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Topics About 'Patient Safety'.

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  1. Most of us have likely searched for a bargain on an internet forum, like eBay or Craigslist. But, what about costly medications that are necessary for your health? A new study, published this month on JAMA Online, shows just how difficult it is for some patients to afford medications for their chronic illnesses. Researchers found hundreds of ads that had been placed on Craigslist for insulin and asthma inhalers over a 12 day period in June 2019. What Sparked the Idea? Dr. Jennifer Goldstein, the lead study author with The Value Institute of ChristianaCare in Delaware, got the idea after reading a news article about someone buying medications on Craigslist. With her curiosity peaked, Dr. Goldstein performed a quick internet search and was surprised to find multiple listings for unregulated drug sales. Study Details The study looked at Craigslist ads, across all 50 U.S. states, over a 12-day period. Researchers found ads for insulin and albuterol inhalers in 240 cities in 31 states. Insulin was advertised with steep discounts, including one ad priced at $37, a fraction of the nearly $300 Humalog retail price. Insulin Price Hike According to the CDC, more than 100 million adults in the U.S. are diagnosed with diabetes or prediabetes. People with type 1 diabetes do not make insulin in the body and can’t survive without insulin injections. Those with type 2 diabetes do not make enough and face serious complications without the insulin they need. For diabetics, insulin is a life-saving medication that is becoming more difficult to afford. Here is a cost comparison of insulin types, for Q2 2019, according to GoodRx: Regular Insulins Novolin R- $93 per vial Humulin R- $185 per vial NPH Insulins $92 to $183 per vial Rapid Acting Insulins Generic lispro- $180 per vial Humalog- $322 per vial Long Acting Insulins Levemir- $397 per vial Lantus- $340 per vial Some people ration their insulin doses to make medication bills more affordable. This is a dangerous practice since uncontrolled glucose levels can increase the risk of infections, kidney and eye problems, amputations and even death. Asthma Inhalers Researchers found that asthma inhalers were actually more expensive to buy on Craigslist. An albuterol inhaler retailed at $25 and was sold on Craigslist for $44 on average. Researchers were unable to determine why they were sold for a higher price on Craigslist. Could It Be… Rescue inhalers are a lifeline for someone with chronic respiratory problems experiencing wheezing and shortness of breath? The decision to purchase inhalers illegally may be a decision based on issues surrounding access to healthcare services (cost, lack of transportation etc.). Perhaps some people choose this option because they are unable to access healthcare for a legitimate prescription. Motivation to Sell Researchers found that a sense of goodwill was one motivation for sellers to list medications on Craigslist. One seller said, “I have been blessed with an overabundance of insulin and know what it’s like to need it and not have a couple of hundred dollars to pay out of pocket”. Others were looking to make enough money to buy new medications after their doctor made changes to their current prescriptions. Just Not Safe Dr. Goldstein warns buying drugs through Craigslist “is just not a safe way to get medications”. Safety concerns include: Insulin that has not been kept in the refrigerator or used within a month after reaching room temperature Whether or not the insulin is sterile Whether or not the medication has been altered or tampered with It is illegal to sell prescription medications without a license It is illegal to purchase medications without a prescription Let Us Hear From You Dr. Goldstein warns that Craigslist is not the only online forum where medications are being sold. Is this a problem or emerging concerns in your area of practice? For More Information Unregulated Sales of Insulin Common on Craigslist Many People with Diabetes Can't Afford 'Good' Insulin. What They Should Know About Switching to the Cheaper Stuff
  2. At Westside Regional Medical Center in Plantation, Florida, ICU nurse Julie Griffin worked in the 12 bed cardiovascular ICU (CVICU.) Until she was fired for refusing to take a third patient. Westside Regional Medical Center is part of HCA Healthcare. HCA Healthcare is the largest for-profit hospital chain in the U.S., owning over 150 hospitals, and earning over 47 billion in 2018. Unmonitored Patients One of Julie's concerns for patient safety was that the in-room monitors provided for a split screen display. This allows for an ICU nurse to be in one of her patient's rooms, set the monitor for a 2-view display, and be able to monitor her second patient. The problem? It does not allow for a 3-way display. If the ICU nurse has 3 patients, one of those patients will not be monitored. In an interview with Hospital Watchdog, Julie Griffin explained that there is a standing order for all ICU patients to receive continuous monitoring, and nurses must electronically attest to the fact that the standard of care was met. HCA CVICU does not staff a qualified monitor tech at the nurses station where the central bank of patient monitors display. If all the nurses are away from the station providing patient care and an unmonitored patient goes into a lethal rhythm, there is no one to see it. An alarm would sound, but there are constant alarms in CVICU that compete for a nurse's attention. Alarms cannot be relied upon as a substitute for a nurse. Hospital Watchdog reports that 2 such unmonitored patients have died. Allegedly, one of the patients was discovered dead and may have been dead for up to 30 minutes. A family member went out to the nurses station to report that something was wrong. In the other case, allegedly the nurse was assigned 3 patients, was able to monitor only 2 of them, and the 3rd patient died of pulmonary problems, possible a pulmonary embolism (PE). Hospital Watchdog qualifies the above cases saying they are not substantiated with medical records or other documentation, they are reported by nurse Julie Griffin in an interview. Whistle-Blower Julie says all of her colleagues shared her concern about patient safety and lack of monitoring, but they were afraid to speak up. They needed to keep their jobs in order to support their families. Julie, previously in the Navy, believed in following the chain-of-command. She reported unsafe patient conditions to her charge nurses and manager. She believed that if corporate only knew about the practice, they would want to do the right thing and rectify the situation. Instead of rectifying the situation, nurses were frequently required to take 3, and sometimes 4, patients in the CVICU. Julie claims that untrained nurses were assigned ICU patients. Julie trusted there would not be retaliation if she complained. There was. Julie claims her Director intimidated her and at one point frightened Julie by getting physically close. Julie's schedule was changed to working every weekend. She felt harassed. Even the HR department at Westside acknowledged that the Director's actions were inappropriate. Even so, Julie was removed from duty within hours the day she refused to take a third patient. On the day she was terminated, Julie had 2 patients. One patient had orders for transfer out to the floor. One of the patients was a post-op open heart surgery, and was on a diuretic. Julie knew that a patient on a diuretic often has to urinate urgently, and was concerned that she needed to respond right away to make sure he didn't fall. Julie refused to accept the assignment of a 3rd patient. At 1700, The CVICU Director came to the unit and told Julie she had to take the 3rd patient. She again refused, was placed on investigative leave, and terminated 2 weeks later, in 2017. Julie had worked in HCA ICU since July 2016. Julie later filed 2 Florida Whistle-Blower complaints in 2018, and has filed a suit against HCA for unlawful termination. Julie's Director says that Julie was a disruptive staff member. Julie says that the standard of care required by HCA called for continuous monitoring of her patients, and she was unwilling to violate that standard. Right or Wrong? Should Julie have gone with the status quo and quietly accepted a 3rd patient, knowing that at least 1 of her patients was lower acuity? Or did she do the right thing? Is her reputation so damaged that she will have difficulty securing employment? Was she acting on principle or imminent patient endangerment? Does she have any chance of prevailing against HCA? Many of us have been in similar situations. What would you have done? Nurse Beth, Author, "Your Last Nursing Class: How to Land Your First Nursing Job"...and your next!
  3. traumaRUs

    Alarm Management Practice Alert

    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. Its 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. Here is the entire interview:
  4. Nurses care for vulnerable populations each day. Patients might be considered vulnerable because of economic, social, or political standings or because of an illness or disability. Regardless of the reason for the patient's vulnerability, it’s the nurse’s role to care for these patients with sensitivity, skill, and above all us - protection. Breaking Headlines If you’ve watched television in the past week or so, you probably saw a story about a nursing home patient who gave birth to a baby at the end of December. When this story first circulated, there were questions about the patient’s mental capacity and who might be the father. A few days after the initial coverage, a nurse, Nathan Sutherland, was arrested and charged with assault and abuse of a vulnerable adult. Sutherland cared for this patient in the nursing home and willingly took a DNA sample, which is allegedly a match with to the patient’s newborn baby boy. As this story unfolded, questions flooded the minds of people across the country. How does this happen in a facility where care providers are working around the clock? What systems failed to protect this patient? And, how can a patient in a long-term care facility deliver a full-term baby, but no one seems to know that she was even pregnant? The answers to these questions aren’t available yet. However, as nurses, it’s our duty to learn from these situations and consider what patients, family members, or loved ones might be susceptible to the same or similar behaviors at the hand of healthcare providers. Vulnerable Patients 101 Our healthcare culture might have us more concerned about reimbursement models, readmission rates, and patients with comorbid conditions over those who can’t speak up in the face of abuse, neglect, and general misconduct. Definitions of vulnerable patients vary based on organizations, locations, and use of the system. One population might be considered vulnerable in one setting, but doesn’t meet the definition in another. A few populations that are generally considered to be vulnerable include: People 60 years or older with physical, mental, or functional limitations in their ability to care for themselves Adults 18 years of age who: Are unable to make medical decisions and might have a guardian Live in a nursing facility, rehabilitation center, group home, or other facility licensed by a state Have developmental disabilities Receive in-home services such as hospice, home care, or individual providers Children under the age of 18 Making Sense of the Dichotomy At the end of 2018, nursing was selected as the most trusted profession again for the seventeenth consecutive year. Nursing has earned this designation because this is how the general public views nurses - trusted. Why are we so trusted? Nursing staff help bring babies into the world. Often nurses are there when the aged, ill, and injured take their last breaths. Imagine any significant life event in the middle of birth and death, and there is probably a nurse supporting, caring for, or educating patients, family, and other caregivers. Nurses speak up when patients have no voice. They fight for the wounded and underprivileged. Yet, this incident happened in a facility filled with nurses. How does this dichotomy live on the spectrum of nursing? I must admit - this story has been hard to understand. And, while it’s essential we remember that Mr. Sutherland hasn’t been found guilty at this time, this situation can make you lose a little faith in humanity. However, being an optimist (most of the time), I feel that this is an excellent time to review ways to keep vulnerable patients safe. Safeguarding Against Abuse and Neglect There are a few things all nurses caring for patients can do to ensure you’re keeping those entrusted into your care safe at all times. Learn the signs of abuse The symptoms of abuse are different depending on what’s happening. Having stellar assessment skills is one of the best ways to protect against any form of abuse. If you notice new bruises, injuries, burns, or a change in the patient’s reaction to care, this might be a sign that something out of the ordinary is happening. If patients are being neglected, you might notice weight loss or gain, poor dental and physical hygiene, and the presences of new pressure sores. When neglect is happening, patients may wear the same clothes for days at a time, even when they are torn or visibly soiled. You might also notice changes around food, such as begging or scarfing down food as though they haven’t eaten in quite some time. Speak Up If you suspect neglect or abuse of a patient, it’s your responsibility to speak up right away. If you’re in a facility, bring your concerns to your manager or the Director of Nursing. When caring for patients in the community, know your employer’s policies and when you should contact the police or other agencies such as adult protective services or children services. If you’ve ever had to file a report of suspected abuse or neglect, let us know about the situation in the comments below. Do you have other ways nurses can protect vulnerable patients from dangerous situations?
  5. As nurses, we are bound by our oath to give quality care to every single one of our patients. As we enhance the delivery of our healthcare practices with high tech, state of the art electronics and devices, alarms have been created to alert nurses of changes in the status of our patients. Although these alarms are quite loud and would normally elicit a concerned response, in an already overwhelming and chaotic work environment, those extra noises may have a less than desirable effect when it comes to patient safety. What is the Issue? RING! BEEP! DING! BING! These are the sounds of a typical busy nursing unit. Though alarming (no pun intended) to someone less familiar with this environment, it becomes background noise to experienced nursing staff. Since it's easy for nursing staff to be overwhelmed, distracted, and even desensitized to the alarms around them, they begin to experience what is called "alarm fatigue". They respond by ignoring the alarm, turning down the volume of the alarm, turning off the alarm completely, or adjusting the alarm settings outside the limits that are considered to be safe and appropriate for the patient. All these can have serious, and sometimes fatal consequences. The US Food and Drug Administration has reported over 500 alarm-related patient deaths in the last five years. According to The Joint Commission, "In 2013, a 60-year-old man died in an intensive care unit of a hospital-not from the injury he suffered to his head from a fallen tree branch-but from a delayed response to an alarm signal that indicated significant changes in his condition." Also, from my own personal experience, I'm often surprised when I work at the bedside how few nursing staff react to the sound of a bed alarm or telemetry monitor alarm. Perhaps I react more assertively to the bells and whistles because I only work at the bedside part-time, but regardless of that fact, I still find myself taken back by the observed lack of urgency from the staff around me when patient care alarms are ringing. What causes alarm fatigue? First, let's point out the fact that it is quite difficult to differentiate between all the sounds going on in a nursing unit. Many medical devices in healthcare centers have alarms that sound similar. Bedside monitors (including electrocardiogram or ECG machines), pulse oximetry devices, blood pressure machines, telemetry monitors, central station monitors, infusion pumps, hospital beds and ventilators all have similar "beeping" sounds that may alarm continuously regardless of a change in a patient's status. Also, it is nearly impossible for nurses to attend to every alarm sounded. Research shows that the number of alarm sounds per shift can reach up to 1,000 depending on the type of unit. Of those alarm sounds, the majority of them are shown to be non-emergent, usually relating to electrode misplacement, or settings being too tight for the patient's status. What can be done? The Joint Commission has required that all healthcare facilities implement comprehensive policy reform regarding alarm fatigue and that they set strict guidelines for appropriate clinician responsiveness to alarms. Here are some of the plans already in progress: Improved clinician education - The American Association of Critical Care Nurses mandates initial and ongoing education related to patient care equipment and alarm response. This education includes proper technique for application of devices, alarm settings, and policies regarding appropriate response times and required documentation. Prevention of over-prescribing alarm producing monitoring equipment - The National Association of Clinical Nurse Specialists recommends that nursing take a collaborative approach at assessing the clinical indications for patient monitoring equipment, such as telemetry or continuous pulse oximetry when it is ordered by a care provider. In some instances, a patient with nausea and vomiting will be ordered for telemetry, although they do not meet criteria for a heart monitor during their inpatient stay. This should be discussed with the covering physician to determine need, thus possibly reducing the incidence of alarm fatigue. Advocate for Peer Accountability - It is recommended that we speak with our colleagues at regular intervals regarding observed evidence of alarm fatigue. If you see other nursing staff sitting near a monitor that is alarming, remind them that it is our responsibility to continuously monitor the patients, and that includes responding to all the bells and whistles. You'd be surprised on how many nurses claim that they didn't even hear the alarm going off, and by redirecting their attention to the severity of not hearing them, they become more vigilant in listening for and responding to the alarms. As we push forward in working hard to correct the alarm fatigue within our healthcare facilities, I am confident that our devotion to upholding the highest standards for patient safety will lend itself to creating positive change for all. For articles in this series, go to: Inadequate Staffing: Patient Safety in Today's Healthcare Marketplace Inadequate Nursing: Patient Safety in Today's Healthcare Marketplace Alarm Fatigue: Patient Safety in Today's Healthcare Marketplace Compassion Fatigue: Patient Safety in Today's Healthcare Marketplace
  6. "We are short again today" - A daily phrase used by nursing staff that summarizes the consistent inadequate nursing staff ratios that healthcare facilities seem to continue to support. Inadequate nursing staffing ratios greatly diminish the likelihood of achieving positive patient health outcomes, as well as significantly decreases nursing staff job satisfaction and retention across our nation. Having an upwards of eight or more patients per Registered Nurse, and 15 or more patients per Nursing Assistant in an acute healthcare setting, such as a hospital, has been the norm for far too long now. As our healthcare marketplace expands and becomes more demanding of nursing staff by offering more treatment options, more medications, more technology, longer working hours, more complex patient illnesses, more computerized documentation, etc., healthcare facility staffing procedures should be reconfigured to include more nursing staff resources, rather than remaining unsafe. According to an article posted in The American Nurse - an official publication of the American Nurses Association, when it comes to achieving high standards of care, optimal patient outcomes and institutional financial growth, adequate nursing staffing ratios should be considered as a necessity. Unfortunately, many healthcare facilities have not set standards for adequate nursing staff ratios. Instead, they continue to base their nursing staff to patient ratios off of a grid that only reflects patient body count - not taking into consideration RN experience levels, patient acuity, or available resources. In a nursing led effort to provide adequate nursing staff ratios across our country, the American Nurses Association, each individual State's Nursing Association, and Nurses Take DC, have introduced Bills to improve staffing in a variety of care settings. The ANA proposed The Safe Staffing for Nurse and Patient Safety Act (S. 2446, H.R. 5052) to the House and Senate for consideration. According to the American Nurses Association (2018), this proposed legislation would require Medicare-participating hospitals to create a committee, composed of at least 55% direct care nurses, to develop nurse staffing plans that are specific to each patient care unit. The idea of having these committees is to utilize the expertise of the direct care nurses, who are best equipped to determine the adequate staffing levels to safely meet the needs of their patients. For example, many charge nurses get report from the bedside nurses regarding how much care their patients need. Someone who is completely bed bound, incontinent, has multiple wounds, IV lines, oxygen, and may be confused, would require the assistance of three nursing staff members. This could be a combination of nurses and nursing assistants. The unfortunate reality is that the charge nurse currently collects this information so that they do not assign five of these high acuity patients to the same nurse. Instead of getting additional nursing staff to help with the increased acuity, they try their best to split up the acuity among the nurses and nursing assistants - which rarely works in regards to maintaining adequate and safe nursing staff ratios. However, if the charge nurse were able to bring on an additional nurse, or nursing assistant to help manage the increased acuity, then patient safety and nursing staff job satisfaction would improve significantly. The ANA states that to date, seven states have enacted nursing staff ratios legislation that closely resembles the American Nurses Association's recommended approach to ensure safe staffing, by utilizing hospital-wide staffing committees, where direct care nurses have a voice in creating appropriate staffing levels. A total of 14 states have implemented laws that address nursing staffing ratios. These states include: CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT and WA. For more information on these efforts, you can visit the Nurse Staffing page on the American Nurses Association website. Nurses Take DC have proposed the RN Ratio Bill S. 1063/HR 2392, which goes further by mandating that each nursing speciality has their own mandated patient to nurse ratio, and places great consideration on other staffing issues such as mandatory overtime, averaging, video monitoring, and keeping nursing administration, such as charge nurses, out of the direct patient care staffing numbers. To see a side by side comparison of the differences among the ANA's Bill and the Nurses Take DC Bill, you can click here. As of this very moment the fight for adequate nursing staff ratios continues. With all of our continued dedication and service to improving nursing care and standards of practice, I am certain that we will prevail in obtaining legislation for adequate nursing staff ratios. For articles in this series, go to: Inadequate Staffing: Patient Safety in Today's Healthcare Marketplace Inadequate Nursing: Patient Safety in Today's Healthcare Marketplace Alarm Fatigue: Patient Safety in Today's Healthcare Marketplace Compassion Fatigue: Patient Safety in Today's Healthcare Marketplace
  7. As nurses, we are bound by our oath to provide quality care for every patient. This means holding hospitals and other healthcare facilities accountable for sufficient numbers of experienced nurses to ensure patient safety and support inexperienced nurses. Unfortunately, this is often not the case. WHAT'S THE ISSUE? "I don't know how to do that" is something that experienced nurses are hearing more often from new hires, float pool and travel nurses. To their surprise, hospitals and staffing agencies are employing nurses with less than two years of experience more often than those who are more seasoned. In fact, some nursing units have up to 75% under-qualified nurses, which pose many patient safety concerns for two main reasons: 1 ) Less experienced nurses do not possess the nursing skills needed to handle the physical, mental and emotional demands of the job. Not even the best nursing programs can take the place of real-life, practical experience. Without the opportunity to gain real-life, practical experience before beginning a new nursing position, new hires often feel "thrown to the wolves", and this poses a major issue for retention and job satisfaction. 2 ) Burnout rates are increasing among more nurses. As the overwhelming need for training, coaching, and mentoring consumes much of the time and energy of the bedside nursing staff, seasoned bedside nurses are forced to take on a greater workload for insulting pay rates and a lack of additional incentive. At the same time, new hires who are in desperate need training and mentorship are finding themselves abandoned and without skilled guidance. According to The American Nurse, "Research indicates that staffing numbers alone don't always tell the whole story or assure positive outcomes for patients in the absence of other considerations. Other factors related to staff expertise, including RN education level, employment status and skill mix, as well as collegiality of nurse-physician relations exert a positive impact on select patient outcomes, such as 30-day mortality and hospital readmission rates." The Joint Commision echoes these concerns: "Nurses are the front line of patient surveillance-monitoring patients' conditions, detecting problems, ready for rescue. Spread too thinly or lacking the appropriate skill set, the nurse is at risk of missing early signs of a problem, or missing the problem altogether." WHAT'S THE CAUSE? There are several contributing factors that lead to nursing staff with inadequate nursing skills. One major factor is that hospitals continue to have strict budget constraints, which creates freezes on nurse salary increases, and low starting pay rates. Without room for growth, in terms of opportunity to learn new skill sets, and higher pay, more experienced nurses might look for work elsewhere. This results in increased job vacancies which are soon to be filled by lower paid, inexperienced nurses. Another potential cause is poor efforts by facility administration to improve nurse retention. Without innovative nurse retention efforts, high staff turnover rates will continue to plague these facilities. If experienced nurses don't feel valued by an institution, they are less likely to stay at that particular job. In a recent article that highlights nurse retention efforts, it was stated that the average hospital loses $5.2 million to $8.1 million due to RN turnover, and each percent change in RN turnover costs or saves a hospital an additional $373,200. So why wouldn't hospitals be on board with improving retention efforts? The bottom line is that nurses report that low job satisfaction is primarily related to heavy workloads, an inability to ensure patient safety, and insulting salaries. WHAT ARE WE DOING ABOUT IT? Many national healthcare efforts are in the works to enhance nurse retention programs and increase salaries and incentives for their nursing staff. Here are a couple solutions already in progress: The Nurse Residency Program. To enhance nurse retention, many institutions have begun implementing nurse residency programs. Research shows that nurse residency programs are an essential strategy to retain new grad nurses. These programs are significantly longer than traditional orientation programs , which can range from 6-12 months or more, and involve much more mentorship and guidance from experienced nurses. Unlike the two day travel nurse orientation, or the two week new hire orientations that most facilities currently provide, they cover in-depth training that focuses on strong connections among workplace colleagues and work-life balance. It is also shown that other studies that focus on skill mix provide strong evidence that when nursing staff members do not have adequate time or training to carry out their work, patient safety and patient outcomes are put at risk. Understanding this fact by all parties involved in making staffing decisions is critical to assuring the effective, safe and reliable delivery of nursing care. Nursing wage and incentive increases. The American Nurses Association has created a Bill of Rights, which states nurses have the right to fair compensation for their work, that is consistent with their educational preparedness, knowledge, experience and professional duties. As a result, many nursing leaders have begun research initiatives to prove that higher salaries for nursing will result in better outcomes for everyone. According to an article published by NCBI, staff of direct patient care nursing roles in hospitals and nursing homes have reported dissatisfaction with wages, as well as non-wage benefits such as: health care, tuition reimbursement, and retirement benefits. Wage rates and distribution should match nursing staff skill levels to encourage entry into the profession and retention within the institution. Competitive wages, combined with good benefits will recruit adequate numbers of nurses to meet the ongoing care demands of the upcoming decades and prevent cyclical shortages that have defined the past half-century. As a result of such healthcare initiatives, you may find salaries and bonuses for nurses to be back on the rise as hospitals strive to attract more longevity within their nursing staff. As we push forward in working hard to correct the disproportionate nursing skills within our healthcare facilities, I am confident that our devotion to upholding the highest standards for patient safety will lend itself to creating positive change for all. For articles in this series, go to: Inadequate Staffing: Patient Safety in Today's Healthcare Marketplace Inadequate Nursing: Patient Safety in Today's Healthcare Marketplace Alarm Fatigue: Patient Safety in Today's Healthcare Marketplace Compassion Fatigue: Patient Safety in Today's Healthcare Marketplace
  8. According to a study published in The Online Journal of Issues in Nursing, compassion fatigue has been defined as a combination of physical, emotional, and spiritual depletion associated with caring for patients in significant emotional pain and physical distress. In a more recent study, compassion fatigue is defined as a cumulative and progressive absorption process of patient's pain and suffering formed from the caring interactions with patients and their families. The physical, emotional, spiritual, social and organizational consequences of compassion fatigue are so extensive that they threaten the existential integrity of the nurse. Such consequences include, but are not limited to: decreased level of job satisfaction, decreased productivity, increased rates of absenteeism, burnout, turnover, stress, insomnia, nightmares, headaches, gastrointestinal complaints, anxiety and depression. What's the issue? When healthcare providers such as nurses become depleted of their ability to effectively cope with the amount of stress that is placed upon them in their daily practice, patient care and safety decline dramatically. When a nurse suffers from compassion fatigue, it does not mean that they no longer want to care for others. Compassion fatigue is not simply a lack of willingness to care, but it is a major barrier to providing compassionate care. Consider that you are a nurse on a busy acute care unit, and it is going on 4 o'clock in the afternoon. You have been at the hospital since 6:45 in the morning and you have not stopped patient care once to drink water, eat anything, or use the restroom. While your very own basic needs are not being met, you are doing your best to provide compassionate care to your patients and their family members. Some of your patients are easy going, and only need a few medications and treatments, while more than half of your patients are very sick, emotionally unstable, and require lots of your time. You have so many things to do - documentation, wound care, and discharge teaching, but you can't think straight. You're beginning to have an internal conflict, where you are trying to decide what's more important at this moment, drinking water so you don't pass out, or using the restroom so you don't have an accident. Now you're distracted. You are no longer focusing on the patient's status, as you are consumed by your own internal conflict. While you are deciding that using the restroom takes priority, your patient comes into the hallway and yells "NURSE! I need my pain medication!". Your colleagues look at you like you are crazy for not giving the patient their pain medication. Then suddenly you feel a little bit of urine trickle down your leg, and you think to yourself "I just can't even right now." It is only a matter of time before situations like this will cause an extremely compassionate nurse to turn their backs on caring - and not caring is the most dangerous thing a nurse can do! What can be done? Although the risk of compassion fatigue is inherent in helping others who have experienced illness, loss & trauma, experts and research in this area provide some guidelines for managing the demands of the work while protecting ourselves. Here are 5 strategies that we can safeguard ourselves against compassion fatigue: Practice self-care. Self-care includes activities, rituals and routines that help to promote individual holistic wellness. Some examples of self-care include: Getting plenty of rest and relaxation Getting plenty of exercise and physical activity Participating in prayer or spiritual ritual Consuming a healthy diet Surrounding yourself with people who love and support you Set emotional boundaries. Providing care for patients who are healing requires empathy and emotional involvement on the part of the caregiver. These qualities of care providers are what makes such interactions so supportive and meaningful, but they can also become overwhelming if we become too involved. It is essential to establish boundaries with our patients so that we do not assume their pain and experiences as our own. The challenge is to demonstrate compassion while being mindful that we are different people with different needs. This awareness can help to secure the space that exists between the care provider and the person receiving the care, which helps the provider to justify putting their basic needs and safety before that of the patient's. Build a strong support network. Research shows a strong correlation between high levels of work stress and the prevalence of compassion fatigue. As a result, It is vital to develop an organizational culture that normalizes grief and other reactions that we may experience while working with those who are ill, rather than assuming that negative reactions are a sign of individual weakness or an inability to fulfill the responsibilities of the caregiver role. Cultivating this kind of work environment can be very helpful in acclimating new staff as well as retaining and supporting existing staff. Use active coping measures. All of us have our usual ways of coping with stress or difficult situations. Which coping strategy we choose to utilize appears to make a huge difference in managing our stress levels. Studies have shown that using active coping strategies such as humor, social support, taking charge, and planning your time and schedule are more effective than negative or avoidant coping strategies. Choosing to cope by engaging in substance abuse, withdrawing from others and activities, or by using acts of aggression do nothing but exacerbate stress levels and can put your patients and your professional license in jeopardy. Maintain a balance. Managing the impact of caregiver role strain and stress requires a daily and ongoing commitment to self well-being. It is easy to remain in the tunnel vision of "caring for others", and I know it can feel impossible to take time out for ourselves so that we can be refueled and replenished. Just remember that holistic self-wellness is NEVER selfish. By upholding the commitment to care for ourselves first will provide us with a fresh perspective and restored energy. By taking care of ourselves as we care for others, we are protecting our valuable personal assets that support us in delivering high-quality care for our patients, their family, and our community. Have you ever experienced compassion fatigue? Have you witnessed a colleague display behaviors that may suggest that they are struggling from compassion fatigue? If so, please feel free to share your experiences in the comments section below! For articles in this series, go to: Inadequate Staffing: Patient Safety in Today's Healthcare Marketplace Inadequate Nursing: Patient Safety in Today's Healthcare Marketplace Alarm Fatigue: Patient Safety in Today's Healthcare Marketplace Compassion Fatigue: Patient Safety in Today's Healthcare Marketplace
  9. Nurses all over the country have united in protest against the comments made about nurses on The View. One single act has managed to unite many despite the inter-nursing battles of different specialties, RN versus LPN, and varying entry-level degrees. It's great to see nurses unite, but can we keep that momentum going to effect change in patient care? Yes, ignorance of the role of the nurse is common within the population. It just so happened that some of those expressed their lack of knowledge on public television to quite a large crowd. Perhaps this will give nursing the visibility and opportunity to educate the public as to our role in health care. But there are many other issues plaguing nursing that, in my opinion, are much more crucial in providing safe, effective patient care. Staffing ratios To date, only California has managed to pass legislation mandating nurse: patient ratios. We need to look to our legislators and put the pressure on them to start introducing bills reflecting safe, doable ratios. Lack of uninterrupted breaks We all need the opportunity to recharge during a shift, get nourishment, and empty that overfilled bladder. But how often does it happen that while on an unpaid break the phone rings or the pager goes off, and that break gets interrupted? Mandatory overtime How safe is it to force someone to work more than their scheduled shift because of a lack of adequate staff? The longer one nurse works, the more likely it is that he or she will be tired and prone to mistakes. We deal with people's lives where mistakes can mean serious harm or even death. Lack of adequate functional equipment How often do we have to run around the unit looking for that one piece of some type of equipment that actually works? How often are we borrowing from other units? How closely do we guard that computer on wheels we managed to claim at the beginning of the shift? Why are the powers that be not providing what we need? Potential for injury How many facilities offer enough lifting equipment and manpower to move patients without risk of injury to the staff or the patient? What about violence from patients, visitors, and even other staff members? There are not enough states with laws on the books specifically to protect nurses and other healthcare staff. Focus on customer service Nurses are not customer service representatives. We are knowledgeable healthcare professionals responsible for the care of patients to return them to their optimum level of health. Scripting, patient satisfaction scores, and a focus on "the customer is right" idea lead to actual healthcare coming in a distant second to keeping patients happy. So where do we go from here? How many of us are members of organizations that are pushing for such changes? Many state nursing associations as well as specialty organizations have sections on their web pages addressing such issues, with ideas of how to fix them. National Nurses United (again, personal opinion) appears to be much more in touch with the issues of the bedside nurse than another national organization. What can we do to continue being #nursesunited and push for the necessary changes? I will admit that one thing that turns me off of some nursing organizations is the political spin and endorsements, but is that really as important as working to improve nursing? Can this sudden unity over something that may be insulting yet not very significant in the day-to-day life of a working nurse continue?
  10. The medical record is a permanent collection of legal documents that should supply an all-encompassing, accurate report concerning a patient's health condition. Physicians, nurses, social workers, dieticians, mid-level providers and other members of the interdisciplinary team contribute to each patient's medical record to paint a comprehensive picture of the patient's status along with any care that has been rendered. The patient's chart needs to contain enough pertinent data to enable each member of the healthcare team to render care in an integrated manner. Most nurses have probably heard the old adage, "If it was not charted, it was not done!" However, some types of documentation should not be entered onto the patient's medical record for various reasons. Since the chart is a permanent record that is subject to entrance in court-ordered legal actions, nurses and other healthcare professionals must exercise extreme caution when documenting. The following is a very general list of the notations that nurses should not document in the chart. Never document nursing care before it is provided Nursing staff should never chart assessments, medication administration or treatments prior to actually completing the tasks because this may contribute to an inaccurate record filled with incorrect data. If the medical record contains nursing care that was never performed, this is fraudulent in some cases. Always remember that other clinicians may depend on correct documentation to assist in formulating decisions regarding patient care. Do not routinely document care rendered by others It is allowable in several instances to document care, tasks or procedures performed by another individual. However, the documentation in the medical record must clearly indicate the individual who actually rendered the care. If the house nursing supervisor applied the four point restraints, be sure to identify him/her as the person who carried out the task. But do not regularly chart actions that have been performed by other people. If a coworker or super-ordinate does something incorrectly that results in patient injury or death, you do not want culpability. Never leave blank spaces between entries In this day and age of prevalent electronic medical records, some facilities and healthcare settings still utilize paper charting. Nurses who still use paper and pen to chart must never leave blank spaces between entries. These unused spaces might be used by others to add questionable notations, so always be sure to draw a line across blank areas. Do not chart that a patient is in pain unless you have intervened No prudent nurse would even think of documenting "Patient complains of radiating chest pain," without subsequently documenting what was done about the issue. Thoroughly chart all notifications, interventions and actions taken to avoid liability. Do not record another patient's name in the medical record Let's assume that Mr. Wright gets into a physical altercation with his roommate, Mr. Robinson. The nurse is violating Mr. Robinson's confidentiality if she documents his name anywhere in Mr. Wright's medical record, and vise versa. To get around this issue, employ a vague description such as 'the roommate' or the 'patient in bed A.' Whenever possible, do not document subjective descriptions Attempt to refrain from charting subjective descriptions such as "Patient's blood pressure is really high." Obtain accurate vital sign checks, intakes and outputs, and other objectively measurable data and record this information in a timely manner. Do not openly criticize the care that was rendered by a coworker The medical record is a group of documents that should provide a comprehensive view of the patient's condition. Conversely, the medical record is not appropriate for criticizing care performed by other members of the healthcare team. Berating a fellow nurse, nursing assistant or technician in the nurses notes will accomplish nothing other than perhaps fuel the fire of state surveyors, malpractice attorneys and anyone who happens to read the chart at a later date. Do not mention short-staffing in the medical record Documenting the existence of staffing issues in the medical record rarely, if ever, helps to increase the number of staff members. On the other hand, medical malpractice lawyers love reading nurses' notes that provide details about a facility's lack of staff. Do not make insulting references to patients while charting Try to avoid referring to patients as 'drug seekers,' 'rude,' 'vulgar,' 'profane,' or 'crazy' when documenting. Utilize objective phrases and direct quotes whenever possible such as 'Patient states to this writer, "You are a ___ (B-Word) and I will kill you!"' Do not ever document the existence of incident reports Never document the preparation of an incident report in the nurses notes. The incident report is an internal document meant to facilitate improvement of systems and processes within the healthcare facility. If a nurse charts a note describing that an incident report was completed, this internal form now becomes subject to discovery by external medical malpractice lawyers if legal action were to arise at a future time. More Tips For Charting... nurses-notes-guidelines-on-what-not-to-chart.pdf
  11. Most people working in hospital understand the impact of the hospital environment on the patient experience. There is evidence that good environments can have a therapeutic effect on patients. But what constitutes a good environment? The mind, body, and spirit are always striving to maintain resonance with the environment. If that environment is unbalanced or superficial it will use up its energy in maintaining its life force. This is why many people are sick and/or tired most of the time. On the other hand, where the environment is balanced and in harmony with nature, little energy is needed to maintain the body in health. People have different needs in different spaces. Studies clearly show that a whole range of environmental factors including lighting, color, aroma, views, art, scale, proportion, sound, texture and materials - have a powerful healing and therapeutic effect on patients. We perceive our environment through our five senses: sight, smell, touch, taste, and hearing. The information we pick up from our senses is relayed to the brain which, in turn, will affect our physiological, emotional, psychological and, ultimately, physical condition. Healing environment leads to faster patient recoveries, reduced pain, fewer cases of infection, greater patient satisfaction and reduced stress level among staff. Upcoming paragraphs would reveal the role of each sense in leading towards better healing. Light: Some things that are easy on the eye can relax and reassure us. Other things may be more stimulating. Interesting views, natural light, works of art, and the use of particular colors can all make us feel better. Light and color are the two aspects of sight that have the greatest impact on a patients overall wellbeing. Our overall environment has a tremendous effect on the way we feel. Natural light, pleasant views, work of art and particular colors can all enhance our sense of wellbeing. The therapeutic value of light has been recognized for thousands of years. If you spend less than three hours outside every day it will help to revitalize your energy and the effect of light on health is really very critical. Second, only to fresh air should be inclined to rank light in importance for the sick. Direct sunlight, not only daylight, is necessary for a speedy recovery Florence Nightingale, 1860. In the more recent past, hospitals had large windows to allow light to penetrate, beds were pushed out onto balconies and terraces and solariums were used as healing environments. With little or no natural light, melatonin, a hormone that depresses mental function tells the body to log off and even causes illness such as seasonal affective disorder (SAD). The diurnal cycle of night and day and the spectral properties of light are essential to the regulation of stress and fatigue, as well as a range of physiological functions. Light is the most important environmental input, after food, in controlling bodily functions. Richard Wurtman, Neuroscientist. The quality and quantity of natural or artificial light have a major impact on the body's healing processes. Careful attention to this factor alone may help to reduce the length of stay for inpatients. Other benefits of full spectrum lighting include; better visual acuity, improved motor skills, less physiological fatigue, overall improved tasks performance, and vitamin D synthesis. Artificial light is often deficient in certain wavelengths compared to natural light. This can cause depression, moodiness, and cravings for carbohydrates and even raise systolic blood pressure. Artificial lighting must mimic natural light as closely as possible inpatient areas. It must enable changes to the patient's skin tone and color to be clearly defined and easily identified underdiagnosis. Particular attention should be paid to the lighting at the bed head and inpatient examination, treatment, and recovery areas. Designers should develop high-quality lighting schemes in public and ward areas that create a non-threatening and relaxing environment. Indirect lighting should be used extensively. Designers should avoid equally spaced light fittings along corridors and hospital streets, as this may have a stroboscopic effect on patients moving along a corridor on a trolley or in a bed. A reflected, diffused light is a better option. Lights should not be mounted on ceilings immediately above patients in incubators, cots, beds, trolleys or couches. Lights should be designed to reflect off walls and ceilings. Where appropriate lighting should be dimmer controlled. Color: color is an extremely powerful, and potentially inexpensive, medium. Appropriate use of color within healthcare settings can make a significant contribution to patients' well being. Certain colors can trigger certain reactions and influence people's moods: Certain colors slow our perception of time and others accelerate it. For example: Specific reds can induce epileptic fits. Other reds can reduce pain caused by rheumatism and arthritis. Blues can subdue aggressive patients in accident and emergency departments. Yellows in patients bedrooms can be detrimental to REM sleep. Orange creates a feeling of wellbeing in social and dining areas. Patients recover faster when they have pleasant and interesting views of the outside world. It is desirable that all patients' bedrooms, wards, and patient areas have outside views. Internal areas can also be enhanced with murals and artwork. Internal plant scapes can be used to create an outside-inside experience. I have seen in fevers, the most acute suffering produced from the patient (in a hut), not being able to see out of the window and the knots in the wood being the only view. I shall never forget the rapture of fever-patients over a bunch of bright-colored flowers. Florence Nightingale, 1860. Prolonged exposure to natural views not only helps to calm patients but can also have positive effects on other health outcomes and shorten recovery periods. Ulrich, Lunon & Eldridge, 1993. Gardens in healthcare facilities tend to alleviate stress effectively if they contain green or relatively verdant foliage, flowers, non-turbulent water, park-like qualities (grassy spaces with scattered trees). Barnes & Ulrich, 1999. The arts can enrich the healthcare environment. They help to reduce patients' stress levels by offering visual stimulation and distracting them from their health problems. One form of healing art is visual art that may be expressed in many forms such as painting, murals, prints, photographs, sculptures, decorative tile, ceramic, textile hanging, and furniture. Art can celebrate life, allay patients' fears and anxieties, amuse, encourage, educate and indeed distract for long periods of time. Artwork images should impart and evoke messages of hope, joy, love, dignity, peace, tranquility, energy, comfort, security, safety, growth and life. Works of art can be used as landmarks for wayfinding in hospitals in the form of icons, sculptures, and water features. Another form of the art is the performing arts have a better effect on patients than visual arts (P. Scher and P. Senior, The Exeter Evaluation, 1999). This form of art includes puppetry, musicians, clowns, opera, dancing, storytelling, poetry reading, and singing. In addition to that, participatory play a key role in the healing process of long-term inpatients in many healthcare departments, from pediatrics to mental illness. Patients take part in interactive activities, which may involve relatives, friends, artists in residence and staff. Smell: Hospitals are remembered with their medicinal smell that increases our anxiety. What if it changes to pleasant smell, which is known to lower our blood pressure and heart rate. Our sense of smell reaches more directly into our memory and emotions than the other senses. The days before hi-tech medicine, physicians and nurses depended on all their senses, including their sense of smell, to diagnose illness. We are told typhoid smelled like baking bread and yellow fever like a butchers shop. A surgeon on his rounds would smell a patients bandage for infection by Pseudomonas bacteria. Apparently, it has the musty odor of a wine cellar. Some research has shown that olfactory message reaches the brain faster than auditory or visual ones. Research has demonstrated that floral and fruit fragrances slow respiration, lower blood pressure and heart rate, and relax muscles. Fragrances may also reduce pain by encouraging the release of endorphins, one of the body's most powerful painkilling hormones; if they are able to relax people, then they can enable them to focus on other matters. Research indicates that this aroma is de-stressing in its own right. In hospitals, medicinal smells can produce anxiety. Unpleasant odors increase heart rate and respiration. It is widely believed that sensitivity to smell increases during pregnancy. Most pregnant women experience an increased sensitivity to all odors, usually with unpleasant consequences. Sprays and aerosols should be avoided to ensure that susceptible patients do not suffer allergic, asthmatic responses. Bacteria metabolizing secretions from various skin glands produce body odors. Touch: Touch is the basic mechanism of exploring world during infancy. Touch confirms what they see, smell, taste and hear. Touch is known as the confirmatory sense. By touching, we confirm what we pick up from our other senses that are what we see, hear, smell or taste. The skin is the largest sensory organ. In nursing, we use therapeutic touch as a method in which the hands are used to "direct human energies to help or heal someone who is ill. Touch is particularly important with visual impairments. Tactile floor and wall surfaces can be used to convey important information about their environment. Changes in texture can also warn of potential hazards or provide directional information. Children need tactile experience to develop their sensory receptors. Where possible designers should introduce textured surfaces, which can form an integral part of a child's play and learning process. This is a useful tool for a child's developing sensory receptors. Placing controls for nurse call, lighting, telephone, television, and radio within easy reach of a patient enhances self-reliance and increases patient safety. In multi-bed rooms, each patient should have equal access to controls for items such as windows, blinds, curtains, and television. An environment scaled for young children and elderly or disabled people will enhance their sense of independence. Very careful attention should be paid to the detailing of furniture and fittings. The design should minimize the risk of users trapping their fingers and toes etc. Where possible sharp corners should be avoided and redesigned to prevent predictable injury. All domestic hot water should be delivered to sanitary fittings at safe temperatures. Furniture that cant be moved may cause patients to feel stressed or anxious and may contribute to a patients sense of helplessness and dependence. It also creates an extra burden for staff. Fixed tables and chairs should be avoided where possible. Taste: both illness and medication can alter our sense of taste, and our ability to identify flavors becomes less acute as we grow older. Taste and smell are closely linked: two-thirds of the capacity to taste depends on the ability to smell. Research has shown that children are born with a desire for sweet tastes. Children will generally explore their environments using all senses including the sense of taste. Offering high-quality food and drink in hospitals will not only help to ensure an adequate nutritional intake among patients but will enhance their overall sense of wellbeing. The Better Hospital Food program aims to improve the quality of food services in hospitals Since we know teething infants sometimes find relief in licking the glass on windows and mirrors, and biting stainless steel handles and other cold surfaces. Designers must check the toxic nature of materials during specification and avoid products containing formaldehyde, wood preservatives, arsenic, white spirit, benzene, and other toxic substances. Hearing: Wounds take longer to heal when patients are exposed to noise for long periods. Noise can also affect our weight and our hormonal balances. Agreeable sounds, such as music, can reduce our blood pressure and heart rate. The sound has a fundamental effect on us, both psychologically and physiologically. Sounds of such as rain, a breeze, the sea, moving water, and songbirds can calm and create a sense of wellbeing. Such sounds create sensations of pleasure affecting the limbic system. They improve the function of the autonomic nervous system and help release endorphins, the body's natural opiates. Biological sounds, such as a mothers heartbeat, have been used to de-stress infants. Courtyards and landscaped gardens close to patient areas should include plants that encourage songbirds Music can have an analgesic painkilling effect, and can also reduce blood pressure, heart and respiration rates. Patients should have the opportunity to listen to music via headphones and live performances. The former should be offered as part of bedside communication. At the same time, it is important to remember that some people will view music as noise. Therefore, people should have a choice as to whether they have to listen to music. Music therapy is used to treat depression, to reach autistic children and to calm and relax agitated psychiatric patients. Relaxing music has been known to lower the level of catecholamines, such as adrenaline, and free fatty acids in the blood. Sounds can be relaxing or agitating both, any unwanted sound is a noise, i.e. what one person views as a sound another may view as a noise this may include music for some people. Noise can increase heart rate, blood pressure, respiration rate, and even blood cholesterol levels. It can reduce weight gain, disturb sleep patterns and negatively affect hormonal balances. As long ago as 1859, Florence Nightingale recognized the vital importance of a quiet and restful environment as an essential aid to recovery. As she stated in her Notes on Nursing: Unnecessary noise is the most critical absence of care which can be inflicted on the sick or well. Noise should be controlled at the source. Sources can include telephones, trolleys, and interactive toys, alarm panels and monitors. These should be monitored and policies should be in place to turn down tones on phones and nurse call systems at night. Designers should ensure that patient areas are located away from external sources of noise, such as road traffic. Noisy spaces, such as restaurants and day rooms, should not be located next to quiet spaces, such as bed areas. To conclude, healing environment provides with an atmosphere that relaxes the mind, body and soul and helps in jiffy physical and psychological recovery.
  12. namzy

    Caring For Unconscious Patient

    It is therefore important for a nurse to know how and what to feed this patient. If the nurse does not know how to feed this patient he may end up developing some complications such as aspiration pneumonia. Immobility is another problem. It's important that a nurse performs a passive range of motion to prevent the development of contractures and also to promote circulation to all body parts. It is also paramount that a nurse understand how to position this patient,lateral position is the most preferred to make sure the airway is patent by allowing free drainage of secretions at the same there is need to monitor accumulation of secretions and suction if needed, blocked airway prevent gaseous exchange and may lead to lack of oxygen to tissues hence tissue death. It is also important to turn the patient every two hours to prevent the development of pressure sores a nurse may also apply talcum powder on pressure areas to prevent the pressure sore development. It is also important to monitor hydration status by skin pinch or looking at mucous membranes for dryness and also monitor input and output. strictly monitor urine for amount, color and consistency before disposing of the urine as the patient may be catheterized. Personal cleansing and grooming needs should be met therefore a nurse need to provide bed bath at least twice a day and dress the patient clean dry clothes, clean his teeth twice a day. Explaining patient condition to significant others is very important so as to dispel anxiety and make them understand the patient condition this also promote cooperation as you want to carry out some procedures. It is very important that every nurse working in areas needing critical care such as High Dependency Units has enough knowledge to assess and intervene appropriately he should also be able to communicate any change in patient's condition for multidisciplinary intervention. A nurse working in these areas should also be able to use equipment available for instance a problem of airway blockage due to secretions has been found and then this nurse does not know how to sunction, this may result in death of this patient because gaseous exchange is vital for metabolic processes of the body hence the need for skill in using different equipment available at that setting. Therefore High Dependency units or any unit for critically ill patient need enough staff to monitor the patient closely, it also needs proper supervision of a charge nurse to make sure the patient gets quality care. Students either nursing or medical should be closely supervised before any decision is implemented to make sure only what is expected is done it is also important that few students are allocated at each unit to minimize errors. An unconscious patient fully depends on us for his recovery as such it is our responsibility to always think critically before intervening if you are not sure to ask a colleague or consult. The more the knowledge we have the greater the difference we can make on our patients. Thanks for reading.

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