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NickICU-RN

NickICU-RN

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  1. Hospital Acquired Pneumonia (HAP) is a severe and sometimes fatal infection. HAP is dangerous because patients already hospitalized have weakened immune systems. Research shows that the suctioning of oral & subglottic secretions in intubated and non-intubated patients decreases the risks of HAP and Ventilator Associated Pneumonia (VAP). This is why there is so much focus on not only oral suctioning, but also pharyngeal/subglottic suctioning. Oral Cleaning and Oral Suctioning should be easy but when the patient bites down it can be very difficult and unsafe for the patient and the caregiver. The process of suctioning these pneumonia causing secretions is commonly stopped when patients bite down. We have all heard countless stories of patients biting so hard that they broke green suction swabs in half. In these situations, some clinicians are very hesitant to attempt oral care again, which is NOT A GOOD IDEA! Pharyngeal Suctioning is also very important in both non-intubated and intubated patients. Yankauers work great for oral suctioning, but clinicians are missing an additional 3 inches of pharyngeal space. This area is usually where the pooling secretions hide out, drip down and further cause aspiration pneumonia. An easy way to reach those secretions, is with a suction catheter introducer for the oral airway. Insert a suction catheter into an introducer and extend your suction an extra 3 inches down into the pharyngeal / subglottic area. How can you help battle HAP & VAP? A suction catheter introducer can decrease the risks of HAP and VAP by making it safer and easier for caregivers to perform oral & pharyngeal suctioning. Introducer devices are made of bite-proof plastic. Therefore it is no problem if your patient bites down on the device, clinicians can easily continue with oral & pharyngeal suctioning. Effective secretion clearance gives weakened patients the upper hand in trying to fight off aspiration pneumonias. Patient Population Think of that little old lady who cannot quite cough out those gurgling secretions caught in the back of her throat... Or that extubated patient that you want to keep extubated, but isn't quite strong enough yet to give a big cough. Pneumonia patients Elderly, generalized weakness History of aspiration pneumonia Dysphagia patients ALS CF CVA Spinal Cord Injury MND-Motor Neuron Disease The Financial Impact of HAP & VAP In 2008, Centers for Medicaid Services’(CMS) no longer reimburse hospitals at the higher rate for complications unless these conditions were present on admission(POA) [1]. In addition, the hospitals cannot bill patients for hospital-acquired complications (nosocomial infections) [1]. In March 2009, the CDC estimated the overall annual direct medical cost of Hospital Acquired Infections to U.S. hospitals ranges from $35.7 billion to $45 billion [2]. Nosocomial Pneumonia is the second most common hospital acquired infection and leads to an increased risk of mortality [3,4]. VAP is the most common ICU-acquired infection among patients requiring mechanical ventilation and the incidence is estimated at 15% with a mortality of 50% [5,6]. Research has shown that Nosocomial Pneumonia can be reduced with suctioning of subglottic secretions and improved oral hygiene in both ventilated and non-ventilated patients [7,8]. Unfortunately patients can resist oral care or tracheal suction catheters can coil in the patient’s mouth, making oral hygiene and tracheal suctioning difficult, therefore increasing the risk that these patients develop Nosocomial Pneumonia and/or VAP. Financial Impact Averages Hospital Acquired Pneumonia (HAP) costs a hospital an average of $17,677 per infected patient [3,4.] Ventilator Associated Pneumonia (VAP) costs the hospital an average of $48,948 per infected patient [5,6]. With hospitals now bearing these costs, they are aggressively seeking suctioning solutions to help battle these Hospital Acquired Infections. Learn about suction catheter introducers and implement them on your at-risk patients. References Steefel L, RN, MSN, CTN, "CMS changes alert nurses to caring's business side" Nursing Spectrum. 5 Nov.2007:1-2 Scott II RD, Economist, Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases, Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention; Mar.2009:7 Patra PK, Jayashree M, Singhi S, Ray P, Saxena AK, "Nosocomial Pneumonia in PICU" Indian Pediatr. 2007: Jul:44(7):511-8. Gomez J, Esquinas A, Agudo MD, Sanchez Nieto JM, Nunez ML, Banos V, Canteras M, Valdes M, "Retrospective analysis of risk factors and prognosis in non-ventilated patients with nosocomial pneumonia" Eur J Clin Microbiol Infect Dis. 1995: Mar;14(3):176-81. Hyllienmark P, Gardlund B, Persson JO, Ekdahl K, "Nosocomial pneumonia in the ICU: a prospective cohort study" Scand J Infect Dis. 2007;39(8):676-82. Efferen Linda S.,MD, "Impact of Nosocomial Infections in the ICU" Medscape coverage of: 96th International Conference of the American Thoracic Society 2000:1-6. O'Neal PV, Munro CL, Grap MJ, Raush SM, "Subglottic secretion viscosity and evacuation efficiency", Biol Res Nurs. 2007: Jan;8(3):202-9. Paju S, Scannapieco FA, "Oral biofilms, periodontis, and pulmonary infections" Oral Dis. 2007: Nov;13(6):508-12.
  2. NickICU-RN

    RESEARCH HELP!

    I would suggest doing the research at a local nurse association conference. Talk to the organizer about setting up a table. I'm sure they would give you a discount. Basically stand there all day and poll people that you can back up their credentials. p.s. Hand out some candy or something like that just to bring people in. Otherwise not many people will talk to you.
  3. NickICU-RN

    RESEARCH HELP!

    Kitiger, RN is correct in terms of a journal worthy valid study, but in terms of polling people for something that will not be published or used in a valid study allnurses.com is just fine. For lack of better words, "for Fun"
  4. NickICU-RN

    Does the BSN in 10 apply to all nurses or just RN's and why?

    I've heard of BSN in 5 years mandatory, but not sure anybody cares enough to enforce it.
  5. I agree, deep tracheal suction is contraindicated, but pharyngeal suctioning is not, especially if you can suction gently with a No-Bite Suction, just to clear out the back of the throat. If you are telling nurses they should not gently suction a dying patient if it is needed.... It's a slippery slope.... Are nurses then supposed to let a patient lay in bodily waste because it is too much pain to turn them? It does not make any sense!
  6. The research was done in Japan at 95 different palliative care facilities. My apologies, I could not find anything like it done in the US. But just as once cannot assume that Japanese perceptions of compassionate dying is the same as Americans, one cannot assume it is different.... I personally think compassionate care of a dying loved one is something innate that cannot be swayed by a "No Suction Theory". Compassion is a feeling that comes from the heart that crosses international lines. I've seen various burial rituals, beliefs on death, etc, but I have never heard of a culture letting one choke on their secretions as they are dying. This palliative care "No Suction Theory" is the first I am hearing of this. Don't get me wrong, I always try to avoid suctioning. I am in no way advocating for suctioning of ALL death rattles, and I am All-In for the medicated patches to help dry up secretions. But I am stating that in some cases a patient may need to be suctioned especially if they had pneumonia previously. For somebody to say secretions do not matter and that is just how patients are supposed to die with impaired airway obstruction, etc.... Then why even use Anticholinergenic patches to dry up secretions.. Are you soon going to be advocating against Anticholinergenic patches because it is only helping the families??? We know these things are not curative, nothing is curative in End-of Life.... Picking one therapy such as Anticholinergic patches and not picking another does not make sense, unless you are terrible at suctioning and always hurt your patient... And if that is the case use a No-Bite suction, it is much easier and more comfortable that pushing a catheter up a patients nose.. To state that Anticholinergenic patches "Always Works" and that is why they do not have to suction.... Or that we "Never" do suctioning no matter what because it goes against a "Do Not Suction Theory", does not make sense. And I sincerely think you stand by your "No Suction Theory" because this is how you were educated. But if they did research in the US that stated the same results: That families perceive the death rattle as high discomfort and although they felt suctioning is an additional discomfort, they still wanted suctioning done..... Would you change your mind on the "Do Not Suction Theory"? Also, Are you stating that they families feelings do not matter especially when they fill out HCAHPS? I know a preemptive education on the death rattle is key, but if somebody needs suctioning and appears in high discomfort, the family is not going to buy your education, they know that their loved one is suffering.
  7. "To Suction or Not To Suction, End-of-Life & Hospice Patients" is an article I recently published in allnurses.com and the responses were very conflicting. As of today Sept. 13, 2018, there are over 16,000 views of the article and 3 pages of clinician comments! So the results are in: "To Suction" = 20 votes vs. "Not to Suction" = 13 votes and 6 people voted that they were impartial. On one hand there is a clinical group that thinks, "Not To Suction". Some clinicians believe suctioning of the dying patient is actually more harm than good. They believe it is uncomfortable and goes against the comfort care principles. They feel suctioning is unnecessary because it is not a curative treatment of the dying patient, but only symptom management. Some think it makes the family feel better but does nothing for the patient. On the other hand, there is a clinical group that thinks, "To Suction". Some nurses believe they are not only dealing with the patient but also the whole entire family, therefore treating both is of most importance. They think it only seems reasonable to suction a person who is in need, even if it is only considered symptom management. They want to give patients a dignified death, not one where they sounded like they were drowning in secretions as the family looks on. Since we did not receive enough votes from the previous article to form a strong opinion, I started to review the research that has been done on family members' perceptions during hospice and palliative care. What Does Current Research Say? A research study at 95 Palliative Care Units of 360 family members that witnessed their loved one's death: [shimuzu, et al. "Journal of Pain and Symptom Management" Vol. 48 No. 1, July 2014]. 46% experienced the "Death Rattle" 66% reported High Distress Levels 53% perceived A Strong Need for Improvement of "Death Rattle" care. 64% thought the patient was drowning 57% felt as if they themselves were suffocating 98.3% reported that Nasopharyngeal & Oropharyngeal Suctioning helped improve the "Death Rattle'. PROBLEM: 62% reported patient discomfort with suctioning and 12% reported rough suction technique. Although I completely understand trying to avoid and not performing excessive suctioning on a dying patient, some suctioning may be necessary. I would not consider any suctioning comfortable, but there are techniques and methods of suctioning that make it much more comfortable such as No-Bite V suctioning with the use of a red rubber catheter. Red rubber suction catheters are much softer and minimize any insertion trauma. And the No-Bite V allows you to introduce a catheter orally and avoid the nose altogether. I think everybody basically considers nasal suctioning an act of torture at this point, especially repetitive nasal suctioning. But if suctioning can be done in a minimally invasive manner, it increases the patient's comfort level once suctioned properly. And I definitely think suctioning a dying patient brings a calmness to the room, as well as the family. I would never want a family to take away that their loved one suffered or went through some difficulty breathing, in that they actually heard the patient's breathing difficulties in the form of the death rattle. This is something a family would never forget. A nurse's goal is to minimize any degree of suffering, physically and mentally, to both the patient and the families. One nurse's comment really sums it up: "I don't want a patient to die on my watch because of poor nursing care instead of their underlying disease. The patient should not die from a plugged trachea, they should die because their body gives out from their disease." Now that the above research has given insight into family members' perceptions of a dying loved one... What side do you agree with:To Suction or Not To Suction?
  8. NickICU-RN

    To Suction or Not To Suction, End of Life & Hospice Patients

    "Always and never.....the enemy of good Medicine!!!" From what I've gathered here the grand consensus is to do assessment based suctioning and then "Suction with Dignity", PRN. Although, some clinicians here are insisting that they NEVER EVER Suction, no matter what. My friend's mother was let go at a hospice facility, sounding like she was drowning on her own secretions, and when he asked to get her suctioned, the staff said they do not suction here. He said this haunts him to this day. (His exact words) again: "Always and never.....the enemy of good Medicine!!!" I get it..., nasal suctioning is considered torture at End-of-Life, but if you need to suction, at least use a No-Bite V and insert a suction catheter into the oral airway. This suctioning is the least traumatic suctioning you can do for your comfort care patients. This is the definition of "Comfort Care" and "Suctioning with Dignity", as long as it is on an assessment based, PRN basis. I don't think anybody was ever advocating for suctioning on ALL End-of-Life Care.
  9. I've been an ICU RN for 15yrs, so I have dealt with End of Life Care plenty. I was always taught to either oral suction or deep suction with a suction catheter if your patient sounds like he or she needs suctioning. But of recent, I have run into some nurses with a different school of thought, in which they do not believe in suctioning of the dying patient. "NOT to Suction" Some nurses believe suctioning of the dying patient is actually more harm than good. They believe it is uncomfortable and goes against the comfort care principles. They feel suctioning is unnecessary because it is not a curative treatment of the dying patient, but only symptom mangement. Some think it makes the family feel better but does nothing for the patient. Nasal suctioning can cause Pain, Trauma, and Bleeding in your fragile End-of-Life Patients. Many patients in the active phase of dying are not aware of their surroundings and therefore bite down on or "tongue-out" suctioning equipment. "To Suction" Some nurses believe they are not only dealing with the patient but also the whole entire family, therefore treating both is of most importance. They think it only seems reasonable to suction a person who is in need, even if it is only considered symptom mangement. They want to give patients a dignified death, not one where they sounded like they were drowning in secretions as the family looks on. The Death Rattle is common and can be a very unnerving experience for families as well as caregivers. Medications and patches used to dry up secretions causing the Death Rattle do not always work... Some patients still require pharyngeal or subglottic suctioning, for example: pneumonia patients. My Conclusion "Suction with Dignity" Although I can understand not wanting to do excessive suctioning to a dying patient, some suctioning may be necessary. I would not consider any suctioning comfortable, but there are techniques and methods of suctioning that make it much more comfortable such as No-Bite V suctioning with the use of a red rubber catheter. Red rubber suction catheters are much softer and minimize any insertion trauma. And the No-Bite V allows you to introduce a catheter orally and avoid the nose altogether. I think everybody basically considers nasal suctioning an act of torture at this point, especially repetitive nasal suctioning. But if suctioning can be done in a minimally invasive manner, it increases the patient's comfort level once suctioned properly. And I definitely think suctioning a dying patient brings a calmness to the room, as well as the family. I would never want a family to take away that their loved one suffered or went through some difficulty breathing, in that they actually heard the patient's breathing difficulties in the form of the death rattle. This is something a family would never forget. A nurse's goal is to minimize any degree of suffering, physically and mentally, to both the patient and the families. PLEASE COMMENT and share which side of argument you are on "To Suction" or "Not To Suction" your End-of-Life Care / Hospice Patients Hospice and Palliative Care provides humane and compassionate care for people in the last phases of an incurable disease. The focus is on patient comfort and symptom management. One symptom, the death rattle, which refers to the gurgling noise of excessive secretions, can be misinterpreted as the sound of gagging or choking to death. The death rattle occurs in up to 92 percent of people actively dying and can be an unnerving experience for the patient's family as well as the caregivers. One way to treat the death rattle is to dry up the secretions with medication. But that does not always work and some patients still require pharyngeal suctioning.
  10. NickICU-RN

    To suction or not to suction?

    I've been an ICU RN for 15 years and worked all ICU specialties. I have seen patients actually broken Yankauers and green swabs, etc.. At our facility we use the No-Bite V Suction to help stop patients from biting down and then insert a suction catheter to do subglottic suctioning. That pretty much solves the problems of patients biting down and other suctioning problems. I do question the nurse and how hard of force had to of been used to create a ecchymosis on the cheek and unfortunately, it has to be reported. And I am not super fond of scpolamine patch as the end all solution to not having to suction. Yes it can help sometimes, but definitely not all the time, nurses still have to suction. Basically anybody with pneumonia it is not going to work on!
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