Archive for September, 2012

Are Nurses Too Noisy?

Posted in Nursing, Nursing Jobs, Nursing News

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As nurses, we are sometimes guilty of making a little too much noise, especially at shift change when our numbers temporarily swell, and during the night when we are attempting to stay awake using any means at our disposal. Sometimes noise is not entirely our fault, such as when a confused patient cries out in the night, oblivious to others who are trying to rest. Let’s face it — hospitals can be noisy places, and while certain noises can be controlled, others cannot.

Some areas are understandably noisier than others. Newborn nurseries can be loud, especially when several infants are vying for attention at the same time. The emergency room can be a very noisy environment, usually full to overflowing with multiple patients in extremis.

Patients in the ICU are exposed to not only the noise emanating from other patients, but from a variety of equipment that beeps, honks, rings and clangs — it’s enough to drive anyone mad! So how do patients perceive the noises encountered in the ICU? A study from the University of Gothenburg set out to answer this question.

Researchers registered and recorded the level of sound around thirteen seriously ill ICU patients over a full 24-hour period of time. On average, the sound levels around the patients fell between 51 and 55 decibels (dB). How loud is 55 decibels? This level of noise can be compared to lying beside a busy road. This level of sound is approximately 20 decibels higher than the level recommended by the World Health Organization. Worse, the noise level surrounding the study participants sometimes rose to a level of 100 decibels in short bursts.

The patients categorized the noises they experienced as being either positive or negative. The positive noises included staff members chatting quietly among themselves or providing information regarding a patient’s conditions or treatment. These sounds were viewed as comforting and soothing, rather than annoying or bothersome.

Negative sounds were those sounds that were unpredictable and/or uncontrollable. Examples included noises from machinery, other patients or treatments. Sounds that were loud and unidentifiable were also frightening. Sounds even became part of the hallucinatory landscape for one patient in the study. Sudden loud noises were deemed to be more disturbing than a generally loud and constant noise level.

What level of noise is acceptable? The World Health Organization actually recommends a level of 30 decibels for patient rooms. Most of us do not walk around with a sound pressure level meter in our pocket to determine how much noise we are making; however, we should make every effort to provide a quiet, calm and restful environment for our patients. Being in a loud environment is not only unpleasant, but the resulting lack of sleep has been found to have a real impact on health outcomes.

Of course, we are only human and are sometimes guilty of laughing or talking a little too loudly, but on the whole we should be cognizant that sound travels and can reach the ears of patients who are trying to earn that most valuable of commodities in a busy hospital environment — a good night’s sleep.

Nurses Mentoring Nurses

Posted in Nursing, Nursing News, Nursing School

September 17th, 2012
Jenna Fischer

Yuri Arcurs/ Fotolia

A pilot mentoring program based in Nevada is hoping to accomplish at least two things. First, help nurses figure out how to take their “book learning” from nursing school and put it into practice. The program also aims to help the experiences nurses who will serve as mentors to rekindle their own excitement about the profession.

The program is called the Nevada Nurses Association Mentoring project, and is sponsored by a grant from the American Nurses Association, according to this article on Nurses with at least three years’ experience and newly licensed nurses each complete profiles and then are matched according to compatibility. Then the mentor-and-mentee pairs communicate via email about any questions or concerns the mentees may have.

The time commitment is minimal — the article states that only 15 minutes a week for 8 weeks is required from the mentor nurses.

Nurses who have just graduated and are facing the real-life challenges of their first shifts often are left “without the parachute” of a classroom environment, said Denise Ogletree McGuinn, RN, APN, who is one of the mentors and the director of the program. “It’s a critical time,” she said. “They need someone who can take them by the hand and tell them what they’re feeling is normal.”

Networking can be difficult, especially in Nevada where vast open spaces separate large population centers. Nurses with questions about a particular specialty may have to travel a long way to mingle with someone in their field.

For experienced nurses it’s a chance to remember why they chose nursing in the first place and an opportunity to “rediscover our joy,” McGuinn said. For struggling nurses, she said having someone to turn to who is not a boss or co-worker can be “like a hot bowl of macaroni and cheese.”

By early September, 10 matches had been made and five mentors were awaiting mentees. McGuinn said they are hoping for at least 250 matches in the next month.

The hope of the program is not only to help nurses through the early years, but also to get them engaged in their profession and ready to help the people who come after them. “These are our leaders of tomorrow,” McGuinn said.

Making Time for Reflective Practice

Posted in Nursing, Nursing News, Nursing School

September 12th, 2012

Yuri Arcurs/ Fotolia

An interesting question was raised online in Nursing Times: Do nurses have time for reflective practice?

Reflective practice can be defined as reflecting on experiences in order to critically evaluate what you do well and how you might improve your personal nursing practice (i.e. skills, communication, interpersonal relationships, professionalism, beliefs, values and behavior). It involves the process of critical thinking. Nursing students are encouraged to perform reflective practice throughout their nursing education; in fact, reflective practice is often a formal component of nursing education in the form of journaling or other forms of writing that are evaluated by nursing instructors.

What happens when we graduate from nursing school and enter the “real world”? How many of us take the time to reflect critically on our nursing practice? How many of us have the time to practice critical reflection?

Some might argue that nurses are not allowed the time to practice critical reflection in the workplace. Many nurses are overworked, with too many patients and too few staff members available. Many nurses are focused on whether they will have time to break for lunch or visit the washroom, let alone take the time to engage in reflective practice.

However, reflective practice does not need to be as formal as it was in nursing school. Most of us engage in reflective behavior regarding our experiences as nurses on a daily basis, but don’t recognize that that is what we are actually doing. For example, when conflict arises with a patient’s family member, we may spend time thinking about how we responded to the family member’s criticism. We may take it a step further when we discuss the issue with our colleagues and ask their opinion about how we handled the situation, perhaps soliciting advice on how to better handle a similar situation in the future. We may grieve the loss of a patient to whom we had grown close, or dread the imminent loss, and spend time reflecting on how the relationship we formed with the patient was special or different from relationships with other patients, and why this particular patient moved us. We may engage in an informal debriefing session following a particularly difficult trauma in the ER, identifying ways to improve performance and what might have been done differently. These are all common scenarios and are examples of reflective practice, whether we think of them in that fashion or not.

The bottom line is that reflection does not need to be a formal process (although it can be if you prefer). As nurses, we constantly strive to become better practitioners. Just as formal continuing education is a requirement of the profession, so too is reflective practice. Reflection is a skill that we learn in nursing school that becomes engrained in our psyche.

We first learn the practice of critical reflection in the form of reflective activities and assignments that nursing instructors comment on, pointing out things we perhaps did not or would not have realized without someone’s greater experience. As we evolve in our ability to reflect critically in regards to our practice, our reflection becomes a reflex, a skill we have learned that we no longer think about consciously while performing, much like the physical skill of inserting an IV or taking a blood pressure reading.

The Case of the Upside-Down Woman

Posted in Nursing, Nursing News, Nursing Specialties

SodanieChea/ Flickr

This is a fascinating case study. It opens with a woman being dangled by her feet by a “giant” in the Emergency Room. Various ER personnel are alarmed and try to get the seven-foot-plus man carrying her to put her down already, but both the (very tall) man and the (very small) woman insist that she needs to stay in her inverted position.

Dr. Louis F. Janeira comes on the scene and tries to make sense of things. He eventually learns that a) the large man holding the small woman is named Jason, b) the small woman is his wife, Mary, who the doctor had in fact seen the day before due a slow heartbeat but didn’t recognize, upside-down.

She’d come in to the Emergency Room the day before with a complete heart block, which is caused when the electrical system that connects the atria to the ventricles fails. Her heart rate had been under 40 beats per minute instead of the normal range for her age group, 60-80 beats per minute. Dr. Janeira had called a colleague for urgent implantation of a pacemaker, which generates rhythmic electrical pulses that bring the heartbeat back to normal.

Dr. Janeira discovered that the pacemaker was successfully installed the day before, and Mary had returned home from the hospital that morning. Everything was fine until about half an hour beforehand, when she had coughed and then collapsed.

Her husband Jason explained that she had fallen behind the bed and he’d picked her up by her ankles, and she regained consciousness. When he’d put her down, she fainted again. This process repeated a few times; she’d pass out, he’d pick her up by her ankles, and she’d be back again. So they’d given up on the experimenting and he was just carting her around by her ankles to keep her conscious.

An Urgent Diagnosis

My mind raced through the possibilities. Mary could have something obstructing the blood flow from her heart to her brain that was overcome when her head was down. Or her blood pressure could be so low that blood reached the brain only when she was upside down. Blood pressure that low could have been triggered by an allergic reaction, anaphylactic shock, or severe dehydration.

Another possibility was that Mary was suffering from cardiac tamponade, a compression of the heart caused by a buildup of blood in the sac covering the organ. If her heart had been perforated during the pacemaker implantation and blood had seeped out into the sac around it, it might be that her ventricles were now being squeezed by this accumulating blood, lowering her cardiac output. That condition could improve when she was upside down by increasing blood flow to the brain.

The first thing to do was to check Mary’s vital signs. “Bring her into a room,” I said. “Let’s get her on a monitor.”

I pointed the way, and Jason carried her into the cardiac room, an entourage of curious ER personnel trailing behind us.

Even once in the cardiac room, Jason was unconvinced that he should let go of her ankles and put her on the bed. “When I put her down, she’ll go out on us,” he said.

I paused for a moment. “We’ll do an assessment of the vital signs first while Mary is upside down. Then we’ll put her in bed and see if and how things change, OK?”

Jason nodded. Mary’s long black hair waved back and forth, which I took for agreement from her, too. Ellie then placed heart monitor electrodes on her chest.

“Normal-paced rhythm,” I said, watching the monitor. “The pacemaker is working perfectly fine right now.”

“And I feel perfectly fine,” said Mary. “Well, except that I’m upside down and have been for about 30 minutes now.”

Ellie wrapped a blood pressure cuff around her arm. “It’s 120 over 66,” said Ellie. “Pretty good.”

“OK, slowly get her on her back,” I said. Jason walked closer to the bed and Ellie and I eased Mary down onto it. The only sound came from the heart monitor: beep, beep, beep, steady at 60 times a minute. We all held our breath.

Then the cardiac monitor showed a sudden change. The alarm began screaming.

“Here I go,” said Mary. “It’s happeni…” Her words dissolved into nothingness.

“No heart rhythm,” Ellie called out. “Pacemaker failure.”

“Get me epinephrine,” I yelled. Also known as adrenaline, epinephrine is a hormone that can constrict blood vessels and get a stalled heart beating again.

“But we don’t have an iv in yet,” said Ellie.

“Out of my way,” said Jason, pushing us aside to get to Mary’s feet. “I told you this would happen.” The big man grabbed Mary’s ankles and pulled them up in the air. Moments after Mary was upside down again, the heart monitor resumed steadily beeping.

“I’m back,” said Mary.

Something must have gone wrong with her operation yesterday, I thought. Then suddenly it hit me. “The pacemaker lead, the wire going from the pacemaker generator to your right ventricle, must have disconnected. Your coughing spell could have done it,” I said. “Somehow, the lead reconnects when you are upside down and continues to stimulate the heart.”

Pacemakers are made up of two main components, a generator and a lead that carries electrical impulses to the heart. Often the lead tip is screwed directly into the heart muscle, but in rare cases it can dislodge and cease to stimulate the heart. Data from St. Jude Medical, one of the largest pacemaker manufacturers, show that out of about 220,000 implants of the company’s most popular lead attached directly to the heart, only 97 dislodged within 30 days of implantation. Apparently, Mary was one of the rare cases.

Getting The Patient Upright

“How are we going to fix this, doc?” Jason wanted to know.

“You’ll need to go back to surgery to reattach the lead,” I said to Mary. “Let’s page your electrophysiologist stat.” I looked at Jason and sighed. “Meanwhile, keep her upside down.”

We inserted an iv in Mary’s arm and hooked her up to an external pacing device. But pacing her heart through her chest wall gave her severe discomfort and was not a good option, even in the short term. Moreover, it turned out that Mary’s slow beat did not respond at all to medications, including intravenous epinephrine. So she was quickly transported to the electrophysiology laboratory, dangling by her ankles, carried by the only man around with enough strength to do it. And my ER shift continued.

The next day I was back on duty. As I came out of a room after examining a small child with a fever, I heard a familiar voice behind me.

“Dr. Janeira, it’s me, Mary. I’m all fixed up.”

I turned and smiled at Mary and nodded at Jason, who towered massively behind her. “You were right. The pacemaker’s ventricular lead had to be re-screwed in my heart,” she said. “I’ll be having the pacemaker checked in a few days and then every three months.”

“How do you feel now?” I asked.

“Back to normal,” she said. “Thanks for your help!”

And with that, she left my ER walking upright and hand-in-hand with her giant.