was a speech or a press conference, but he said this " I thank you from the bottom of my recently fibrillating heart." That just struck me as really funny. But the condition he referred to is one that we see in medicine very frequently and so need to have a working knowledge of in our intellectual arsenal in assessing our patients.

When assessing a patient , the first thing you will notice when checking the pulse is an irregularity of the rhythm. If you patient is on a cardiac monitor, the visualization of the irregularity will give you a clue as well.
In assessing the rhythm, the first thing you look for is P waves. Is there a P wave in front of every QRS complex? Are the QRS complexes regular? Do you see additional P waves between QRS complexes where there should be none? And then of course, how about the rate? How does the patient look? Are they symptomatic ? Vital signs? Oxygen saturation?

FIRSTLY, treat the patient if they are symptomatic!

THEN, the question becomes why did they do that? I had a friend of mine tell me that the easiest way to run through possibilities is with this little jewel of a mnemonic.....CPRHEARTS.

C Coronary artery disease, acute MI or acute CHF
P Pericarditis or myocarditis
R Rheumatic heart disease or valvular cardiomyopathy
H Hypertrophic or Hypertensive cardiomyopathy or severe hypoxia
E Embolism,principally pulmonary
A Alcohol
R Rule out other causes
T Trauma, theophyllin toxicity, thyrotoxicosis
S Surgery (post coronary artery bypass grafting CABG), sick sinus syndrome, sympathomametic toxicity

This really helps me in the trenches when I am figuring out what is going on, or what could rear it's ugly head if I see someone has a history of any of these things.

We run into people that are in chronic Afib all the time. They are frequently on some combination of Digoxin, aspirin, warfarin, diltiazem, metoprolol, and more recently we are seeing them on Amiodarone. We need to know Digoxin levels and the PT/INR if appropriate. Knowledge of whether or not these folks have had previous elective cardioversions is helpful. They may be more resistant to chemical cardioversion on your watch.

But for the sudden or acute onset of Afib, you need to be able to recognize what is contributing to your patient's stress at that moment in time that could set up the right conditions for this to occur. Is it something that you ,as a nurse, can work towards relieving and therefore decrease the overall systemic stress? Can you increase their oxygen some to decrease hypoxia? Are they ventilating adequately? Are they volume overloaded therefore increasing myocardial oxygen demand? Are they having pain? Could they need some steroids for inflammation if appropriate? Do they have any symptoms of a pulmonary embolus? What about a urine tox? Are they a post op CABG or valve? What about blunt chest trauma?

You may need a chest xray and some labs. You definitely need an EKG and possibly some cardiac enzymes. You may need some ABG's. This depends on the situation.You may need an Echocardiogram, again situationally dependent. And, last but not least, you may need to cardiovert....NOW. Again, depends on the patient.

If a cardiologist is not yet involved with this patient, it may be a consideration. All of the things mentioned above are things that you can bring forward to the physician when treating the patient. In some areas, like ER, Tele, and ICU, there are guidelines to work under when these situations occur. On the floor, these are just some things that you can run through your mind to figure out the puzzle that is facing you and your patient

More On Cervical fractures

leslie — Thu, 11 Oct 2007 08:44:08 GMT

I wanted to write a bit more on fractures, specifically upper cervical because of Grandma. She is, by the way, doing much better and has been moved from Seattle to our local area and is currently rehabbing (is that a word?) at a nursing home. She was able to play the guitar a little the other day and is able to partially dress herself, so things are moving along. Thanks for wondering.

She had a C1-C3 posterior fusion, because of stability concerns and because she had broken off the pedicle of C2 so therefore the possibility of shift and movement was too great without surgical intervention. She is able to move everything, and walk some and has good fine motor dexterity distally, hence her Bon Jovi imitation. No, she has always been a guitar player so this is great rehab for her.

But I wanted to review the stability a bit more. I had initially written quite a piece on that, and lost it somehow in cyberspace. So the one I did enter was not the best. The C1-C2 area is the most mobile of the cervical spine. The bottom part of the skull, or the occipital condoyles, rests on C1,s lateral masses. This allows for most of the flexion and extension of the head as the condoyles articulate on the top of the body of C1. C1 has no vertebral body as we picture them farther down the spine,but it is connected with C2 with the pedicle, AKA odontoid. Most of the lateral rotation of the neck occurs at the C1-C2 junction. The mobility here is high, and stability of that area is mostly supported by ligament structures.

I think I mentioned that C1 is a closed ring and that fractures result in disruption of this structure. The pieces do not have to be out of place to disrupt the inherent stability. The strength of the ligament structures can pull these pieces out of place and can result in weight displacement that is uneven. Now in someone Grandma's age, or those with curvatures of the spine close to the area, normal alignment can be altered and injury can be atypical. Just an added bonus for those trying to repair the problem.

Grandma had a burst fracture of C1, meaning the pieces stayed in place. My orthopod described my L1 burst fracture a few years ago as very much like when you are cooking a hamburger and you press down on the meat, sort of squishing it but that all the pieces stay in place. The main structure is the same, but there are fractures in the integrity of the original mass. And we all know that fractures weaken. A Jefferson fracture they called Grandma's. Forgive me if there is repetition here, but diving accidents are the main cause of these fractures. The can also occur in motor vehicle accidents if you are thrown against the roof of the car, I may have originally said dashboard...regardless, the forces are distributed to the body through the neck.

Stabilization is the key to prevent further neurological damage. Edema will certainly be present in the area, and like any other injury site, that will initially impair function on varying levels, differs with each injury. This edema will go down, back to baseline in 6-12 weeks. But the edema itself can effect function, depending of course, on severity and particularity of the injury. Depending on severity of injury, there can be complete spinal cord injury necessitating intubation and eventually tracheostomy to support respirations. Severe injury can leave the person with only sensation to the face and motor control of the facial muscles from cranial nerves.

This I can say...Grandma was damned lucky. Whether God was on her side, as I suspect may be the case, or she was lucky, who knows? But her guitar playing days are not yet over. Bon Jovi has nothing on her.

Cervical fractures...ow, my broken neck

leslie — Thu, 04 Oct 2007 10:33:16 GMT

We got a call the other day at work that our 87 year old Grandma had fallen and broken her neck. Now, this was third hand and no one seemed to know the extent of the break. All they knew is that she was being airlifted to a level 1 trauma center in Seattle for treatment. we were able to talk with the physician that treated her in the community hospital and found out she had sustained a C1-C2 fracture but was still moving, talking, and complaining when she left on the helicopter ride north.

I spent my first 12 or so years in nursing working with backs and heads. I knew where this could head, but also knew that she could have an injury that was survivable and recoverable. It all depended on the details, so to speak. Meaning, just having a fracture itself is not the really bad part. The bad part is what else happened.....muscular tears, additional fractures, vascular injuries, facial fractures, closed or open head injury, and God knows what else.

My partner found Grandma on a stretcher in the ER alone and crying. She hurt, she was scared, she was overwhelmed. She was able to talk to the docs and get a better picture. Grandma was still moving and feeling and they were planning surgery perhaps the next day. This was all good news.

But I had a million other questions...what about spinal cord injury. It was apparent to me that she had not sustained severe spinal cord injury because she still had the ability to move and feel and that the docs were comfortable with delaying the surgery a bit. Other questions might be had it sustained a bruise, did it tear anywhere, could compression be a factor at some point. And what about vascular stuff. the most likely circulatory impairment would be of the vertebral-basilar artery. But there are others, and a lot of them. Sustained circulatory impairment of these could lead to paresis or locked in syndrome and even on to death. What about muscular injury? Tears, seperations, hematomas. Ligament damage? The same concerns.

C1 is also called the atlas. It is a bony ring that does a lot in stabilizing the head. Fracture results in cracks or breaks and may separate the ring into pieces. If it fractures yet the pieces stay in place it is called a burst fracture. but those same breaks can shift and the begin to separate.

If they do, the base of support for the weight and stabilization of the head begins to erode, and not evenly in most cases. If there is accompanying muscular injury and rigidity and spasm(which there most often is), those forces can actually work to pull the rings farther apart.

C2 is called the axis. It has a protrusion that extends upward, and actually slips into C1, almost interlocking. This protrusion is called a pedicle. Grandma had broken that off and that was leaning forward and could cause serious damage if not treated. So the answer was surgery for stabilization. C1-C3 posterior fusion.

She made it through surgery ok. Next time, I think I'll go into the spine a bit more.

Burnout....Opening soon in a theater near you

leslie — Thu, 27 Sep 2007 09:47:26 GMT

We deal with emotions on varying levels all the time. In almost any sort of health care, you deal with emotions stressed on many levels. There is fear, anxiety, grief, depression, emotional and physical pain, loss of control of many aspects of your life and decision making....and that's just the staff. That's an exaggeration, but not much of one. As health care professionals, we are given the responsibility of being the ones who have empathy not sympathy. you have to be able to be in some heart wrenching, gut tearing bedside scenes and stay focused and meet the needs of the patient and the family. Each situation so different because of the different families and different situations. And you have to be able to handle whatever you are graced with.

The pace of our jobs is ever increasing, the demands growing, the regulation increasing, and the technological systems ever more complex. I may have mentioned that before sometime. The stress is always growing, like an insidious white noise in your environment. The higher the level of continuous stress, the higher that is tolerated on a continuous level. Up to a point that is. I can start to feel mine coming on. I never seem to recognize it right off the bat. It then occurs to me what's going on. Sort of like realizing you have PMS symptoms...oh, so that explains it!

I start to think about not wanting to do certain things, just kind of lay low, do my job and not have to interact very much. those are days when I would prefer to have two complex and vented patients that require a lot of physical care compared to emotional, and one that have low maintenance family dynamic situations. I get a little more impatient with my co workers and myself. Things sometimes get me close to tears, mostly of frustration and anger than sad or upset. I want to sleep a little more, I don't sleep a lot really anyway so a little more for me is a lot.

But that's me. There are some things that you may find yourself experiencing that could indicate you are feeling some stress on your job. Firstly, you could be feeling like you want to sleep more too. Maybe not want to get out of bed in the morning. Also feeling fatigued all day long. 2)feelings of also not wanting to do things, not that you won't do them, but perhaps with less enthusiasm or involvement 3)a decrease in your productivity, not completing tasks on time... stuff like that 4) Missing work more frequently. Now sometimes that best thing you can do is take a day to regroup, but you have to use this judiciously. 5) Substance use and self medication of any sort. That one can sneaks up on you. Be careful. 6) Additional anger or impatience with co workers...yeah, I know , guilty. 7) Boredom with your job. Lack of intellectual stimulation or the grind of routine can be indicators you meed a change because this is getting to you 8) How about if you can't sleep? Reliving things, running through feelings about the job, your co workers, the corporation, and on and on. 9) And how about not being able to mentally take the day off on your day off? This one gets me too.

So if you do recognize that some or all of these things are present in your life in an unbalanced proportion, what next? Pat yourself on the back for your moment of lucidity. Then, talk to someone, a friend, a trusted co worker, pastor,counselor. Sort it through. You may find that it's enough that you are considering a career change. You may find that you need to change units. Or, you may find that a toothless grin of a little old man that you just helped get out of bed washes it all away.

But know that it will come. In the environment in which we work, it is inevitable.

Nursing Shoes

leslie — Wed, 26 Sep 2007 07:17:48 GMT

Twelve hour days can be very long. Most of the time the time goes by quickly. These days, with workloads as they are, the days go very quickly. In a typical 12 hour shift you can put some miles on. I have always thought a good fund raising idea would be to put pedometers on nurses for a select period of time and then pay per mile. Maybe Bill Gates or some mystery Arabian oil man could afford it...a little exaggeration but illustrative of my point. We are on our feet and moving for 12 hours, mostly on concrete floors. We put a lot of stress on our feet and lower legs. Some wear support hose. But the best answer is a pair of comfortable shoes.

When I first graduated from nursing school, it was still expected that you wore "nursing shoes". Usually they were clunky and cutesy, They were however, leather and therefore durable, and well padded. You had to buy the little white polish bottle and pretty much keep it within arms reach because scuffs just somehow magically appeared all the time. One trip from the hospital door to the car and it looked like you had been in a stampede. Then, the appearance of more trendy and expensive tennis shoes happened, and more and more facilities, in their dress code revisions, began to allow them. They were comfortable and were pretty snazzy as well. Still governed by OSHA regulations (www.osha.gov), strapless were still a no-go and that is a good thing.

Then, the Birkenstock revolution began. What a great thing for tired and aching feet. The individual molding as you wore them, the comfort of slipping your feet into something so wonderful made me happy to be tromping around in them all day. But they are not the most attractive things, that's for sure. And I found myself looking for that old white shoe polish bottle a lot. I wore the cork down all sideways and had to finally pitch them.

Now because they are about 120 bucks or so, I have yet to spring for another pair. My Reeboks and Nike tennis shoes are nice, but I yearn for the days of stupid looking, round toed shoes that make my feet happy. Maybe this year for Christmas Santa will remember.

Losing someone

leslie — Sat, 08 Sep 2007 08:21:03 GMT

As a nurse in the ICU, we see death frequently. I think probably that ER nurses see it more, certainly more graphically, but we see it a lot. I have seen thousands of people die in my 26 years of nursing. It gets easier, but still is a very sad and somber event for me. I will not allow someone to die alone. Something inside of me will not allow the last breath of someone to be exhaled into the loneliness of a sterile hospital room. I have been that way throughout my career, maybe it's just me. I cannot remember the first death I was present for, I only remember the last twenty or so. I hold the hand of the person and talk to them, I don't know if it makes any difference at all in the big picture, but for one moment in time...all that matters is that individual and their journey home.

The ICU is a place where sudden traumatic events are precursors for their stay with us. Families are worried, some shattered, some have come to terms with events, some not prepared at all for events to come. Since so many end up with us through unforeseen events....car accidents, debilitating heart attacks, severe intercranial bleeds and hemmhorages, traumatic falls...there are few times that families are ready for their loved one to die.Their pain is evident and so raw. They search for any sign that could be a positive one, perhaps indicating improvement. I think I would do the same. Sometimes we as nurses are helpless to make the situation any better. We can make sure that the patient is as comfortable as possible, try and provide emotional support for the family members, and just be there for whatever may come up.

We become calloused about things. Continued exposure to something does desensitize you, but I have found that when I am about to lose someone all of that falls away and I feel small in a big world. But at that time, I always feel as if the ONLY job I have at that moment, is to escort that individual to their appointed destination. I feel a bit like a military honor guard walking beside a casket. Actually, to be with someone as they die IS a honor, at least to me.

The grief of family members is so painful to watch sometimes. The wife or husband of 45,50, sometimes 60 years, the children, grown or not, the grandchildren...watching their grief is difficult. Tears are sometimes present for nurses, either you have made a connection with the patient or family, or something strikes you in a way that touches you deep inside. I cried a lot in the months after my father died with families as their loved ones died. It was grieving for him all over again. But I have not cried of late.

I think it is more difficult for new nurses to handle. I remember how it felt when I was new. Now I know that i have done everything that I could have done, that we as a team have done everything, the rest is out of hands. I have witness various cultural rituals at the bedside in preparation of passing. Perhaps the most memorable was the Native American Shaker ritual of bells and chanting, because even with the door closed the haunting sounds of chanting voices and muted bells drifted through the dimly lit hallways. As I write this I can see and hear it in my mind.

I write this as an obituary for Pavarotti is on TV, and his voice plays through my living room. I will remember now for the rest of my life, sitting at this computer, writing on this subject, and Luciano's voice as it drifts to the land of perpetual silence.

Staffing..Or The Lack thereof

leslie — Fri, 07 Sep 2007 09:42:25 GMT

As nurses we are all feeling the ever tightening belt of fiscal allotment in the budgets for staffing our units, whatever they may be. The acute and long term care sectors, the home health care sectors, the government health care sectors...every one of us has a small bite out of tails in this area. Some moreso than others. I feel fortunate that I am working in a non-profit hospital, the almighty dollar is present, but there still is some tempering of it because of the nature of the beast. but it is there, and over the years it has come more to the forefront. I really am not sure if it is because the non profit area has become more business astute, and has been changing systems to accomodate the financial fray in which it is involved...actually probably more like survive in the fray, or if it because the old guard had retired and the new guard had taken over.

I work in a corporation that has multiple facilities, and I would imagine it has become quite a juggernaut. Reversal of direction is not a small effort, so I would think that raising awareness of financial responsibility makes us all more conscious of our day to day actions and their effects on the bottom line. Nurses don't really like that sort of thing. If we did, perhaps we would have chosen another profession. We are all conscious of the fact that the care we deliver is expensive, and we do make efforts to minimize that when we can. But we also strive to deliver the very best care we can in the environment we are in. And I think this is an across the board statement.

Are we part of the problem? Some say we make too much money, that we are lazy and want to do as little as possible for our money. That, my friends, is a bunch of crap. Granted, my salary must be figured in to the mix when budgeting and planning, so it is a factor. We still pay the certified car mechanic more to fix our cars than we do those who stay at the bedside and save our lives. We pay the timber worker more, the steel worker more, the computer geek more( no offense intended),the construction worker and pipe fitter more. There are the priorities of this society, in things not people. And they say that we are greedy and materialistic. Some rapper gets paid astronomically for whatever it is that they do, but that is okay. Just don't raise those salaries much of the nurses. Okay, maybe that was a bit extreme, but there was a point to be made.

Money rules the staffing. There are multiple models and systems all trying to achieve the purpose of adequacy in staffing. But they don't live and breathe like the flow of a nursing unit. They can't stretch minute to minute to accomadate turnover. They don't take into account radical jumps in patient needs over the period of just a few minutes. We all work within inflexible walls and strive to make them stretchy and pliable. We must look at the systems we use, scrap them for new ones if they don't work. Keep trying to solve the problem.

Decent Exposure

leslie — Thu, 06 Sep 2007 14:57:27 GMT

I've decided to go global. Not literally, at least at this point...although Egypt and Isreal are still on my wish I could visit there radar. So I've decided that I'm going to start expanding the horizons of this work. I've registered this blog at the following

Technorati Profile.

One step at a time,baby.

Travel Nursing

leslie — Thu, 06 Sep 2007 09:44:32 GMT

Part of me has always wanted to do some travel nursing ( or is it traveling nursing)? It would accomplish two purposes I think, the need to feel as if I was making a difference if volunteering, and the need to satisfy me overall health and fitness by the change of scenery and breathing different air. I can remember when I was about 8 or 9 and we were living in Pakistan, seeing the conditions that so much of the world outside of the United States lives in and wanting to make it better. Helping those who scooted around on cardboard begging on the streets. Wanting the families that had mud huts they carved out of the ground to have the conveniences that I did.

But the travel nursing that I come in contact most currently are those brave individuals who take contracts of varying lengths in different areas throughout the country and work from area to area. That takes a bit of courage in my book any way you cut it. A bit of the vagabond and some wanderlust sorely lacking in most of us as well. We get attached to our surroundings and have families, or build financial responsibilities that keep us from moving. We get older and don't want to deal with moving again. We build a life for ourselves and then can't find a good enough reason to change that. Now, all that being said....and I apologize for offending anyone in advance...why does it seem like there are so many travellers who are a bit odd?

Usually, they are perfectly nice people. Oh, occasionally you get a sour one, but for the most part they are pleasant enough. There are some you are glad to get rid of for one reason or another. But it is rarely a professional one. They don't make it long enough in the unit. if it is determined that you have no idea what you are doing, that you a truely a danger or a portential one to some one, you will be removed form your assignment. Nurses do not tolerate incompotence in their vicinity. Something dangerous, or someone dangerous, to patients is not tolerated. There are some you don't want to see leave, and hope that they get another contract so they can stay longer. or better yet, that decide theywant to stay and hire on at your facility.

But there are some....well, they are just odd ducks. There was a perfectly delightful woman to work with, pleasant with patients, helpful, compotent...but thought that aliens were controlling us through the power grid. There was a woman from Minnesota or North Dakota who loved running naked in the mid winter there because she felt planetary connection. Not just occasionally, like a couple times a week. There was the retired army nurse who just would not shut up, and always was a better nurse than you...he had delsuions of grandeur. Now that I think about it...maybe most of them are not so odd. Maybe just some of them are odd.

Okay, just back to the top for a moment.The time is coming closer to the fact that travelling now may be a possibility...I find myself financially imbedded in where I am, the thought of moving again annoys me, I am comfortable where I am. So I live vicariously, to some degree, to those folks who momentarily share my ICU space. And maybe someday, some nurse will be saying about me " you know, that woman who always went to that volcano".

Nursing jobs

leslie — Fri, 31 Aug 2007 09:48:29 GMT

The reason I don't work in th ER is simple. I can't stand things sticking out of people; like bones sticking out of skin, and intestines....well, you can fill in the rest. There is just something about that. I will gladly take the helm when people are so ill or injured their survival is questionable or in doubt. My love in nursing had always been the most complex and difficult patients that are in my area, what ever that may be. The more tubes, wires, medications, IV's, monitors and machines the better for me. But that is me.

Nursing is a profession that is one of the most versatile, flexible, creative, advancing, and sustainable around. There will always be a need for nurses. There never will be an end to those who need medical care. As the population grows, so do future requirements for those who can care for them. As technology advances, so does the need for experienced people to run the equipment AND still keep the individual in the bed the primary focus.As medical costs continue to balloon, so does the necessity of finding workable and cost effective solutions to continue to provide care.

These situations stretch across the board....they effect all sectors and levels of governments, businesses,
charities, educational institutions, socioeconomic brackets, and the list goes on. Every single individual is effected by a health care need in their life. Some more than others. And it is well known that there is a huge outlay of resources for people late in life regardless of how healthy they have been. Because of all of this, our profession stands to be one of the most important links in the chain.

There are nursing jobs everywhere. Not only in a geographic sense, but also in the way in which nurses are used to achieve a purpose. There are school nurses, insurance company nurses, nurses who do physicals, travel around and draw blood, nurses who work in the home health care sector, skilled nursing facilities, psychiatric facilities, doctor's offices, ambulance companies, flight transport nurses, hospital nurses,nurses who work in medical research, drug company reps and sales personnel, and I know there are more but I just can't think of them.

My point is this....you can do anything pretty much anywhere with this profession. Now most of the time you do have to work with people, so enjoying that would be a benefit. The money is decent...better in some aspects than others and the more experienced you are the more money you make. With that experience, the windows of opportunity expand.

I know that I can go anywhere and have a job very quickly. Within 24 hours most of the time. I can go anywhere....a-n-y-w-h-e-r-e. So in the winter when the weather may be dismal, if I choose Florida or Hawaii to Arizona could work for me. Wyoming in the summer? Vermont in the fall? Southern Utah in the spring? The Navajo reservation? These are all real possibilities with a nursing job. This job is for me.

Nursing School

leslie — Thu, 30 Aug 2007 04:42:15 GMT

Nursing school was not my original plan. I had always been expected to get a bachelor's degree, principally because my father was in higher education and neither my older brother or sister finished a four year degree. I wanted to be the one who actually did get a four year degree, I sort of felt my father deserved that. But I originally had planned political science or history, most certainly not nursing.

But I needed a job while going to school, one that would accomodate my school schedule. there was a nursing home down the street from my parents house that perpetually had ads in the paper for nursing assistants and I knew that they would have off hour shifts that could accomodate that. I figured that I could do anything for the time I needed the job. It wasn't the cream of the crop as far as nursing homes go, the smell of old urine was prevalent upon opening the doors, but it was close and they needed workers. They asked me if could work that night, even though I had not one lick of experience with patients. I did.

I worked there for about a week before I realized that this actually was pretty fun.I worked initially under an LPN who was smart and had good common sense, and watched her skillfully handle the 48 patients and their treatments and their medications and still keep smiling. I watched her make a difference in those patient's lives, though sometimes the difference was as small as the right position for their back, or the medication to relieve their discomfort. I asked her one day what kind of education she had had for this job, and was startled to find out that it was a couple of pre requisites and nine months of school with clinicals.

Since my father was a big advocate of vocational education, I thought this would be something that he was okay with. I did not think my changing horses in midstream would upset him much. My future job possibilities would certainly be more numerous than with political science. So I started investigating schools in the area and found there was a program very close. So I made the call to my parents to tell them what I had decided. I was right, they were okay with it. I think my dad thought it was a good idea, he never really said, but I know that when he had open heart surgey many years later he had a newfound respect for his youngest, because that was what I was doing at the time.

There are varying levels of nursing degrees. One can Be a LPN/LVN in Texas (licensed practical urse or licensed vocational nurse), an ADN (associate degree in nursing) Registered nurse, a BSN (bachelor's degree), and then I believe there are a select few three years hospital based programs still in existence. Now let's just forget the advanced degrees right now....MSN,PHD, And Nurse Practitioner.

I have an associates degree in nursing, i did eventually complete my bachelor's degree in nutrition and community health, but have elected not to pursue a further nursing degree at this point. I can only see my going on for further degrees to teach, that would be the only reason that comes to mind. I work in a critical care unit that does 600 plus open heart surgeries a year and we handle pretty much everything else that comes in the door. There is no difference in the duties of those of us with bachelor's degrees and those of us with associates'. We handle the same loads, the same patients. Skill level is the differentiator.

I have eleven years of ICU experience now. I am one of the old hands. I have had physicians tell me they do not worry about their patients when I am their nurse. This makes me feel good. But it took multiple encounters and sometimes years of working with them to get to that point. My education is not a factor here.

But that is me. There are some that are driven to get the bachelor's in nursing. Excellent...go for it. You will be able to have access to more doors that way. Go as far in education as your drive takes you. An more educated workforce promotes a more professional appearance to what we do. The ANA (American Nurses Association) for years has been advocating all nurses get your bachelor's. Hospitals frequently post positions as BSN preferred.

But remember this, a piece of paper does not make you a good nurse. Experience and assimilation of those experiences does.

Infectious diseases

leslie — Sun, 26 Aug 2007 16:21:35 GMT

I just got back from seeing The Invasion with Nicole Kidman and began to think about other movies along the same theme and then my thoughts meandered to the infectious processes I deal with on a daily or frequent basis. So I thought I would just run through the most common ones I see, their routes of transmission and general risks to me, the nurse, and you, the public.

The most common ones I see are Hepatitis(s)A, B, C, D, E, herpes, Meningitis (both viral and bacterial), Tuberculosis, HIV/AIDS, and one I don't see but am interested in, anthrax.

HIV/AIDS is a serious threat to us all. The routes of transmission include IV (most prevalent in IV drug users), sexual, and exposure to infected blood. Safe sex, abstention, and proper contact precautions are the most effective barriers. But exposure and seroconversion can result in decreased immune function, pneumonias, and cancers.

Hepatitis A is transmitted through a fecal oral route usually, and we most frequently see it as connected with food servers and consequently the signs in bathrooms of food establishments about washing your hands. Acute and usually reversible inflammation of the liver occurs.

Hepatitis B can be transmitted via the IV/sexual/blood exposure and birth routes. Resulting complications can be acute and chronic hepatitis, cirrhosis of the liver, and possibly liver cancer. There is a vaccination required for all health care workers, and I believe public servants such as policemen and firemen are also recommended to take the series.

Hepatitis C is blood borne. This too can cause chronic cirrhosis, chronis hepatitis, and liver cancer.

Hepatitis D routes of transmissions are IV or sexual and birth. Chronic liver disease is usually the principal condition developed from this.

Hepatitis E is transmitted through a fecal-oral route. The differentiting factor here is that infection in a pregnant woman can have high mortality to both the mom and baby.

Herpes is a very common infection. A large part of the population had experince with cold sores or shingles, they both being the same virus. Route of transmission is skin contact and can result in lesions called cold sores and also shingles. the dormancy of the virus earlier causing cold sores can then reappear later with a vengenance as shingles, a painful reminder of infection.

Tuberculosis is reappearing in the population at an increasing rate. I remember the stroies of the TB hospitals, moivng to a warmer drier climate,and iron lungs. The re-emergence of the disease has been growing at a rapid rate of late, attributed to a global transportation system and the ability to be in Mumbai in the morning and New York in the afternoon. We all have some recollection of the TB patient arrested after going to Greece for his wedding and potentially infecting thousands. the route of transmission is coughing, sputum contact, IV transmission, and other body fluids. Of course, active Tb and pulmonary infections are the principal conditions of manifestations.

Meningitis is one seen on an infrequent basis, and usually follows vague symptoms for a few days that accentuate in a high fever and headache. This is principally contacted through nasal secretions and depending on viral vs bacterial, the severity of symptoms is individual.

And the last is anthrax. this threat loomed large after 9-11 and the various mailings of infected envelopes of white powder to some government offices. Transmission can be through contact with skin lesions, eating contaminated meat, and inhaled pulmonary spores. Infections via skin contamination have a 25% mortality but lessened if treated, ingestion of meat has a high mortality unless treated with antibiotics, and last, but most certainly not least, pulmonary infection or spore infection has as high as a 95% mortality rate, but lower if identified and treated. Frankly, this scares me greatly.

Nurses live and work with The Invasion every day. We use standard precautions on everyone to protect ourselves. We wash our hands tons of times every day. Oh yeah, and don't go to sleep.

Nursing Homes: a Double edged sword

leslie — Sat, 25 Aug 2007 09:15:17 GMT

Frequently during a hospital stay, the choices of what do we do after the hospital arises. Sometimes going directly home is an option, but sometimes the possibility of a short term stay in a nursing home is the best solution to some problems. Regardless of age, nursing homes can sometimes be the best option for short term rehabilitation, physical therapy treatments mostly, necessity of a high level of nursing care that is unavailable at home because of insurance reasons, strength increase, and extension of activity toleration. Sometimes a nursing home is the only option for people...their health condition precludes them from their spouse or family being their caregivers, or there is no family ready or willing to help the patient. For some their previous environment is no longer safe for them to continue to live there.

For most it is not the news they want to hear.Some are oblivious to the choice. For family members presented with the choice, it is most difficult. There are a few guidelines that one should follow when faced with this situation. In the best case scenario, placement in a long term care facility or skilled nursing facility is anticipated abd plenty of preparation time is available. For some the news is unexpected and guilt ridden. But these guidelines can give you some information to assist in making the best call you can at the time.

Firstly, be aware that different insurances cover long term and rehab care differently. The social worker at the hospital in which the person is a patient should be able to interpret the insurance lingo for you and be able to identify the benefits, if any, covered. If there is none, state or federal assistance is an option and the social workers and finance department personnell should be able to assist in applications for those programs.

And now...the choice. How do you go about it?

Firstly, if you feel that your loved one is being released without adequate preparation and they are on Medicare( a federal program) you can file an appeal to Medicare to buy yourself a little more time. If you just found out this morning that a long term care facility is the destination for your loved one, you can file the appeal and spend a FAST couple of days on a reconnisance mission.
Get a list of facilities in your area...you can get this from the social worker or discharge coordinator. Lists are also available form your local area council an aging plus a national Eldercare agency.
Look close to home initially. You may be in an area where the needs of your family member exceed the care level of the closest facility, and then you must expand your search area. But if possible, close proximity is the best for ability to frequently visit. You may find that you don't like the closest facility, and that's okay, but make that one of the first considerations.
Go to the facility unannounced. the best foot forward concept we are all familiar with whne company is coming, so an unannounced visit allows for some semblance of the true picture. Quality facilities should have no objection to a spontaneuos visit, and if they do, that could be a big red flag. Ask the question...why do you object to me seeing the facility now? Normal office hour visits are most appropriate. They may just want the person who can best answer your questions to be there, but find out why.
Look at and for residents. Are the ones in the hallways and dining and entertainment areas clean, clothes not soiled, hair combed, in wheelchairs or chairs appropriate for them? What about restraint use? Using chairs with trays(similar to high chair set up) that do not allow resident movement on their own, are they tied with a waist belt in the chair, do they have a wrist band sensor type system for those residents who frequently try to elope the facility, and what about after hours safety features for the facility itself? If you see residents being changed that should say something about the facility's emphasis on patient privacy and dignity of the resident. Point is....you should NOT be seeing them being changed.
Check out the food! Folks who are on the mend have funny appetites. Some eat very poorly by nature, so attractive food may assist in increasing their appetites. Check out the appearance, smell, ambiance....TASTE IT.
Palates in nurisng home are not dead, merely dulled so good food is a must. Check out the kitchen. Is it clean? Food well stored?Specialty diets well accomodated? Are the staff approriately attired to serve food, like hairnets? And what about snacks? If possible and appropriate for your loved one, can they eat when they want or only at designated times. Can they have food in their rooms? What if they have a diet soda fetish and it's okay with the doctor?Where can they keep that? And what about water? The risk of dehydration in the eldery is very high, so what is the provision for that? Is there a reachable water fountain? Fresh water at the bedside daily?
Check out the state inspection reports. All facilities are required to have state inspections on a periodic basis, your state makes it's own rules so check with them. If the facility accepts Medicare patients they also are required to have federal inspections, so check with them as well.
Ask the residents. All facilities are required to have resident councils where some decisions are made. Sit in on a meeting if possible. Or just walk the halls and ask people what they think. You will be directed by facility staff to the most positive take residents, but veering off the directed path may take you to other opinions. byt remember, you may ask soemone who does not know who they are, much less have a grasp on the facility they are in.
And last...if you have the time...visit again and again and again. Each time you will glean something new. You will talk to more people, you will get more opinions. And you will come to the conclusion as to whether or not thid facility is right for you and your loved one.

Shock

leslie — Tue, 21 Aug 2007 11:47:43 GMT

Shock is something we see a lot of in the ICU. Frequently, aggressive intervention can reverse, or at least, mediate the symptoms and hospital course. There are times though that the response is too advanced to be reversed, and the result, fatal.

Shock is not a single entity. It is a clinical syndrome that is complex and multi faceted, and manifests itself in various hemodynamic scenarios. The etiologies are multiple but the end result in all situations is compromise of end tissue perfusion. The reduced perfusion can be due to low cardiac output, maldistribution of blood flow, or both. Shock usually presents as hypotension, sometimes profound, decreased renal and cerebral blood flow, and frequently respiratory distress.

Shock can be grouped into three categories...cardiogenic, hypovolemic, and septic.

Cardiogenic shock can be secondary to brady or tachy arrhythmias, related to mechanical factors such as aortic or mitral regurgitation, interventricular septal rupture, a sizable left ventricular aneurysm, left ventricular outflow obstructions like congenital valve stenosis and hypertrophic obstructive myopathy, and left ventricular inflow obstructions such as mitral stenosis. There are also myopathic considerations such as those that impair left ventricular contractility such as acute MI, impairment of right ventricular contractility such as RV infarct, and an impairment of left ventricular relaxation or compliance such as hypertrophic myopathy.

Hypovolemic shock is from hemmhorage such as GI bleeding, multiple trauma. Dehydration or volume depletion can be caused from diarrhea, vomiting, diabetes mellitus, diabetes insipidus,pancreatitis, burns, adrenal cortical failure, ascites, pheochromocytoma, and villous adenomas. Correction, if possible, of the cause offers some symptomology mediation.

Septic shock is usually a result of gram negative organism infection characterized by acute circulatory failure, accompanied most often by hypotension, and followed by multi system organ failure. Bacterial toxins triggered by infection generate large, systemic, immunlogical reactions resulting in a lrge number of mediators causing vasodilitation of streries and aterioles, decreasing peripheral arterial resistance with normal or increased cardiac output even though ejection fractions may be decreased. Later in the sequelae cardiac output may decrease and peripheral vascular resistance may increase. This results in decreased organ perfusion and can profoundly impact the brain and the kidneys.

Assessment of some acute problems

leslie — Mon, 20 Aug 2007 08:34:24 GMT

It's easy to tell a patient in distess. Sometimes the problems are glaringly apparent..like hands clutching the chest or holding their head. like folks breathing like a guppy(fish out of water) in air hunger. But some problems are not so apparent, and ruling out the possibilities are something we have to do quickly. So I'm going to run through a few major symptoms and then what some of the causes of those symptims could be.

What if your patient is complaining of shortness of breath or having chest pain. Both of these complaints can have multiple causes and we have to differentiate some particulars. Think about the major causes in generality as you assess. Is it cardiac or pulmonary or a combination of both? Could it cardiac ischemia, congestive heart failure, a bronchospasm, a COPD exacerbation, a pulmonary embolus, or possibly some aupper airway obstruction? We should, in addition to assessment, be checking things like respiratory rate and oxygen saturation, medications recently taken and the possibility of an allergic reaction or side effect to them, do they need an EKG or a chest x-ray, and should we consider coags or a BNP or cardiac enzymes? In treating the patient we should be considering oxygen, sublingual nitro, further labs( arterial blood gases), and then more intense mechanical interventions suach as Bipap,Cpap, or intubation. Do they need to be on a cardiac monitor?

What if you notice sudden hypotension or pulse rate change? I should be thinking about hypovolemia, hemmhorage(GI bleeding), sepsis, or perhaps a dysrhythmia? Check , if you feel appropriate, the patients temperature and other vital signs, I&O's, any medications taken) again a side effect or allergic reaction), check the stool for blood, check an H&H, or again perhaps an EKG. Does you r patient need IV fluids for volume support, do they need blood or vasopressors, and do they need a cardiac monitor or increase dlevel of care and monitoring of the ICU?

And what about a change in level of consciousness? We should be thinking about things like medications (sedatives and analgesics firstly), hypoglycemia (when was the sugar checked last), hypoxia and hypercarbia, hypotension, sepsis, and the dreaded possibilty of stroke or intercranial bleed. We should be checking the respiratory rate and effectiveness, oxygen saturation, blood glucose, medications administered, and labs like sodium, hemoglobin, CO2,UA, ammonia and creatinine. We should be thiking of giving oxygen or glucose as appropriate, narcotic and sedative reversal agents like Naloxone and Flumazenil, an evaluation by a neurologist or the primary physician, and again a cardiac monitor or a trip to the ICU.

The above are just a few thigs, but perhaps the most common things we run into as nurses that require a timely assessment of. All interventions are suggestions and must be tailored as appropriate to the patient. But by running through these common steps, timely treatment of acute symptoms can result in early treatment of complex, and perhaps fatal, conditions of your patient.

Strokes

leslie — Sun, 19 Aug 2007 04:43:25 GMT

I'm thinking about strokes this morning, dropsey they used to say in the old days. I spent the first half of my nursing career working on a neuro floor, and I feel like I have seen a ton of them.

The current terminology for the public is brain attack, the association with heart attack to emphasize the necessity of rapid treatment. Time is brain tissue.

The current symptoms being publisized is as follows:
1. a sudden onset of symptoms

2.weakness, clumsiness, heaviness, or numbness on one side of the body or hands and face

3. drooping on one side of the face

4.slurred speech or difficulty understanding language

5. loss or blurred vision in one or both eyes

6. diziiness or imbalance

7. unusually severe headaches

Now, since we know that strokes are either from ischemic or hemmhoragic causes, let's differentiate between the two a little more.

Hemmhoragic strokes tend to have an early and ptologed loss of consciosness, prominent headache (sometimes described as the worst headache of my life), nausea and vomiting, sometimes retinal hemmhorages, nuchal rigidity from meningeal irriation as blood comes in contact with brain tissue, and focal signs that do not fit the pattern of a specific vessel.

Ishemic strokes tend to have stepwise deterioration or progressive worsening of symptoms, waxing and waning of findings, focal neuro impairments in the pattern of a single blood vessel, and signs that point to a faocal or subcortical lesion.

Angiography, CT scans, MRIs can all be a part of diagonstics. Time is sometimes also a ruling factor in determing some treatments. The questions go through your mind...Is it a vessel malformation? Related to high blood pressure? Throw a clot? Is it a TIA?

Bottom line is, no matter what the cause, time is brain function. Expediency of treatment can lessen some symptomology, but sometimes it cannot help at all,

But do not think about treatment if you are experiencing symptoms.....JUST GET IT!!!!!!

Hormones and Menopause

leslie — Fri, 17 Aug 2007 08:29:42 GMT

Wee, I've just been through another night of interrupted sleep, waking up every 45 minutes or so soaking wet and soooo hot. When I began to have these hot flashes about a year and a half ago, they were insidious at first.

I started out having a few here and there, but then the numbers really ramped up. After a trip to St. Louis and southern Illinois, I began having sometimes 40-50 a day. I don't think St. Louis had anything to do with it though.

My sleep really began to suffer.I can't remember now when the last time was that I slept for more than 4 straight hours. Since I normally don't sleep more than 6 hours, it meant not enough good sleep, and, as an end result, a cranky girl.

So I went to the doctor, the nurse practitioner actually, and we discussed hormones. The split is 50/50 on whether hormones should be taken, whether they really work at all. At least that was then. The medical advice is conflicting and confusing . Do hormones really reduce your risk for cancer? Do they assist in maintainence of your overall health? The prevailing opinions seem to keep changing with the wind. There is no concrete answer.

So I tried the hormones and found myself sleeping better but "Little House On The Prarie" bawling at every turn. So that was not going to work for me. I stopped taking them and told my doc.

We decided that when the symptoms got unmanageable or unbearable again, to come back and we would try another alternative. Maybe one that would work better for me. Maybe the bioidentical patches.

It's the wee hours of the morning now, at least it was when I first wrote this. Those bioidenticals are looking better and better.

Back Pain

leslie — Thu, 16 Aug 2007 07:43:22 GMT

So as I sit here to write this I have a nagging, burning sensation between my shoulder blades taht tells me 25 years of moving patients and leaning over people and a couple of short term injuries to the area sustained while moving patients are beginning to take their toll.

Oh, yeah, and that lumbar burst fracture from getting thrown off my horse isn't helping either.

The area is getting arthritic, I can tell from the continually tight and spasming muscles to the area. Leaning and puling does not help there either. Many healthcare providers find themselves in similar, or worse, situations. Back injuries are the number one injury to nurses.

We continually are pulling up in bed that weigh more than we do. We turn them. We move them up in bed. We transfer them to chairs and back..and stretchers and tilt tables. We position them for procedures. We feed them, bathe them, and make them comfortable. All of this requires leaning and twisting. I have been leaning twisting and pulling people up for too long.

We are also continually reaching up and over them for various reasons...to adjust traction, hang IV's, input information into monitors buried in banks of IV pumps for which we frequently have to lean in and twist to get to.

But the fact remains that as we age on the nursing floor, we begin to feel it. I relieve my pain with over the counter medications, ahot water bottle, and working my sore and spasming muscles loose with whatever is available. I find corners to be helpful to work the muscles loose. I find coworkers to massage(forcefully and painfully) the area for a brief period of time. I find the strongest pair of hands on the floor that day and have them apply bfief and painful pressure. Sometimes it works.

We have to take care of ourselves. Our facility has begun installing ceiling lifts in most rooms, to ease the back burden. And they work well. But to move someone who weighs 160 lbs, they are a bit cumbersome. For someone who weighs 300 lbs plus, they are wonderful.

We have large beds for people that need them. We work together to move most people. Sometimes it takes 4-7 of us to move someone or perform different things. And we all feel it.

Low back pain and neck pain cen be debilitating to anyone. Other symptoms include pulsating pain down lega or arms, constant or not, numbness and tingling of fingers or toes, electrical sensations that follow a specific pattern. These sensations can impair normal movement, and can, if in the right area, interfere with bowel and bladder function. But the most aggrevating to people is the overall interference in normal life activities.

Over a period of time, these symptoms can effect your overall tolerance and performance..of work, of life, of pretty much everything.
You have to take care of yourself. It's rather like never maintaining your car engine.The vehicle will continue to run for awhile, but eventually it will break down. Maintain your vehicle.

congestive heart failure

leslie — Thu, 16 Aug 2007 07:43:37 GMT

If you know anything about plumbing, you already have a basic understanding of the physics of congestive heart failure, You see, the principles are the same...pipes are pipes, valves are valves, and pumps are pumps. They all work the same way.

We used to tell our kids..."it's physics". That's exactly what it is. You basically have two functions for the heart...collection on one side and circulation on the other. The right side is the collection side. The unoxygenated blood returns to the heart via the superior vena cava and fills the right atrium, then drops into the right ventricle and moves into the pulmonary circulation to pick up more oxygen.

After re-oxygenating, the blood then moves into the left atrium and drops into the ventricle to be ejected and circulated throught the body.

The blood moves from chamber to chamber via the valves. Valves are actually passive in nature, working on a principal of rising pressure forcing the valve open when the pressure in a chamber opens the valve to allow blood flow into the chamber with the lower pressure.

With congestive failure, one or both sides of the heart become less effective in their pumping action and blood then tends to back up in the system. It can cause downrane or uprange congestion in the circulation

With right sided failure, there may be swelling of the feet and ankles and can cause circulation impairments all the way back up to the heart. Liver congestion can occur in more extreme cases (portal hypertension). Weight gain can be on that list as well. Shortness of breath can be a trickle down symptom. Symptoms vary with each individual.

With left sided failure, the symptomology is principally pulmonary, with symptoms involving shortness of breath, fluid build up in the lungs, and possibly full blown pulmonary edema, whose principal symptom is pink frothy sputum.

The trickle down of all of this is extra cardiac workload, increased oxygen demand, and extra stress on the overall system.

Treatment includes improving symptomology...medication, sometimes stenting procedures, getting rid of any built up fluid, diet change, gradual increasing of activity based on exercise tolerance, and lifestyle changes.

The causes of failure are many. Those I'll run through another time.

Nursing Scrubs

leslie — Wed, 15 Aug 2007 08:11:52 GMT

I have a pair of Caribbean Blue scrubs that are bad luck. it seems that every time I wear them something bad happens. That something bad is usually admitting a patient that has a balloon pump.

A ballon pumps official name is Intraaortic Balloon Pump (IABP). It's purpose is to decrease the overall workload of the heart.Essentially, it creates an artificial pressure in the heart so that when the heart exerts pressure for systole, there is partial pressure already in the chamber and the heart, therefore, does not have to exert as much force to eject the blood.

Cardiac, or myocardial (heart muscle) oxygen demand is then lessened as the force exerted is less to achieve the same purpose. Less force equals less oxygen demand. What that really means is that your heart does not have to work as hard to do it's work, hence the trickle down effect is a lowering of blood pressure and less stress on the patient.

Nursing care involves monitoring the insertion site for complications (bleeding, hematoma, circulation impairment to the distal extremity, pain), timing the pump correctly with the patients rhythm( which can change), proper positioning of the pump in the patient (meaning it has not moved up or downstream in the vessels..there are measurments on the catheter and the box) potentially causing occlusion of the renal arteries, and ballon rupture (THIS IS BAD). Whe , and if, the patient has an arrhthymia or flips back and forth between rhythms, timing of the pump can be altered so as not to interfere with the cardic cycle.

Every time I wear those things, I anticipate we'll get a balloon pump that day. Most days we work in controlled chaos. But the re are those days when even we feel like things are out of control. And inevitably somebody says "are you wearing those scrubs again??????"