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Answers to Your Nursing Career Questions

Is July the Most Dangerous Month in Hospitals?

July 12th, 2010 by – Marijke Durning

It’s all over the Internet nursing boards now, but if you haven’t heard yet, there’s a CNN article out that discusses the supposed increase in deaths in the month of July – coincidentally the same month that interns and residents begin their rotations (Are Hospitals Deadlier in July?).

The article cites a study published in the most recent issue of the Journal of General Internal Medicine, written by two members of the Department of Sociology at the University of California at San Diego. The results of the study said, “We found a significant July spike in fatal medication errors inside medical institutions. After assessing competing explanations, we concluded that the July mortality spike results at least partly from changes associated with the arrival of new medical residents.”

However, further on in the CNN article, the author concedes. “Other studies find that there is no increased risk of error and that the reported July effect may reflect the quality of care at certain locations.” This includes studies as the one published in 2009 in the Journal of the American College of Surgeons found that this was not so. After studying the mortality rate in a Level 1 trauma center, the physicians found “The July phenomenon does not exist at this Level I trauma center with in-hospital attending supervision.” So, is there one or isn’t there? Or, was the journalist being sensational?

If you mention the July Phenomenon, many nurses will quickly agree that it exists. Pretty well every nurse has a story to tell about dealing with new residents. Many of us have spoken up to new interns and residents, saying, “Are you sure you want to order that?” or something to that effect. Smart residents will pick up on that cue and probe a bit further, seeing if maybe they are making a mistake, but others just brush it off and use their “I’m the doctor” mentality. But, does this translate into the July Phenomenon?

Medical students learn a lot in school – their workload and academic expectations are high. They have a bit of patient contact, but they don’t have the experience that comes with time and practice. Now, having just graduated with all this knowledge, they are thrown onto the floors and units and expected to perform – and perform well. Of course, they are supervised, but these newly minted doctors still have a lot of responsibility.

Without a doubt, as in all professions, you get the good doctors and the not so good doctors. You get the ones who ask questions and take the time to learn and you get the ones who jump into it thinking that they know best because they are, well, they are doctors – and we aren’t. Maybe their inexperience and attitude jumps out at nurses because there are so many of them at the same time, but how many of us have worked with new, inexperienced nurses who have exactly the same attitudes of the nastier new doctors?

We all have worked with new nurses who didn’t want to hear about our experiences, who thought they knew best, who figured they didn’t need our help. How must it feel to come onto the floors hearing the horror stories of nurses who have no time or patience for stupid questions?

How must it feel to come into a place, as a newly graduated medical doctor, knowing you’re supposed to know so much, but you feel like you don’t know anything? It must be frightening. But they can’t show it.

So, how about nurses giving these new doctors a bit of slack? We don’t have to kowtow to them and tolerate obnoxious behaviors. But maybe we can be a bit more understanding of what they may be going through – and maybe offer some encouragement. After all, isn’t that what we would like if we were learning all over again?

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Posted in Doctor/Nurse Relationships

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Anatomy and Physiology

July 10th, 2010 by – Sue Barton

  Can you suggest some easy ways to get through anatomy and physiology?

I’m assuming you are a student taking the science courses you need for nursing school.  “Easy” is probably not an option, but there are a variety of study skills and techniques to master the material that you will be using through out your nursing career.  Start by showing up for class every time, and asking questions and participating in discussions and labs.  You may want to form study groups with other students to review material together.   Many schools offer online courses that allow you to do some of the work on your own schedule, and then be on campus a couple of hours a week for lab times.  While online courses are more flexible, and can offer individual pacing, some students do better with the interaction of a traditional classroom.  You will need to decide what works best for you.  Since anatomy requires a certain amount of rote memorization, using study guides and memory prompts is helpful.  It also helps to know your own learning style, and for some people it is worthwhile to have an educational evaluation through your student services department to help you sort that out.  You may find you need to use audio or visual aides rather than a text, and hone your test taking skills.

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Posted in General

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Psychiatric Medications

July 9th, 2010 by – Derek Brocklehurst

Which are the most common medications used for patients with behavioral problems?

Patients with “behavioral” problems might be referring to patients with psychiatric instabilities. An individual’s mental health status often goes unchecked and not maintained properly. Psychiatric conditions that can arise from an underlying, unchecked mental health issue include bipolar disorder, schizophrenia, depression, anxiety, and many others. If you think you or a patient may need a psychiatric evaluation, it’s important to get one promptly because the longer these issues go undiagnosed, the more severe they may become in the clinical setting.

There are different classes of medications to treat the above listed conditions, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOs), serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, barbituates, and 1st-, 2nd- and 3rd-generation antipsychotics. Generic name common medications for the listed conditions include Aripiprazole, Lorazepam, Clozapine, Olanzapine, Quetiapine, Citalopram, Venlafaxine, Fluoxetine, Alprazolam, Buspirone, Clonazepam, Lithium, and Sertraline.

These medications do not come without side effects. If you are thinking about taking any medications for psychiatric indications, please consult your primary care provider about what may be right for you.

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Posted in General

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Learning IVs and Injections – on Each Other?

July 9th, 2010 by – Marijke Durning

How did you or how are you learning to start intravenouses (IVs) and give injections? Do you have dummies or models on which to practice or do you practice on each other?

I’m old enough to say that we didn’t learn IVs in nursing school, but we did learn how to give injections. Inserting IVs was taught in the hospitals that hired us, because not all hospitals allowed nurses to start them at the time.

I am very pleased to say that we did NOT practice injections on each other. I honestly believe I would have quit school and not returned if that was the case. I know that many people do learn this way, but to me, it’s barbaric and unnecessary.

When I was 17 and starting in nursing school, I was terrified of needles. I had had bad experiences receiving injections, so I avoided them as much as I could. Luckily for me, that’s no longer the case, but back then, it was a real phobia. I would pass out at the thought of receiving an injection.

We began learning how to give injections as we practiced in the nursing lab at the college. We had realistic feeling models on which to practice. We could practice IM injections on body parts that had the feel of skin and, remembering back, they were quite accurate on how they felt when the needle pierced the “skin” and entered “muscle.” I was quite scared when learning – after all, when you don’t like receiving injections, it’s quite intimidating to give them. But learn I did, because it was on an object, not a person.

When I learned IVs, we had extremely realistic “arms” on which to practice. You could insert into a vein, blow a vein, you name it. It must have been a good learning experience, because I had no problems beginning an IV in a patient when I had to. My first few experiences with patients were effortless – I was well prepared.

People who advocate learning on each other as students say that it’s good practice because A) it’s a real person and B) it gives you an idea of how it feels to have it done to you. While opinion A may count, I strongly disagree with opinion B.

Whenever you start an IV or even give an injection, you are performing an invasive procedure. IVs, in particular, can be quite painful if you don’t have ideal veins. When and where was it written that we must receive an invasive procedure from a fellow student in order to learn? If so, why stop at injections and IVs? Why not start catheterizing each other to get the “real” feel of it. Of course we don’t do that – it’s ridiculous, right? So how is poking each other with sharp needle any less ridiculous?

What about you? How did you learn and what do you think?

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Posted in Common Nursing Procedures

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Can LPNs be cardiac nurses?

July 8th, 2010 by – Sue Barton

I’m an LPN and I’d really like to work in with cardiology patients.  What do you suggest?

There are role for LPNs in a range of cardiac settings.  While we all tend to think first of all of the hospital setting, you might also look at outpatient clinical sites.  A cardiology office may use LPNs to do basic patient preparation and assessment before the patient is seen for further evaluation by the cardiologist or by the nurse practitioner or physician assistant.  In the hospital cardiac patients are cared for in both surgical and nonsurgical areas, and in both settings an LPN may work with patients under the direction of the registered nurse.  Some facilities do use all RN staff in specialty units; this is something you will have to find out from the hospitals you are interested in.   Home care agencies also may use LPNs to provide nursing care in the home to patients with cardiac diagnoses.  Teaching patients about their care and medications, supporting them during testing and procedures, and ensuring that at discharge they have a plan in place for followup are important nursing roles with cardiac patients.  If the field of cardiology nursing really interests you, at some point you may want to look into becoming a registered nurse so that you can be more knowledgeable and have more responsibility.  There are of course a variety of LPN to RN educational options to choose from depending on your individual needs, and Medi-Smart has nursing education information tailored to your situation.

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Posted in General

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Treatment for MRSA

July 7th, 2010 by – Derek Brocklehurst

I am suffering from frequent boils under my armpits. I have gotten them lanced, take antiobiotics, and used heat compresses but they still wont go away. They have puss coming out of them but they still seem to keep coming back. Please help me as to what i can do.

So, right off the top of my head, this sounds like an uncontrolled staph infection. Methicillin-resistant Staphylococcus aureus (MRSA) is a bacteria that is found living on the skin and in the nose. MRSA likes warm, moist places likes cracks and crevices on your body (arm pits, buttocks, nose). It is becoming more and more of a public health concern and issue as skin infections are easily acquired, easily transmissible, and becoming difficult to treat.

Lancing infected boils is often a last resort if the pain is too great to stand and the redness and swelling is overwhelming. Lancing means that the bacteria have a chance to get out and spread onto your skin more. Lancing should be done in a sterile, aseptic environment.

For immunocompromised patients (HIV+, on chemotherapy), providers will typically use Bactrim as an oral antibiotic to help treat MRSA. If there are patients in the community who do not have access to oftentimes-expensive antibiotics, the recommended over-the-counter treatment is a strong antiseptic agent such as Hibiclens surgical soap or a benzoyl peroxide 5%. Both of these can be bought at your local drugstore and should be used daily for 30 days to help control the MRSA infection and reduce the size of the colonies.

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Posted in Common Nursing Procedures, General

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Walking in Someone Else’s Shoes

July 7th, 2010 by – Marijke Durning

You know how we often think that our job is the most difficult and that the others who work with us just can’t understand how hard it is to be a nurse? We work with so many people, from the cleaning staff to the kitchen staff, but sometimes we forget that all jobs and professions have their own set of skills and problems.

I read once of a place where they had a “Walk in Someone Else’s Shoes” program. Once every so often, people were taken from their usual tasks and assigned to follow someone in another department. So, on any given day, you could find a unit manager observing in the kitchen on the food line, an accountant giving out trays, a licensed practical nurse (LPN) helping alongside the housekeeper, a lab tech folding laundry, and an IT guy observing a certified nursing assistant (CNA).

At first, this may seem kind of hokey – a kind of new age, feel good type of experience, but if we don’t find some way of learning what others do, it can be difficult to understand that they also have their stresses.

Those mops that the housekeepers use – it may seem easy to mop a floor, after all, we do it home. Have you ever felt how heavy these industrial mops are? And are the messes they clean up really like the ones we clean up at home? Not to mention, we clean as we need it, they clean all day long.

The kitchen staff needs to be commended for some of the conditions they must tolerate. Working in a kitchen is very fast-paced, especially if you’re filling trays on a food line. Different diets, different foods, different patients – and all the food must be delivered, hot dishes hot and cold dishes cold, on time.

Pharmacists are often overwhelmed because of the number of prescriptions they must fill. And if they receive several stat orders at the same time, well, they do only have two hands, much like we do.

And the list goes on. Do you think your facility would benefit from a Walk in Your Shoes program? The other staff members developed a new respect for what nurses did – before the program, they’d only caught glimpses of the nurses and never understood all that was required in the course of a day.

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Posted in Work-Life Balance

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Doctor of Nursing Practice

July 6th, 2010 by – Sue Barton

  Isn’t it confusing to patients if the nurse practitioner who is providing their care has a doctor of  nursing practice degree?  Will they call him or her “doctor”? 

Well, this is certainly a concern that is being raised by physician groups.  The DNP degree is being proposed as a requirement for advanced practice certification in the future, and many nursing schools are now making the transition to offering these programs.  In reality, so many professionals now use the title “doctor” and have a doctorate as an entry level degree, that it is hard to see that it will complicate matters any further when  nurses are among that group.  Optometrists, physical therapists, pharmacists, psychologists, among others may be addressed as “Doctor.”   It certainly is important for  each member of the health care team to be as clear as possible when introducing themselves to patients as to who they are and what their role is. Professionals in any field who have earned a doctorate obviously have the right to be addressed by that title, but whether advanced practice nurses (nurse practitioners, nurse midwives, and nurse anesthetists) would commonly choose to do so is still an open question.  My guess is that nurses with DNP degrees will want to be respected for their achievements as nurses and will go out of their way to identify themselves as nurses to their patients and to the public.  Further education is in every one’s best interest; quibbling about titles is really a non-’issue.

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Posted in General

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HPV and You

July 5th, 2010 by – Derek Brocklehurst

Should I see a doctor for an infected wart?

Human Papilloma Virus (HPV) is the virus that causes warts. Different strains of the virus carry differing susceptibilities to developing cancers. Depending on what strain of HPV you have or where the wart is located, it might be a good idea to have warts checked out by a provider regardless of an infection.

HPV can lead to cervical cancer in women and colorectal cancer and oropharyngeal cancer in both men and women. It would be a good idea to know the strain of HPV you have and to be aware of the need for annual pap smears or anal paps.

Usually, if an infection isn’t getting any better and only getting worse (more reddening, swelling, pain to the touch), then you will want to consult a provider and perhaps think about antibiotics. An infected wart means that you have a wart with some sort of bacteria creeping its way around the tissue of the wart, leading to swelling and pain. It’s always good to know your body and if something is telling you that you should go consult a provider about any infection on or in your body, then you probably should!

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Your Biggest Nursing Fear

July 5th, 2010 by – Marijke Durning

Do you have a fear you just can’t shake when it comes to your job as a nurse? Is there a nursing act or task you wish you didn’t have to do because you’re worried about messing it up?

Whether you’re a licensed practical nurse (LPN) or a registered nurse (RN), there may be some part of nursing that makes you worried. Mine was always inserting indwelling urinary catheters – Foleys, we called them.

I knew how to insert catheters and I had no problem inserting them, in either men or women. But my concern was always, “would I insert the Foley far enough in that when I pump up the balloon, will it be safely in the bladder?” No matter how many times I did the procedure, I worried about this. Theoretically, I understood that this wouldn’t be possible the way I inserted them. I understood and practiced the techniques to ensure it wouldn’t happen – but I still worried about it.

Years passed and I had inserted more catheters than I could ever remember. Then, one day, when I was working in a school for physically handicapped children, I had to insert a Foley into a 15-year-old girl who had broken her neck in a diving accident a year earlier. We had taught her how to self-catheterize, but for various reasons, someone had decided that she should have an indwelling catheter. So, I inserted it.

After I inserted the catheter, I went into the bathroom to clean up my supplies and when I went back, the girl couldn’t say my name. She was beet, beet, beet red. I’d never seen a person that red in my life. My initial thought was “oh my God, I finally did what I’ve been so scared of doing all my career. I blew up the balloon in the urethra.” So, since I thought I had done this, the first thing I did was deflate the balloon to remove the catheter. I then ran to get the BP cuff to check her blood pressure. It was so high, I couldn’t measure it.

At this point, I was close to panic – although her color was starting to come back and she could speak, I had no idea what was going on. I called the nurses at the clinic where she was followed. I quickly explained the situation and the nurse on the other end chuckled. She said and I’ll never forget, “Oh, that’s not unusual. It’s a vasovagal response that many quads will have when you catheterize them.” I explained that her BP sky rocketed, it didn’t drop, but she still wasn’t concerned.

After the conversation, I went back to the girl, checked her BP and she was back down to normal. I later mentioned this to our doctor when he came in – he wasn’t concerned either. The girl had no lasting issues from the event, although her mother forbade any indwelling catheter from then on.

I was relieved to find out that the incident wasn’t my fault, but it has stuck with me all these years. This happened over 23 years ago.

Is there anything in particular that you’re afraid of?

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Posted in On-the-Job Fears

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