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Kathy Van Dusen MSN, RN, CEN, CPEN, NHDP-BC, FAEN Every day, critical care nurses show up for others, often during the hardest moments of patients' lives. We advocate, intervene, educate and support. We are the calm in the chaos, the steady presence amid crisis. But while we're trained to care for everyone else, it's all too easy to forget something essential: We need care, too. That's why NTI — the National Teaching Institute & Critical Care Exposition is more than a nursing conference. It's a space for you. A time to reconnect with the why behind your work. A place to learn, to breathe and to stand shoulder-to-shoulder with thousands of other nurses who get it. You Deserve to Be Seen One of the most powerful parts of NTI is how deeply it validates your experience. Whether you're a new nurse finding your rhythm or a seasoned clinician, NTI offers sessions, networking and connections that can help guide you on your professional journey. The energy is electric. The learning is relevant. And the people? They're your people. Real Learning for the Real World The sessions at NTI are built for critical care, progressive care, advanced practice and pediatric nurses. From clinical deep-dives to leadership tools, NTI delivers the kind of knowledge you can take home and actually use. You'll gain access to the latest evidence-based clinical content, presented by world-renowned nursing experts. You'll leave with new strategies, new insights and new confidence in your ability to care, not just for your patients and their families, but for yourself and for sharing with your team. Explore what's planned for NTI 2025 sessions are grounded in evidence-based practice, frontline relevance and meeting the challenges nurses face right now. A Chance to Just ... Be When was the last time you had space to think, reflect or feel inspired? NTI creates those moments. The keynote speakers, interactive events and wellness activities are designed to fill your brain and also to fill your cup. It's a reminder that your work is noble, your voice is vital and you are never alone in this profession. Reconnect With Purpose Attending NTI is more than professional development. It's a time for personal renewal. And in a field that demands so much of your heart, that kind of renewal is necessary. Thousands of nurses return to NTI year after year. They come for the education and they come back for the community, the connection, the inspiration and the clarity that NTI brings to their practice and their purpose. Learn more about what NTI can offer you, and start planning your path forward. Bonus: Resources to Help You Attend Need support to attend NTI? AACN offers toolkits to help you build a case with your employer, tips for budgeting and scholarship opportunities. Because this experience should be within reach and not out of it. Come for the education. Stay for the inspiration. Leave with what you need most. We hope to see you at NTI. -
AACN Pioneering Spirit AwardCathie Guzzetta, PhD, RN, FAAN, is a nursing mentor, consultant and award-winning researcher who is focused on the importance of holistic care. She has served on the clinical faculty at George Washington University School of Nursing, Washington since 2007. Dr. Guzzetta received the AACN Pioneering Spirit Award on May 16, 2016, at NTI 2016 as the preeminent nurse expert on family presence - and as the consummate mentor of pediatric patient care research by nurses at the bedside. allnurses.com was fortunate to have the privilege of interviewing Dr. Guzzettaon the same day that she received her prestigious award. "I've worked on adult and pediatric family presence during resuscitation since 1994, " she stated to Mary, allnurses Community Manager during the interview. Nurses at that time questioned why families were not present during resuscitation. She related a story from earlier in her nursing career where family presence during resuscitation of a fourteen year old boy was honored, but the nurse was admonished and almost lost her job for doing so. She went on to reiterate the importance of family integrity during these very stressful situations. Holistic NursingHolistic nursing is the framework for family presence and spans birth to death and emphasizes family involvement in every patient care unit. ICU is frequently the location where end of life decisions are made. Nurses that staff these units want to be the best of the best. So, utilizing family presence fits this goal of being at the top of their game. Some holistic nursing techniques includeVisualizationGuided imageryDistractionPartnering with the patient to meet the outcome that the patient wants is also extremely important. This is relevant to both adult and pediatric patients and families. Nowadays patients and families demand family presence and shared decision making. With the advent of information readily available on the Internet, patients and families are better informed than ever before. Family Presence During ResuscitationDr. Guzzetta relates that in pediatric resuscitation research shows that 97-99% of parents want to be present. In adult resuscitation the numbers are approximately 87%. However, in all instances the families' wishes must be honored and respected. Families often feel the need to be present but also experience some ambivalence during the event. Research has also proven that despite the fact that families wish they didn't have to make the decision about family presence, they are universally positive that they made the decision to be present. Sometimes this is the last act they can give their family members. The Emergency Nurses Association has well established practice guidelines for family presence. AACN has also recently updated their guidelines as to family presence. These are all based on the latest research and provide much information for nurses. We want to publicly thank Dr. Guzzetta for her time. Her research and authorship of many books on the subject of family presence have elevated nursing professionalism and brought this topic to the forefront of many discussions in the medical community. What has been your experience with family presence? Does your facility promote family presence and shared decision-making? NTI Interview with Dr. Cathie Guzetta References AACN Family Presence Guidelines Clinical Pediatric Emergency Medicine. Family Presence in Emergency Medical Services for Children ENA Family Presence Journal of Emergency Nursing. Family Presence During Cardiopulmonary Resuscitation
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We attended an NTI session this morning about moral courage and ethics for the APRN. This is applicable to many nursing specialties The lecture was Sarah Delgado ACNP Clinical Practice Specialist from San Viejo. She brought up some excellent points regarding "ethical creativity" and the ability to troubleshoot very troubling ethical decisions. Utilizing case studies she provided steps to solve complex ethical issues involving withdrawing care from a pediatric patient, discussing DNR status of an elderly ICU patient with multiple comorbidities and general ethical dilemmas. Critical care is an arena where ethical decisions are often found. As critical care nurses, having a toolbox of skills to add to our orificenal helps to meet our patient care goals She broke down the decision-making process into a path with several different directions. Looking at practical alternatives she provided a clear solution to even very complex issues. She pointed out out common pitfalls as well as potential resolutions. Ms Delgado also brought up a team approach in order to provide a united front. Social workers, risk managers, unit managers, nursing staff, families and providers must all be in agreement in order to provide the best solution. Some of the tips Ms Delgado provided to solve ethical issues Know elements that promote ethical dialogue Advertise and use your ethics resources Utilize interdisciplinary teams Mentor and collaborate as a unit Voice conflicting views in calm voice Open body language These tips are not all inclusive. Ethics issues are by their nature sometimes quite fluid without a definite answer. Instead take a proactive approach... Work toward preventive ethic by being open with staff, patient and families. Work thru the emotion of the situation. Accept your responsibility for resolving the situation before it becomes a problem. Being proactive is better than being reactive. How have you handled an ethical situation recently? Have you used any of these techniques? What resources did you use? Reference AACN Ethical Guidelines
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Dr. Cathie Guzetta, author of Holistic Nursing, a Handbook for Practice and Pocket Guide to Holistic Nursing, and faculty at George Washington University School of Nursing received the AACN Pioneering Spirit Award at the 2016 AACN NTI Convention on May 16, 2016 at the New Orleans Ernest N. Memorial Convention Center. Dr. Guzetta who is a nursing mentor, consultant and award-winning researcher focused on the importance of holistic nursing care, received the Pioneering Spirit Award as the preeminent nurse expert on family presence and as the consummate mentor of pediatric patient care research by nurses at the bedside. allnurses.com had the privilege of interviewing Dr. Guzetta. Watch the following interview in which Dr. Guzetta shares personal experiences of having family present at the bedside during resuscitation.
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With more than 37.5 continuing education (CE) contact hours, the outstanding and diverse learning opportunities and inspirational gatherings promise to reignite your commitment to your practice and our profession. Hundreds of learning activities feature the latest innovations in practice, technology, and healthcare delivery, evidence-based practice and research to meet your clinical and professional practice education needs. Connecting with friends and colleagues at special events throughout the week will round out this inspirational experience. There are more than 275 sessions. There are also 2.5 hour sessions at the mastery level. For advanced practice nurses, the Advanced Practice Institute will allow you to obtain pharmacology contacts and to build on your advanced practice nursing skills. Update your knowledge, refine your skills and learn something new in critical care. This educational conference features the latest innovations in high-acuity and critical care practice, technology, healthcare delivery, evidence-based practices and research. When and Where May 21 through May 24, 2018 Boston Convention and Exhibition Center 415 Summer Street Boston, Massachusetts 02210 (800) 899-AACN (2226) Hotel Westin Boston Waterfront 425 Summer Street Boston, MA 02210 (617) 532-4600 Education and Sessions For attendees that come early, there are pre-conferences that offer opportunities for hands-on experiences with 3- and 6-hour sessions providing deeper coverage on relevant topics. If you are an early morning person, consider the Sunrise Sessions which are funded by unrestricted grants from corporate supporters. Reservations are required. SuperSessions are where you can share the joys and challenges of caring for acutely and critically ill patients and their families with thousands of your colleagues. The keynote presentations from AACN leaders and popular motivational speakers will motivate, inspire and celebrate our profession. At the National Teaching Institute & Critical Care Exposition, there are so many educational opportunities that align with the needs of high-acuity and critical care nurses. Choose from hundreds of sessions covering 30 diverse clinical and professional development topics, and visit over 400 exhibitors at the Critical Care Exposition. Attendees practice in many areas in many diverse roles ranging from staff nurse to manager and APRN. Whether you are a new or experienced nurse, the curriculum offers in-depth content using the most up-to-date evidence-based guidelines and practice standards. The Critical Care Exposition is the largest, most comprehensive trade show for high acuity and critical care nurses. Attendees will experience hands-on interactions with exhibitors. The Critical Care Exposition offers 14 hours of exhibit time over three days, with 10 hours unopposed by clinical sessions. There is more than 300,000 square feet of exhibits including the newest equipment, devices, pharmaceuticals, supplies, and technology. Also, there are hundreds of ExpoEd education sessions where you'll receive continuing education recognition points (CERPs). And don't forget all the product demonstrations. Attendees Come to a conference where there will be over 7,000 critical care nurses. Registration and Pricing Registration is CLOSED. Register by April 4, 2018 and save $80.00 Member Pricing Early-bird full conference - $450.00 Regular full conference - $530.00 Pre-Conference - $106.00 - $212.00 Daily registration; Mon/Tue/Wed - $225.00 Daily registration; Thu - $144.00 Non-Member Pricing Early-bird full conference - $580.00 Regular full conference - $660.00 Pre-Conference - $140.00 - $280.00 Daily registration; Mon/Tue/Wed - $280.00 Daily registration; Thu - $196.00 Reservations Book your reservations today at the Boston Convention & Exhibition Center
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Intensive Care Unit (ICU) orientation is the cornerstone of success for nurses working in the ICU. As nurses move into new positions, there are many choices and aspects to consider before saying yes to the job. Mary Watts, BSN, RN and Maureen Bishop, MSN, CNS discussed ICU orientation and how to be a successful ICU nurse. They met at the 2018 NTI Conference in Boston, Massachusetts. They talked about the changing face of nursing employment. Nurses on the Move A recent study found that millennials will change jobs an average of four times in their first decade out of college, compared to about two job changes by Gen Xers their first ten years out of college. Ms. Bishop explained that the expectation of employment at her institution is two years. Essentials of Critical Care Orientation (ECCO) Ms. Bishop has been hiring new grads into the ICU for the past 10 years. "Mostly we look for passion. We do what is called a blended orientation concept. They do online modules, classroom time where they learn basic critical thinking skills and they take an 8-week arrhythmia course." In addition, they are required to take and pass ACLS and "of course the most important part is to spend time bedside." Ms. Bishop attributes her facility's orientation success to utilizing AACN's ICU Essentials of Critical Care Orientation (ECCO). According to the AACN, "ECCO's up-to-date, interactive evidence-based education easily blends into your existing orientation plans. AACN's 24/7 customer support, comprehensive reports, and progress tracking tools make implementation straightforward." The ECCO program has earned accolades for its content: "American Association of Critical-Care Nurses (AACN), a leader in providing standard-setting education and expertise that nurses and healthcare organizations can trust, recently won two prestigious Brandon Hall Group silver awards for excellence in the Best Learning Team and Best Advance in Custom Content categories." Even after the 4-6 month official orientation, there is a mentorship program too; where new grads and seasoned have added support for an extended period of time. They also have follow up with Ms. Bishop as well as the unit manager. Mary asked about whether orientation is customized for the experienced nurse and Ms. Bishop assured her that the orientation must be flexible in order to meet the needs of everyone. Customized orientation is also important to AACN and their ECCO program. Ms. Bishop also emphasized that they welcome nurses who apply from out of state, both new grads and experienced nurses. Evaluation Evaluating the end product of orientation is extremely important. Ms. Bishop states that the criteria she uses to evaluate orientees consists of their ability to grasp the concepts of ECCO and put them into practice. She also emphasizes the need to utilize solid critical thinking skills when confronting complex patient care. Other important aspects of a successful new ICU nurse are that they are able to coordinate all the aspects of care including physical assessment into a solid plan of care. This includes understanding lab results, medications and how they affect the overall care of the patient. She concludes, "so for me, it's really how they are doing on the job. Are they putting that knowledge into practice?" Nurses want to be successful in their chosen career. There are many barriers to a successful orientation but using a known product to facilitate this process will increase the odds of retaining ICU nurses.
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The 2018 Marguerite Rodgers Kinney Award for a Distinguished Career was awarded to Beth Tamplet Ulrich, EdD, RN, FACHE, FAAN at the 2018 American Association of Critical Care - National Teaching Institute annual conference. While at the NTI conference, Mary Watts, BSN, RN, allnurses.com Community Director interviewed Dr. Ulrich and discussed her career and some of her accomplishments. Dr. Ulrich received her bachelor's degree from the Medical University of South Carolina, her master's degree from the University of Texas Health Science Center at Houston, and her doctorate from the University of Houston in a collaborative program with Baylor College of Medicine. When she moved to El Paso, Texas; due to her husband's job, she started in dialysis and learned from the ground up as dialysis was in infancy. She worked to set standards of care and is a past president of the American Nephrology Nurses Association (ANNA). While earning her doctorate, she worked in hospital administration developing nursing simulations and nurse residency programs. She became interested in the healthy work environment and began her work with the American Association of Critical Care Nurses (AACN). She assisted with development of the first Healthy Work Standards survey in 2005. Dr. Ulrich stated that AACN brought together "an expert panel to create the standards.” In 2006, it was decided to "obtain opinions from those nurses with boots on the ground; the staff nurses who do the doing every day.” She further explained that AACN is "absolutely committed" to obtaining information to help the bedside nurse work in the safest environment possible. The 2005 survey was a snapshot. By the 2008 survey, AACN began to assemble comparisons of data which expanded when the 2013 survey data was added and AACN was able to took at trends. Now in 2018, AACN has received over 8000 responses to their current survey. Every time the survey is done, there are more and more nurses responding. Mary stated, "nurses see the value in these surveys because they want changes" via the published results. Dr. Ulrich continued, "When we first looked at this, we were looking for a baseline. In 2013, we saw the down turn of the economy: nurses were returning to work, they were changing from part time to full time, or for those who were working full time, they were looking for overtime.” In this scenario where the economy dictated how much you needed to work, there were not a lot of changes in the work environment regarding safety as income was the number one reason to work. Mary asked, "What contributes to an unhealthy work environment?” Dr. Ulrich answered that inappropriate staffing - results showed that 39% of the respondents reported they had appropriate staffing. Another more concerning result was that 32% stated that <50% of the time, they had adequate staffing. "This is pretty scary for the patients and the nurses". Dr. Ulrich pointed out that "staffing isn't just about the patients; it's about the nurses too, because when staffing isn't adequate, nurses don't practice at the top of their license. They get done what they have to get done. They don't get to do the things only nurses can do - the critical thinking things, the discharge planning, comforting, teaching patients and families. They have to do tasks and then nurses aren't satisfied with their jobs.” This results in decreased job satisfaction. Staffing is more than just about enough nurses to take care of the patients. It reflects on everything in the work environment. "I was surprised at the high number of incidents of discrimination with the 2018 survey.” This included verbal and physical abuse experiences. "We capped it at 200 incidents in the survey.” Nurses aren't leaving nursing, they are leaving the hospitals - they have many options. They aren't limited to work in the hospitals. "Once a nurse, always a nurse,” stated both Mary and Dr. Ulrich in unison. The survey results are published in Critical Care Nurse, AACN's clinical practice journal. Link to study Allnurses.com extends their gratitude to Dr. Ulrich and AACN for continued support in disseminating vital information for nurses.
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Nursing certification is a goal we should all aspire to - it shows dedication and the willingness to go above and beyond. And it can help your career.... AllNurses.com's Content and Community Director, Mary Watts recently interviewed Karen Kesten, DNP, APRN at NTI 2018 on the subject of nursing certification. Dr. Kesten is the past chair of the national board of directors for the AACN Certification Corporation, as well as an associate professor George Washington University School of Nursing. Many nursing certifications are available from AACN Certification Corp. for both RNs and APRNs. Dr. Kesten recommends certification for all nurses as a "mark of excellence and distinction." She went on to state that this proves credibility of knowledge and leads to higher patient and nurse satisfaction. New Certifications Two new certifications; CCRN-K and PCCN-K are now available. These certifications are for nurses who do not currently deliver direct bedside care but who indirectly affect patient care thru management, instruction or staff development. The "K" stands for "knowledge." This is a way for nurses to continue to use their knowledge even though they are no longer bedside. Other new certifications include palliative care, and forensics nursing. These specialties show patients and colleagues that the nurse has attained a level of expertise in their specialty. Dr Kesten foresees possible future certifications for nurse navigators and nurses who are involved in transitions of care. APRNs and the Consensus Model Advanced Practice Registered Nurses (APRNs) also need to consider the Consensus Model when choosing their educational pathway. The APRN roles are: Nurse Practitioner Clinical Nurse Specialist Certified Nurse Midwife Certified Registered Nurse Anesthetist "To help take APRN practice to the next level, AACN collaborated with over 40 nursing organizations to address the inconsistency in APRN regulatory requirements throughout the United States. The result was the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (LACE)." The Consensus Model sought to improve patient access to APRNs, support nurses to work more easily across different states, and enhance the certification process by preserving the highest standards of nursing excellence. Through consistency and clarity of APRN Consensus Model criteria, APRNs were empowered to work together to improve health care for all." LACE also determines what patient population and focus the APRN certifications cover. This is an effort to delineate out each APRN specialty and to develop more consistency. Dr. Kesten encourages nurses to consider a primary care APRN role as nurse practitioners are in great demand especially in underserved and more rural communities. With the current physician shortage, nurse practitioners are filling many provider roles. More and more nurse practitioners are seeking roles in specialty care, which extends the availability of providers. Why Certification is Needed Dr. Kesten encourages nurses to obtain certifications. She emphasized that nurses are in a life-long learning pattern and with certification, they have more options. There are many faces of nurses so there are many certifications and she expects that nurses will have many more opportunities in the future. Dr. Kesten advocates for nurses having a louder voice in order to advocate for their patients. Overall there are many more opportunities available for certified nurses. Consider certification! References: AACN Certification Corporation APRN Consensus Model
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When was the last time you saw a nurse in the media? You might not remember. A new study conducted by Diana Mason and Barbara Glickstein found that you won't remember because they simply aren't there very often. Here, we discuss a recent interview at AACN-NTI with Diana, and what you can do to improve the future of nursing in the press. As a nurse, you speak with the public daily. You educate patients, support families, and provide information to community resources to get your patients the care they need. When our country experiences disasters, nurses are at the bedsides, providing care, and advocating for their patients. But, when a journalist covers a story about the latest flu epidemic, acute flaccid myelitis, or another violent attack, who do they interview? Do they look for the nurse at the bedside who cared for these patients, or the doctor overseeing the care? We're quite sure you just said "doctor" in your head, right? But, do you know why? A recent study conducted by Diana Mason and Barbara Glickstein replicated the original Woodhull Study that was done in 1997 to explore how often nurses were identified or interviewed in the media for general healthcare stories. The study was reproduced to determine if there have been any advancements of nurses in the media. At a recent AACN-NTI Conference, we sat down with Diana, who is the Senior Policy Service Professor for the Center for Health Policy and Media Engagement at George Washington University School of Nursing during the American Association of Critical Care Nurses meeting. The Original Woodhull Study In 1997, the "Woodhull Study on Nursing and Media" was published, and was the first of it's kind to explore the representation of nurses in the media as sources of health-related stories. Dianna explained that the original study found that nurses were sources in quotes less than 4% of the time in newspapers, and about 1% of the time in newsweeklies. During the interview, she explored the notion that even when nurses were at the heart of the story, such as with HIV/AIDS care in the mid-90's, they were nowhere to be found in print publications. Even rarer was to find nurses being interviewed about nursing policy or actually photographed for news stories. Following the release of the original findings, Sigma Theta Tau raised awareness of the need for nurses in the news. Then in 2010, the Institute of Medicine (IOM) released the Future of Nursing Report in which the Robert Wood Johnson Foundation and the IOM conducted a two-year initiative to assess and transform the profession of nursing. The study concluded that nurses played a vital role in the advancements of the healthcare industry, but that barriers existed that prevented them from being well-positioned to lead change and advance health. Have We Progressed? According to the preliminary results released by The George Washington University, the new study examined 365 randomly sampled health news stories published in September 2017. They looked at the type and subject of the article, the profession, and gender of the speakers, and how many times nurses were references without being quoted. The researchers found that nurses were identified as sources in just 2% of the health news coverage and mentioned in 13% of health news coverage overall. While this is a decrease in the representation, Dianna explained that it's not statistically significant, so the conclusion has been made that nothing has changed. She acknowledged that this might not be accurate because nurses might be cited in stories, but not recognized for their role. It's normal to see stories where Dr. Smith is quoted, even if he or she isn't in a hands-on provider. However, when a nurse holds an executive level position, their credentials aren't always given. Other findings included that females are less represented that males in the media, even though the profession is predominately made up of women. There were also preconceptions in the news media about positions of authority and journalists admitted that they weren't sure what nurses do and when nurses would add to a story unless it was explicitly about nursing. How Do We Make Change? Nurses provide more hands-on care than any other healthcare professional. Yet, they aren't equally represented in the media. Is this because nurses are not comfortable with being in the spotlight? Could it be that when journalists request an interview for a story nurses are not the ones provided by healthcare systems? Or, maybe journalists aren't even sure how to access nurses for stories. Actually, all of these were found to be true. So, how do we ensure that this won't be the same 20 years from today? Here are a few things you can do to help progress nursing representation in the media: Support movements like Show Me Your Stethoscope (SMYS) that advocate for positive cultural changes within the nursing profession and the healthcare community. They strive to provide a united voice for nurses on issues facing our communities. SMYS was founded in response to a public attack on the nursing profession and has ultimately led to the #NursesUnite concept. Talk about your credentials. Diana points out that you don't need to include all 7 of the certifications you hold, but identifying yourself as a nurse with a hard-earned degree and license is paramount to the required changes in media. Improve media competence by training journalists and offering media training to nurses. If you want to be a presence in your local community, seek out the media relations department at your facility and request to be trained on how to speak to the media. This training can teach you how to talk with journalists, stay on your message, and just be yourself. Anticipate healthcare happenings and identify nurses who should be at the forefront of stories. This should be accomplished on a local, state, and national level by healthcare facilities, organizations, universities, and government agencies. Our time with Diana was eye-opening and empowering. Have you been in the media as a nurse? Were you well-represented in print? Or, maybe you have ideas on how to empower nurses to be in the press? Whatever your thoughts are about this study, we want to know. Comment below and get the conversation started.
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Nurses have bad days just like everyone. What's the difference between burnout and moral residue? This is an important issue for all nurses. Many people have thoughts about how to combat nursing burnout. There have been studies, conversations, symposiums. Speaking to someone who has experienced burnout helps to clarify the issue and a possible solution. Interview with Anna Rodriguez, BSN, RN, PCCRN, CCRN allnurses.com's Content and Community Director, Mary Watts, BSN, RN recently spoke with Anna Rodriguez, BSN, RN, PCCRN, CCRN at the AACN/NTI Conference about her journey through nursing burnout. Anna explained that she went thru an experience approximately 3 to 4 years ago when she was in the right place at the right time and became a unit manager of a 10-bed CVICU. She held this position for two years and during these two years they had many changes including starting a new ECMO program, launched new and different technology and it just was a perfect storm. Anna got to the point where she went back to bedside via travel nursing. Currently, Anna is working in endoscopy. She had started a blog, The Burnout Book to collect her thoughts and to share with others as well as to bolster her spirits. This is based on the original burnout book that was a little journal she started writing during her second year of nursing school. She commented, "It's important to remember our "why" in nursing. It's the little things that matter. Now I'm a burnout survivor.” Any human being will have bad days. As a nurse its important to develop a skill set to deal with bad days. However, when you have moral residue, it becomes harder to see that perhaps it's just a bad day versus actual burnout. From the ANA, moral distress is defined as: Understanding and Addressing Moral Distress - American Nurses Association Signs and symptoms that can be indicative of moral residue include: Physically, and emotionally exhausted Dreading the job that you used to like Less connection with your job Chronic illness All of this can lead to burnout. Early recognition is the key. Possible solutions: Talk with someone, perhaps a trusted co-worker Acknowledge your feelings Employee assistance program Counseling if your mental health is endangered Changing jobs, shifts or specialties Mary then asked if there are some personality traits that make a person either more prone to burnout or more resilient to this phenomena? Anna answered that in general people that are empathetic can have more issues with less resilience and this describes most nurses. As nurses, we have to find the balance between being compassionate and caring and separating ourselves from these feelings. They also discussed compassion fatigue which is when you take on the feelings of others to the detriment of yourself. Anna's advice identifies that the goal is to be more resilient. When you feel a burnout moment, you need to get out of it. However, don't make huge lifestyle changes at the moment. You need to resolve the immediate stressor but once the stress lessens then you can rethink the situation and look at your life to see if you need to make big changes. All nurses experience this to some degree but its how you handle it. Don't quit nursing, find your spark, there are a lot of different ways to be a nurse!
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How to manage the many alarms that the bedside nurse must assess? "The Joint Commission has identified alarm management as a national patient safety goal and requires hospitals to take action to reduce unnecessary alarms as a condition of accreditation." allnurses.com's Community Manager, Mary Watts, BSN, RN had the opportunity to interview Halley Ruppell, PhD, RN and Stacy Jensen, CNS at NTI. Some issues they discussed included: Tailoring the alarm setting to the individual patient and the disease process. For instance some children with congenital heart issues experience a "normal" SpO2 saturation below the standard so setting the parameters lower results in fewer nonactionable alarms Actual alarm management teams including engineers have come together to enact age-appropriate alarm settings that would somewhat standardize parameters. Placement of electrodes, skin prep prior to placement, and the amount of pressure applied to skin are all part of the monitoring process SpO2 sensors being applied correctly and the use of the correct sensor on the correct body part are key to proper management of alarms also Quality improvement activities are very important to the care of the critically ill patient; for both pediatric and adult patients. Nonactionable alarm overload can result in nurses actually not hearing alarms as well as disregarding alarms. With many "false alarms,” this results in less response to the alarm increasing the chance of missing an actionable alarm. The process alarm alert was updated in 2018. Here is the link to the practice alert. During the interview, it was discussed that there is not a lot of research involving the differences between pediatric and adult critical care monitoring. This has resulted in a standardized monitoring system for both adults and pediatrics which isn't always individualized. It is imperative that clinicians order appropriate monitoring for patients and that monitors are not overused. This can also lead to alarm fatigue. Another issue that was discussed was buy-in from the bedside nurses. The feedback received after the initiative was published involved hard data. This provided the bedside nurse with evidence-based information proving the efficacy of the practice alert. Listening to fewer alarms really engaged the nurses and brought awareness of alarm fatigue to the bedside nurse. This is important also for the families bedside and promoted the engagement of both staff and visitors. Change in practice can sometimes become burdensome for the bedside nurses but with evidence-based information, you can obtain more engagement. It was eye-opening for nurses to realize that they didn't hear all the alarms. It's a sensory overload type of situation. Leadership must also recognize the need for change. Per AACN; "The strategies for nursing leaders include the following: Establish an interprofessional team to gather data and address issues related to alarms Develop unit-specific default parameters and alarm management policies Provide initial and ongoing education on monitoring systems and alarm management for unit staff Develop policies and procedures for monitoring only those patients with clinical indications for monitoring" Yet another piece of this project was a collaboration between the researchers and the industry that makes the monitors. It is very important to involve business leaders and engineers.
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AACN offers the premier critical care conference, National Teaching Institute (NTI) annually. Recently allnurses.com’s Content and Community Director Mary Watts, BSN, RN, interviewed Anna Dermenchyan, MSN, RN, CCRN-K. In 2010, she founded the first hospital-based chapter of the American Association of Critical-Care Nurses (AACN). As the first chapter president, she began an annual Leadership Symposium for nurses and nursing students within the hospital and the community. Issues Associated with the Job Anna started her nursing career in a CVICU at UCLA. She relates; “they cared for such critically ill patients and provided such an enriching environment for a new nurse. What I was not prepared for was the issues associated with my job.” She progressed in her nursing career and had many roles including resource nurse, preceptor, and charge nurse. Approximately five years down the road, she wanted to take on a quality role. She went back to school and is currently working on a PhD looking at outcomes for HF patients in primary care. Idealism as a New Nurse allnurses.com asked about the issues surrounding nursing care. Anna discussed the idealism that is felt in nursing school, “you don’t know the expectations of the new job.” She went on to discuss the need for teamwork and that sometimes this isn’t always there and “the patients suffer.” One of the stressors at the start of her career was that the CVICU manager left within six months and the unit felt “lost.” Another issue was that she had numerous preceptors which added to her stress. Healthy Work Environment Anna also commented that AACNs healthy work environments (HWE) initiatives are so important for critical care nurses. The six initiatives are: Skilled communication True collaboration Effective decision making Appropriate staffing Meaningful recognition Authentic leadership The Importance of Networking Next, they talked about networking which is a great way to make connections that will lead to success in your nursing career or any career. Mary asked, but how do you network successfully at a large conference like NTI? Anna replied, “It is a place to learn clinical topics and there are 300 sessions, motivating. It’s also a value-added commodity. You can let your guard down and network and it's an amazing experience. It’s not only about practice education but also a great way to connect and make new members. You can find a mentor.” Don’t take learning for granted. Collaborate with others. Here is the complete interview presented in 2 videos:
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In 2013, the Society of Critical Care Medicine (SCCM) recommended the following as basic to ICU patient care: routinely monitor all intensive care unit (ICU) patients for pain, depth of sedation, and delirium, using valid and reliable PAD assessment tools;(2) assess and treat pain first, before sedating patients; (3) avoid deeply sedating patients; (4) use nonpharmacological delirium management strategies over medications to prevent and treat ICU delirium; and (5) link PAD management to ventilator weaning and early mobility efforts. ABCDEF Bundle - Recommendations of best practices: A - Assess, prevent, and manage pain B - Both spontaneous awakening and spontaneous breathing trials [SATs/SBTs];C - Choice of analgesic and sedationD - Delirium: assess, prevent, and manageE - Early mobility and exerciseF - Family engagement and empowerment; Integrating pain, sedation, and delirium managementallnurses.com staff recently interviewed Joanna Stollings, PharmD, a clinical pharmacist in the department of pharmaceutical services at Vanderbilt University Medical Center (VUMC), Nashville, Tennessee. Here is what we discussed: Q: This is a multi-disciplinary assessment. How are institutions initiating this aspect? Daily meetings/huddles or is each discipline responsible for their own part of it? Institutions are using many different methods to implement the ABCDEF Bundle. One of the best has each of the team members to present a separate component of the bundle during interdisciplinary rounds. Another approach is to include documentation of the entire bundle in one area of the medical record. Our group is actively working with Epic and Cerner to help with this documentation process. We want to avoid having practitioners practicing in silos and to promote the interdisciplinary aspects of this bundle to promote the best care of the patient. Q: Regarding family engagement in ICU care of their loved one, does the introduction of a formal palliative care program fit into this objective? Does open (24/7) visitation of family members help to achieve family engagement? In many pediatric ICUs, there is open visitation. Could adult ICUs take this as an example? A formal palliative care program can be part of the objective of family engagement. The Family element of the ABCDEF Bundle promotes involving the family in all decisions about patient care. Adult ICUs definitely could use the open visitation policies that are commonly found in pediatric ICUs. Open visitation by family members definitely helps with family engagement. It allows the family members to be present during interprofessional rounds and to assist in the implementation of other parts of the ABCDEF Bundle such as assistance with physical therapy. Q: Regarding mobility assessment - does implementing early physical therapy referral assist with this goal? Implementing a referral for early physical therapy can help with obtaining appropriate mobility assessments. However, nurses, physicians, advanced practice nurses and physician assistants, etc. also need to be able to do an appropriate mobility assessment to better triage the utilization of physical and occupational therapists to the most complicated patients. Q: With the opioid overuse crisis, utilizing a range for dosing of opioids for pain control is often ordered for ICU patients. Of course, this must be regulated by hospital/facility policy. What educational material would be utilized to provide this education and best practice for the bedside ICU nurse? We would recommend utilizing resources from the Joint Commission and/or the American Pain Society to educate nurses about range dosing of opioids. Q: How do you get "buy-in" from the bedside nurse who can already be overwhelmed with documentation and care of the patient? Seeing their patients have better outcomes and other results from implementing the ABCDEF Bundle help secure buy-in from bedside nurses. While it is important to introduce the concept of the ABCDEF Bundle as a whole when implementing it, the team can focus on the various elements individually over time. This allows the unit to keep the big picture in mind while fine-tuning the details along the way. It always helps the whole team to remember that these elements are interrelated. When ICUs start to use the ABCDEF Bundle, we recommend they start with one letter and to start with only a couple of patients. As nurses start to see the results of each of the different components of the bundle in a few patients, they will want to implement the Bundle in more patients. Resources Utilized by Joanna Stollings:Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ABCDEF Bundle Improvement Collaboration AACN news release: Practical Advice for Implementing the ABCDEF Bundle Society of Critical Care Medicine
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Come and join your fellow critical care nurses at NTI 2019 in Orlando, Florida from May 20-23rd. With more than 37.5 hours of CEUs offered, this conference is sure to teach, inspire and impress all high acuity and ICU nurses. Reasons to attend NTIIt would be easy for us to tell you the reasons. However, here are a few of the of the comments from recent attendees: "It pumps me up." "Chance of a lifetime." "Makes me motivated to be a better nurse." "Gave me back my enthusiasm to be a bedside nurse." There are many reasons to attend and some of the past attendees have stated some of these reasons. The sessions are also a solid reason to attend NTI. They are divided into pre-conference offerings that include Chapter Leadership for those nurses who want to advance to an AACN leadership role. The pre-conference sessions also cover other topics such as a cadaver lab for APRNs, advanced 12-lead EKG interpretation, certification prep courses, in addition to other critical care exploration options. The pre-conference topics are offered on Sunday and run most of the day so that you have the ability to more fully explore the topic. Concurrent sessions are usually 60-75 minutes in length and cover such topics as: 12-lead EKG Interpretation, Candida: The Fungus Among Us and From the Playground to the Nurses Station: Understanding and Eliminating Workplace Bullying. NTI 101One of the most interesting topics is NTI 101. This is an introduction to the conference, how to navigate it, how to get the most out of the experience. Here's what AACN says about NTI 101: "Perhaps it’s your first time or you need a refresher; attending the National Teaching Institute and Critical Care Exposition (NTI) can be an adventurous and sometimes, an overwhelming experience. The Program Planning Committee Chairs offer strategies to help you navigate your way through NTI. Please be sure to bring your mobile devices so you can participate fully in this dynamic session. Learn how to plot your educational journey through hands-on use of the NTI Program Guide, Program Schedule, Learning Action Journal and ExpoEd Guide which can be found in your NTI bag. Join the API or NTI Chair in this interactive and engaging session to explore how to develop a personalized education schedule, identify available resources and use My NTI. This session is designed to answer questions about the multitude of diverse opportunities available to every attendee and to help make your NTI an enjoyable and rewarding professional experience." This session will lead you on your way to a satisfying and enjoyable NTI 2019 and its offered several days and times so fitting it in shouldn't be difficult. The Advanced Practice Institute (API) offers some great options for the APRNs; whether you are just beginning your APRN journey or have been around the block several times. The ECMO session is always a highlight, as is the cadaver lab. Some other topics include: Vasoactive Pharmacology for Pediatric Shock, Neuromuscular Blockade in the ICU: A Review of Practice, Top Sepsis Studies 2018-2019 and Acute Decompensated Heart Failure, Management and Prevention of Recurrence. And these are only a few of the selections. The Exposition HallThis is where you learn, see, and experience all the new technology that is currently available or soon to be available for your critical care units. Its also where you can learn about educational opportunities to advance your career and also where the jobs are found. There are over 300,000 square feet of experience and you can truly spend the entire day here and not see everything. The opportunities are endless - pick up a brochure about a new piece of equipment, listen to a seminar about a new process to make patient care more efficient, network with other critical care nurses about the challenges and rewards. Registration Register NowWhere to StayAACN has a very comprehensive list of available hotels with pricing included here. There are a wide variety of options with many hotels located near the convention center. There is also a shuttle that runs between many of the hotels and NTI. We have just briefly touched on what NTI 2019 offers you. AACN has a very comprehensive site with all the details. Several allnurses.com staffers will at NTI 2019. We love to meet our members. Please let us know if you are attending. Also, we do have the opportunity to interview some of the speakers - who would YOU like us to interview? Tell us!
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Allnurses staff recently attended AACN's National Teaching Institute 2017 in Houston, Texas. One of the interesting presentations was Mastering the Art of Professional Networking, presented by Alvin Jeffery, MSN, CCNR, RN-BC and Anna Dermenchyan, RN, BSN, CCRN-CSC. Networking is one of the best ways to make connections that will lead to success in your nursing career. Getting to know other nurses on a professional basis often leads to a tip on a new job, insider information about a prospective facility or unit and can expand your circle of friends. Develop a Goal for Your Network AdventureAre you looking for a new job? Do you want to expand your knowledge of your present specialty? Are you returning to school? Do you want to expand your social media network? What is your goal when you talk about networking? Before you go to a networking event, determine your goal and decide what you would consider success? Is it getting an insider view of a particular hospital or unit? Getting the name of a unit manager or recruiter? Making new contacts in general? Benefits of NetworkingPotential employment and consulting opportunitiesIdentity for oneselfBe more effective in your current jobEngagement with othersBuild a support systemNetworking at a Nursing ConferenceThat said, few of us can walk into a room of strangers and start instantly networking. Here are some tips for your networking success: Be interestingIf you want to have interesting conversations you must be an interesting person. You can do this by staying up-to-date on current events, both in and out of nursing, and doing some homework before the occasion. Check the agenda in advance and research the guest speaker, host, sponsor, or award recipients. Knowing these details will empower you to initiate discussions. Step outside your comfort zoneMost of us are more at ease conversing with people we know, which means we often end up not meeting anyone new. Summon the confidence to independently work your way around the room. While you're at it, introduce yourself to someone you've never met before and start a dialogue. If you're unsure whom to approach, simply look for a person who is alone. Invite others to join you People naturally gravitate toward those who are warm and welcoming. Display open body language, wear a smile, make eye contact, and always be ready to shake hands and introduce yourself and the others in your group to newcomers. Make every effort to be inclusive of everyone. Refer to people by name When you meet someone new, use his or her name as soon as you can in conversation. If you forget the name of a person you've met before, ask for clarification. A gracious way to do this is to say, "I remember meeting you, but somehow I've forgotten your name. Can you please tell me what it is again?" Have an escape planKnowing how to exit a conversational cul-de-sac can be your saving grace. If you need to leave a group discussion, simply excuse yourself at an appropriate moment. When someone has you cornered in a one-on-one situation, however, acknowledge that you were listening before you leave. Wait for a natural break, comment on a point they made, say their name, and move on. Try something like this, "It sounds like your research project is fascinating, Jeremy. Best of luck. Enjoy the rest of the conference." And here are some additional networking questions for national conferences: What's your name?Where are you from?What do you do?Is this your first time at NTI? If not, which other ones have you been to?What's been your favorite thing so far?Who inspires you?Which workshops/tracks are you attending at the conference?Social NetworkingThe rules for social networking vary depending on the goal of your networking. Some of the more common tips are: Create a professional networking profile. No matter what social media platform you choose, it is imperative that you develop a professional profile. Include a professional headshot of you. Do not use a selfie or a picture that could be misinterpreted as less than professional.Join professional groups or discussion boards. You already have a common ground and this makes it easier to talk about your commonalities.Volunteer with your professional organization - this is a great way to network and develop relationships. Volunteering doesn't necessarily have to involve a lot of time and effort but volunteers are noticed and that's one of the goals of networking.Pitfalls of NetworkingAs with anything positive, there are also negatives. Avoid the following issues: Always go to a networking event prepared: find out the dress code in advance, bring plenty of business cards and understand your goals.Do your research on the organizer: what is their goal for this event?Don't arrive late. When you arrive with others, it automatically opens up a conversation. If you arrive late, the conversations will have already started and you have missed out on valuable networking time.References: Networking for Medical Professionals Networking Tips for Every Healthcare Professional Can Use 3 Business Networking Pitfalls to Avoid
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Staff of allnurses recently attended the AACN National Teaching Institute (NTI) in Houston, Texas. One of the sessions was "Owning Your Future: Building Personal Resiliency in Times of Burnout and Challenging Environments", presented by Vicki Good, DNP, RN, CENP, CPPS. "I'm fried!" "I just can't do this anymore!" "I'm burnt out!" How many times have we heard our colleagues or even ourselves say or think these thoughts? Nursing is a high-stress environment. Burnout is a state of stress that many high achievers experience. Some of the symptoms are: physical and emotional exhaustioncynicism and detachmentfeelings of ineffectiveness and lack of accomplishmentExhaustion is generalized fatigue that can be related to devoting excessive time and effort to a task or project that is not perceived to be beneficial. Depersonalization is a distant or indifferent attitude toward work. It manifests as negative, callous, and cynical behaviors or interaction with colleagues or patients in an impersonal manner. Reduced personal accomplishment is the tendency to negatively evaluate the worth of one's work, feeling insufficient regarding the ability to perform one's job, and a generalized poor professional self-esteem. Experts estimate that one out of three critical care nurses is experiencing severe burnout syndrome, which is often referred to as a "silent epidemic" in healthcare. Organizational and individual factors lead to the presence of burnout syndrome and both must be addressed to prevent the negative consequences of the syndrome. Critical care nurses are at high risk for burnout due to the complexity of care as well as the high mortality and morbidity of the patients they care for. Over the years, as patient acuity has increased, so has the immense responsibility of the critical care nurse. The ethical journey that we take also takes it toll. The question is no longer "what can be done?" but rather, "should we do it?" Should we continue full court press for all patients regardless of their quality of life? Should we offer all modalities and treatment options even knowing they come with a high potential for a limited quality of life? These questions and much more lead to stress which in turn leads to burnout. We constantly care for others, yet sometimes we are not kind to ourselves. How many times have we put off going to lunch, break, bathroom because "our patient needs us?" How many times have we said "yes" to overtime that we didn't really want to do just so our co-workers wouldn't work short? Again, all circumstances that lead to added stress and burnout. So...how do we combat burnout? Based on a report from the American Association of Critical-Care Nurses, 6 standards are needed to establish and sustain a healthy work environment: Skilled communicationTrue collaborationEffective decision-makingAppropriate staffingMeaningful recognitionAuthentic leadership.Additional commonly recognized tenets of a healthy ICU environment include "avoiding or managing conflicts" and "improving end-of-life care." Communication, collaboration, and effective decision-making during times when emotions are elevated are critical in engaging the team to decrease stress and BOS. A healthy work environment may be enhanced by utilizing team debriefings, structured communication, and collaborating with team members on critical decisions. From Dr. Good's presentation, here are some environmental or organizational solutions: Acknowledgment of stress and burnoutEstablished wellness programPalliative care consultationsActive Ethics CommitteeAs individuals there are steps we can also take to reduce or relieve burnout: Stress reduction trainingMeditationsWork-life balanceEnsuring adequate rest, breaks, time with family and outside activitiesWe all realize that we work in a stressful environment. To continue to care for our patients and ourselves we need to recognize ways to minimize and cope with stress. It is important that both our organization and nurses work together to focus attention on this increasingly common issue and work jointly to combat it. In the end, this will provide improved care for both patients and nurses. References: American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2nd ed. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2016. Burnout Syndrome in Critical Care Healthcare Professionals Owning Your Future: Building Personal Resiliency in Times of Burnout and Challenging Environments Tell-tale Symptoms of Burn-Out
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Hospitalized patients often experience pain. In the ICU, most patient experience pain to some degree. As more invasive and painful procedures are performed, pain escalates. Add in intubation, multiple lines and your patient experience a wide variety of painful sensations. How to manage this pain? What is the best pain regimen for the opioid naive and opioid-dependent patient? Principles of Pain AssessmentPain is a subjective complaint based on many factors: Procedures being performedPatient past medical historyHistory of opioid usePerception of care receivedJust to name a few. Assessing pain can also involve many avenues - for the verbal patient: Wong-Baker Pain ScaleFaces Pain ScaleVerbalization from the patientIt becomes more difficult to assess pain in the unresponsive patient. Patients can be unresponsive for various reasons: intubation, sedation, paralysis, dementia, psychiatric disease. However, here are some tips: GrimacingTachycardiaIrritabilityDecreased interaction with the environmentOpioid-Tolerant PatientsThere is no exact formula to follow to ensure adequate pain management for your patients that already take opioids. The first task is to obtain information regarding the patient's past/current opioid use. Do they have cancer and take escalating doses? Are they on maintenance suboxone for past opioid addiction? Do they use street drugs? Not always easy questions to ask. If the patient is unresponsive, asking the family in a non-judgemental manner is essential. Emphasize that you want to provide optimal pain relief and in order to do so, you need to know if the patient takes opioid medication/drugs frequently. From the Society of Hospital Medicine: "Patients with chronic pain present a special challenge. When they have pre-existing pain and undergo an operative procedure, it becomes important to differentiate pre-existing chronic pain from new acute postoperative pain. Additionally, patients already on chronic opioid therapy may require a 200 to 400 percent increase in preoperative opioid requirements.24 Thus, it is important to establish preoperative analgesic requirements to create a postoperative pain management plan, not to mention a keen awareness of comorbidities that may preclude the escalation of regimens due to patient safety concerns." The Stepwise Approach is recommended - this involves the use of non-opioid medications such as NSAIDs, Cox-2 Inhibitors and non-pharmacological options also. However, in opioid-tolerant patients, "always start off with an immediate release medication. Long-acting opioids are not appropriate to be used to treat acute pain and for initial dose titration. The route of pain medications also makes a difference in the frequency of administering pain medications. Short-acting oral opioids peak in 45-60 minutes. Intravenous dosing will peak in 10-15 minutes. Knowing these parameters makes it easier to dose medications sooner to achieve adequate pain relief in acute pain. When dosing medications for acute pain, it is appropriate to give an additional dose if the pain is not relieved by the expected peak time. As an example, if a patient in acute pain is given an intravenous dose, then it is appropriate to give the same dose again or double the dose (depending on the clinical situation) if there is no relief in 15 minutes once peak onset of action has been reached." (Society of Hospital Medicine) Opioid Naive PatientsPatients that do not take opioids merit consideration also. "When using a patient-controlled analgesic (PCA) in opioid-naïve patients, only patient-controlled dosing should be used initially. Starting a continuous basal dose on an opioid-naïve patient is generally not appropriate. Once steady state is achieved with patient-controlled bolus dosing in 24 hours, then starting a continuous basal rate can be considered if the clinical judgment deems it necessary to use opioids for a longer time period." (Society of Hospital Medicine) Other ConsiderationsAlways be mindful of renal function as this can adversely affect pain control. Also, due to many factors, renal function can deteriorate while hospitalized. Dose adjustment must be considered. NSAIDs and Cox-2 Inhibitors are usually precluded for the patient who has decreased renal function. Patients on dialysis or CRRT also pose special pain management issues and it will be important to bring on the care of the nephrologist. References: Getting Out of Your Comfort Zone With Opioid Tolerant Patients Multi-Modal Pain Strategies for the Post-Op Patient - Society of Hospital Medicine
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At AACN's National Teaching Institute recently, Post-Intensive Care Syndrome (PICS) was discussed. Here is a personal account of what PICS looks like: Carrie was an active 2 y/o, running, jumping, getting into mischief and talking up a storm. One day, Carrie was outside playing on the swings in the backyard. Anne, Carrie's Mom was sitting outside watching Carrie. Suddenly, Carrie was on lying on the ground - Anne ran over and picked her up thinking maybe she had fallen. However, Carrie was strangely quiet, and she was barely breathing. Anne rushed into the house, and called 911 - what was wrong with Carrie? Why was she having such a hard time breathing? She needed help. She related later that the 2-3 minutes that it took for EMS to arrive took "forever." The paramedics quickly arrived, placed Carrie on the cart and into the ambulance. As they had concern for a partial airway obstruction, they placed her in a position of comfort, applied oxygen, and cardiac monitor and off they went...to the level one trauma center and children's hospital. Carrie remained minimally responsive. In the ER, Dave, Carrie's Dad met Anne and Carrie. They were allowed to stay with Carrie though she didn't seem to even be aware of them. The ER resident asked what had happened but Anne couldn't really even say the exact circumstances except that "she fell and then she had trouble breathing." The ER attending comes in and they decide to take Carrie to the OR for an emergent bronchoscopy and intubation under direct visualization, at this time, still thinking there was a partial airway obstruction. Dave and Anne quickly hug Carrie, kiss her forehead and then watch as their precious little one is wheeled off to the OR. They meet up with Carrie again in the PICU where she is now on a ventilator with a central line, foley catheter and arterial line. All the tubes, the equipment, and Carrie lying in the middle of the big bed surrounded. The attending ENT MD who was in the OR with Carrie told them there was no airway obstruction and the thoughts then turn to something neurological causing this decreased LOC. So, in comes another specialist, a pediatric neurosurgeon. Off Carrie goes for MRI. Again Dave and Anne quickly kiss her foot (the only body part they can touch) and start to cry softly. Okay, finally a diagnosis: Chiari I malformation that acutely caused a massive stroke. Some relief that there is a diagnosis but then again, what's going to happen? Will Carrie wake up, what needs to be done to decompress the syrinx/Chiari? Will she be the same enthusiastic little chatterbox? So many questions, so many people: nurses, techs, pastoral care, doctors of all kinds. It's overwhelming! The first order of business: emergency brain surgery....oops did I forget to mention that Carrie's vocal cords are paralyzed and that was the reason she wasn't breathing right? So....more questions, more worry, more tears. Carrie comes out of the brain surgery after a compression laminectomy, remains intubated, sedated and paralyzed. Time drags on as more doctors, nurses, techs, and many students parade thru the room. Her BP is labile so she is now on pressor support. Then, she becomes febrile and is diagnosed with a UTI. The family arranges a schedule to always have someone with Carrie 24/7. Though they are trusting and grateful for the care that Carrie is receiving, they also know that she can't answer for herself. And...they don't want to miss any chance if Carrie's condition changes. Soon, two weeks have passed, her incision is healing well, the sedation is lessening and it's time to try to wake her up and see if her vocal cords have regained function. However, when they extubate her, she doesn't breathe on her own, so reintubation is necessary and plans are made for trach/PEG. Dave and Anne are beside themselves. They are told that Carrie will need home care, nurses and lots of equipment. It's so overwhelming! What to do, how to hire nurses? What about the space needed? Will Carrie ever be back to normal? Insurance coverage limits? Once the trach/PEG are placed, Carrie must then be sedated and paralyzed for yet another week so the trach heals. After this, Carrie is allowed to wake up. As she wakes up, there is much joy as she immediately recognizes her parents and other family members. She is not talking of course but is waving her arms and moving her legs too. By now a month has passed...a month in the PICU where it's always noisy, always bright and so many strangers coming in to touch and help Carrie. However, as a 2 y/o, she doesn't realize that sometimes these strangers have to hurt her in order to help her to get better. She becomes afebrile once again and blood cultures show bacteremia so the central line is dc'd as well as the foley catheter. A PICC line is inserted but within days it is noted that her arm is erythematous and ecchymotic. So, an ultrasound is ordered and unfortunately, she has a DVT. Anticoagulation is started and multiple peripheral IVs are placed. Over the next month, Carrie begins to recover, she starts to gain strength and she is eventually weaned from the ventilator. PT/OT/ST are all involved in her daily routine. She looks adorable using her baby-sized walker to parade down the hallway. The family starts to learn trach and PEG care and how to use all the equipment that Carrie is going to need to go home. Then...suddenly she is speaking. She is later taken back to the OR to have a detailed exam of her vocal cords and the family is greatly relieved that it shows they are moving again. Plans are made to downsize the trach and finally to decannulate. She must still go home with PEG tube and thickened liquids. At the conclusion of 2 ½ months, Carrie was deemed stable enough to go home. She would still need PEG tube feedings and therapy, but she was going home! However...this isn't the end of the story. The fallout from a prolonged PICU stayed with this family. It is now three years later. Carrie has required multiple MRIs to assess the syrinx. She has also had another surgery to place a shunt and had her PEG tube dc'd. At 5 years old, she is an old hand at all this medical stuff. She climbs right up on the table for MRI, lays quietly and does not require sedation. She skips into the neurosurgeon's office, gives him a hug and tells him thank you. Dave and Anne are still very keen on watching Carrie closely. They are hyper-vigilant if she gets a cold or ear infection. As a result of PICS though these are some of the effects of a prolonged PICU stay: Carrie is extremely comfortable with all the needed medical procedures - much moreso than what is developmentally appropriateShe is very aware of her trach scar and her "extra belly button" where her PEG residedDave and Anne have had the added stress of worrying about what will happen next. They lean on their faith and their families for supportThough the physical scars have faded, the emotional distress caused by these events never allow Anne and Dave to completely relax, though it has become easier as time passesSo, PICS is real - it can affect patients and their families in different ways. However, we as caregivers need to be aware that our actions, verbal exchanges and simply caring will always be remembered. Preventing PICS is a multi-focal process: Awakening and Breathing Coordination with daily sedative interruption and ventilator liberation practicesDelirium monitoring and managementEarly ambulation in the ICU, when feasibleTreatment consists of individualized plans focusing on the deficits associated with each patient. Educate yourself on the prevention and treatment of PICS so that damage is lessened. References: Post-ICU Syndrome
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AllNurses staff recently attended NTI in Houston, Texas. Andrea J Efre, DNP, ARNP, ANP-BC presented on the topic of medical marijuana. Medical marijuana is used to treat many conditions so it is reasonable to assume that many of us will come into contact with patients who use this. It is important to take this into consideration when caring for patients. Currently, 29 states have medical marijuana laws. According to the Pew Research Center, in 2015, 53% of Americans favor legalization while 77% approve of its use for medical reasons. Each state has their own procedure for issuing "pot cards." It is important that if you work with a population that uses medicinal marijuana that you are familiar with the procedure or can provide info to the patient who asks questions. The Center for Cannabis Research at the University of California, San Diego has an interesting site that provides a lot of evidence-based information regarding the efficacy of medical marijuana. They are in the process of several research studies regarding the use of medical marijuana in neuropathic low back pain, and HIV neuropathic pain. There has also been research into what disease processes can be helped with medical marijuana and these are just some diagnoses that have been approved by some states for the use of medical marijuana: AIDS/HIVArthritisEpilepsyAlzheimersNausea related to chemotherapyChronic painGlaucomaMultiple sclerosisAs you can see, this covers a wide range of patients. And as with any substance, you ingest while there positives, nurses have to consider drug interactions too. According to Mayo Clinic: An interesting drug interaction can occur between medical marijuana and birth control pills that contain estrogen. According to the Susan G. Komen Foundation: And then there are the ethical and legal concerns for nurses who might prescribe or administer medical marijuana. From Medscape: As with any drug, there can be side effects which may include: Nausea, vomitingDizzynessSyncopeFatigueFeelings of intoxicationBehavioral or mood changesAnxietyCognitive impairmentPsychosisParanoia and hallucinations may be exhibited by new usersThese side effects can increase also due to the original disease process which is being treated by the marijuana. For instance, in multiple sclerosis patients, who already have an increased risk of depression and anxiety, these feelings can be magnified. For patients with a cardiac history, marijuana possibly can cause tachycardia which may lead to an acute coronary syndrome (ACS). Studies that have looked at cardiac events for marijuana users are not definitive though as many also ingested tobacco products thus putting them at higher cardiac risk. There is a difference between the recreational use of marijuana and medical use. It is important to be aware of the uses, drug interactions and side effects of ALL the medication that your patient takes. References: 29 Legal Medical Marijuana States Center For Medicinal Cannabis Research Marijuana: Interactions with Drugs Medical Marijuana: A Primer on Ethics, Evidence and Politics Susan G Komen Foundation Ten Diseases Where Medical Marijuana Could Have Impact Why Americans Support Medical Marijuana
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Most of the time the patient recovers uneventfully. However, what happens when they don't? Would you know how to troubleshoot and care for the patient with complications from these commonly performed procedures? Some of the associated complications are retroperitoneal bleed, lacerated liver, perforated myocardium, and pneumothorax. AllNurses staff recently attended NTI in Houston, Texas. Cheryl D Herrmann, RN, APN, CCRN, CCNS-CSC-CMC facilitated a session about post-procedure complications. Cardiac Catheterization and Pacemaker Insertion Cardiac catheterization can be done for a variety of reasons but is most performed for chest pain evaluation. Pacemaker insertion also involves multiple disease processes from sick sinus syndrome to patients post-myocardial infarction (MI) to patients with congenital heart malformations. Some of the complications that can occur include: Bleeding from the insertion site Hematoma Perforated myocardium Allergic reaction to the contrast medium Death The risk of death is 0.1% per 200,000 procedures per UpToDate. The most common complication is bleeding, either acutely hemorrhagic which usually occurs in the first 12 hours or contained hemorrhage in the femoral region which might not be evident until days to weeks later. The perforated myocardium is one of the rarer complications. The risks are increased with the use of stiff catheters, including transseptal catheterization, endomyocardial biopsy, balloon valvuloplasty, needle pericardiocentesis, and placement of a pacing catheter. Cardiac perforation often results in bradycardia and hypotension due to stimulation of the vagus nerve. If the patient remains stable, an echo can be done. However, as these patients tend to go downhill quickly emergent pericardiocentesis should be performed via the subxiphoid approach. Nursing Care of the Patient with a Perforated Myocardium Most often these patients will be identified mid-procedure as once the myocardium is breached, the patient's blood pressure (BP) will fall and the patient will develop bradycardia. Nurses monitoring patients in the cath lab are on the forefront to note changes in BP and heart rate (HR). These patients will be transferred emergently to the operating room (OR) or if stable, may have echo while still in the cath lab. Nursing care will include: Close monitoring and documentation of baseline vitals, time of sedation, time of procedural start points as well as any concerns or issues during the procedure. Inform the surgeon of any discrepancies or changes in the patient's vitals or status If the patient is to be taken emergently to the OR, have another member of the team notify the family and move them to the appropriate waiting area. Chest Tube Insertion and Thoracentesis A thoracentesis can be either diagnostic - to find out what is causing the excess pleural fluid or diagnostic - to remove the excess pleural fluid. Sometimes a chest tube is inserted to drain the pleural cavity. Chest tube placement and/or thoracentesis can be done bedside, usually in an intensive care unit (ICU) or more commonly it is done in Interventional Radiology (IR) under sono-guided fluoroscopy. These procedures are usually accomplished with local anesthetic and sedation. In the ICU environment, the patient may be on ventilatory support. When doing a thoracentesis for diagnostic purposes, common tests performed on pleural fluid include cell count, protein, lactate dehydrogenase, pH, glucose, amylase, gram stain, culture, and cytology. The pleural fluid should be immediately placed in the appropriate specimen tubes and bottles, and then sent to the laboratory for analysis Common Complications associated with chest tube insertion or thoracentesis include: Pain at the puncture site Bleeding (eg, hematoma, hemothorax, or hemoperitoneum) Pneumothorax Empyema Soft tissue infection Spleen or liver puncture Central Line Removal The most serious complication that can result from central line removal is an air embolus. Key points to avoid air embolism when removing the central line: Place the patient in the supine position (they should not be sitting or upright) Instruct the patient to hold their breath and perform the Valsalva maneuver (forced expiration with the mouth closed) when the catheter is being removed If the patient is unable to cooperate with instructions, the catheter should be removed following inspiration Cover the insertion site immediately with sterile gauze, maintain firm manual pressure until hemostasis is achieved. Then cover the site with an air-occlusive dressing, which should remain in place for 24-72 hours. Procedures are not without risk of complication. It is important to have all the needed emergency equipment readily available to care for your patient during and after a procedure. References: Diagnostic Thoracentesis Myocardial Rupture Treatment and Management UpToDate, Complications of Diagnostic Heart Catheterization
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Nurse Blake has invented a nursing "onesie" called a Scromper. He demonstrated the versatility of the Scromper for the allnurses team at NTI. It is a useful and fun item with plenty of pockets, room to move and breathe and relax in! He has partnered with a US scrub company to produce the product. Made out of an ultra soft scrub material, it is available for men and women in sizes small, medium, large, and X-large. Although this would not meet dress codes for work, you can wear it anywhere else and rock it at parties, conferences, or even for Halloween. Nurse Blake launched a Kickstarter for the Scromper this week so everyone can have a chance at getting their very own Scromper at an affordable price while also helping to raise money for a great cause. Proceeds will go toward starting a nursing scholarship fund, because as Blake states, "I want to take this opportunity to give back to the field of nursing and I believe that helping the next generation of nurses is the best way to do that!" Get your Scromper today
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Monitoring the hemodynamics of your critically ill ICU is so important. Use of the Swan-Ganz pulmonary artery catheter is one of the ways to quickly assess the cardiac status of your patient, make interventions and improve their care. However, the monitoring systems for Swan lines aren't that intuitive. Until now, that is. Edwards Lifesciences has a new monitor, the HemoSphere advanced monitoring system, which was just recently approved for use in the US which is both intuitive and user-friendly. As an ICU nurse, your monitors are your pathway to your patient. Having a small, portable, easy to use monitor makes your shift just a little easier. This monitor has an interface similar to a tablet and can continuously assess flow, pressure and the global indicator of oxygen saturation (CCO, RVEF, RVEDV, SVO2). Allnurses staff recently attended NTI 2017 in Houston and spoke with the Edwards staff about the HemoSphere on the exhibition floor and got a demo of how intuitive and easy-to-use the HemoSphere is. Would you recommend this to your hospital?
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Hibiclens has been around for 30+ years. Many of us remember the Hibiclens teal-colored bottle that we had our patients wash with preoperatively. Hibiclens is a chlorhexidine gluconate (CHG) solution that reduces infection risk even after use. Reducing cross-contamination is also a concern - we all know we have more than one patient to care for in a shift. Convenience is the key to the HIBI Universal Bathing System. The HIBI Bathing Cloths are dry and untreated because it is firmly believed that soap should be washed and rinsed. The packaging of the cloths becomes a portable wash basin that contains dry cloths that you add warm water to and then bathe your patient using the Hibiclens foam product. This results in a bacteriocidal effect for 24 hours. The warmth of the cloth is comforting for your patient and the ease of the task is comforting for the nurse. Allnurses recently attended NTI 2017 in Houston and talked with a representative from Molnlycke Health - the company that produces Hibiclens. Have you used this product? What do you think?
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Capella University is a fully accredited university that offers RN to BSN and RN to MSN completion programs. Could furthering your education expand your career choices? Yes! More and more hospitals and facilities look to the BSN and MSN prepared nurses for management positions, leadership roles and educator positions. Capella offers their Flexpath programs which allows you to get your degree on a self-paced track. Shiftwork, family responsibilities, and just life sometimes dictate your educational path. Maybe one semester you CAN take two courses but then you might want to slow down the next semester. Flexpath offers the flexibility to work at your own pace. And if you would like to pursue a business degree, Capella offers that too. Combining a nursing degree with a business degree can lead to more opportunities too. It is very important for nurses to be aware of healthcare degree choices. Staff recently attended NTI in Houston and talked with a current student.
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The Merit Medical DualCap System was developed by two infusion nurses who understood the unavoidable shortfalls of the Joint Commission's "Scrub the Hub" protocol for preventing IV catheter-related bloodstream infections (CRBSI). CRBSIs are a serious healthcare problem which carries a 12 - 25% mortality rate and cost billions of dollars annually to treat. Many insurance companies and Medicare do not cover reimbursement as these are preventable. The DualCaps are designed to help prevent intraluminal contamination as well as cross-contamination from other devices. The DualCap System disinfects both the male luer connector at the end of the IV tubing and the needle-free valve in just 30 seconds and provides a physical barrier for up to 7 days. It contains 70% isopropyl alcohol (IPA). It comes in male or female ends for different types of needleless connectors. This is the only male connector that protects while it prevents the IPA from entering the line. We've all struggled with tiny connectors that either don't open when we wear gloves or fly off into some corner of the room once we get them released! The DualCap has a large surface area to grasp and smooth edges to prevent skin tears or irritation. Within 30 seconds of use, your line is protected. While at NTI, the allnurses team talked to some of the Merit Medical staff about the DualCap System and watched a demonstration of how quick and easy it is to use.
