Category Archives: Evidence-Based Practice ‘N’ Stuff

The Undeading

Simply the best CPR public service announcement ever. Here’s a link to the behind the scenes goodness. Sorry, Ken Jeong, but this one is my favorite (after the British version with Vinnie Jones ).

Learn CPR today, and maybe you can save a life and/or someone’s brain so you can eat it later.

Staying Organized During Football Season and Your Average Hospital Shift

Staying Organized During Football Season and Your Average Hospital Shift

Really, there aren’t two topics of more importance, so why not lump them together. Since I’m sort of between teams right now (oh, the heck with it, Go Raiders!!!) it will be fun to work through this flowchart, since I hate thinking for myself!

On another note, I’m attaching the shift routine worksheet I’ve made to keep on track at work, and prevent charting deficiencies. It really helps me remember to order labs when I’ve got patients on protocols (e.g.; K+ replacement, etc.), to identify Core Measures (thanks, Jay-Co and CMS!) and mind my p’s and q’s. I’m attaching it should it be useful to others on the internets.  Here you go:  Shift Routine for Med-Surg

 

A Few Lessons Learned this Week

A Few Lessons Learned this Week

It was an interesting week for this newbie float pool nurse. Here are the primary lessons learned this week:

1. Saving hundreds of dollars by replacing cable with Netflix will be partially cancelled out by Mr. DisorderlyCNA watching the show My Cat From Hell and deciding that our well-behaved Russian Blue needed an 8′ cat tree (costing more than I used to gross in a week as a CNA). Oh well, the cat’s happy.

2. If you run piperacillin-tazobactam (running at 12.5 mL/hr) as a primary line and “Y” the patient’s maintenance fluids into said ABX line, you are a bad, bad person. No, I didn’t do this, but I was the lucky nurse who got to completely re-route this disaster someone left for me. I guess my infusion skills can always benefit from practice, but , seriously!!! Zosyn run at a very slow rate and NOT piggybacked into some NS set to run at 21 mL/hr leaves you with air in your line, which is miserably difficult to clear (and will definitely wake up your poor, sleeping patient).

3.  Not used to working with psych patients?  Well, reflective communication and therapeutic silence are your best bets!  Otherwise known as stall, stall, stall until someone who usually works with the patient shows up and saves your bacon!

4. People with health conditions should/must wear medic alert tags or bracelets. There really is no excuse, and, in an emergency, even the most composed person can miss an important detail when giving a history to the medics.  Don’t settle for the cheapie kind that let you put a label or labels with the person’s condition on the tag, go ahead and get an engraved one like this.

5. When making a new muffin recipe for the first time, bake just five (one in each corner of your muffin pan and one in the center) to gauge the success of the recipe and/or make adjustments before using the vast majority of your batter and having to to start over.  Waste not, want not!

So, with that, here is a lovely recipe for Orange (ahem, Grapefruit) Glazed Poppyseed Muffins!  (Adapted from this recipe.)

Cook’s notes:

1. This recipe could be lightened substantially by going halvesies with the oil and some applesauce. These are not for the faint of heart, and one muffin goes a long way.  Probably could reduce the sugar to 1.75 cups and be just fine, as well.

2. Do not, do not, do not underbake these babies! Or you will wind up with your muffins doing a Jim Breuer imitation (early career).

3.  No orange juice?  Raid Mr. DisorderlyCNA’s secret stash of ruby-red grapefruit juice!  Or apple juice would work, I suppose.

4. A colored dishtowel makes a lovely backdrop for a photo of your baked goodies. Thank you, Costco!

INGREDIENTS:

Muffins:
3 eggs
2 1/2 cups white sugar
1 1/8 cups vegetable oil (or half oil, half applesauce for a lighter muffin)
1 1/2 cups milk (you can actually skip this if you don’t want it – I forgot to add this and the muffins were still bomb!)
1 1/2 teaspoons salt
1 1/2 teaspoons baking powder
1 1/2 tablespoons poppy seeds
1 1/2 teaspoons vanilla extract
1 1/2 teaspoons almond extract
3 cups all-purpose flour
Glaze:
3/4 cup white sugar
1/4 cup orange juice
1/2 teaspoon vanilla extract
1/2 teaspoon almond extract
2 teaspoons butter, melted
DIRECTIONS:
1. Beat together the eggs, 2 1/2 cups white sugar and vegetable oil (and/or applesauce if using). Add in milk (or not!), salt, baking powder, poppy seeds, vanilla, almond flavoring, and flour. Mix well.
2. Bake in paper lined muffin cups filled 3/4 full at 350 degrees F (175 degrees C) do not adjust temperature if using a convection oven for 20-25 minutes. The tops should be browned and a toothpick inserted in the center should come out clean.
3. Remove muffins as soon as you can while still warm/hot and cool to just warm before dunking tops into glaze. Turn right side up and cool on a cookie rack (with a cookie sheet under it or you’ll have a hella fun mess to clean up).
4. To Make Glaze: In a saucepan over low heat, combine 3/4 cup sugar, orange juice, 1/2 teaspoon vanilla, 1/2 teaspoon almond flavoring and 2 teaspoons melted butter. Warm in pan until the sugar is dissolved. Dunk muffin tops into glaze when cooled to room temperature. (Omit the glaze altogether if you don’t like the mess, but you’ll have to live with yourself for being such a chicken!)

Do LTACs Benefit ICU Patients?

So, this interesting study explores the efficacy of LTACs in the post-hospitalization survival rates of ICU patients. Essentially, the gist of the matter is that older patients with lots of comorbids don’t have a very high survival rate a year after hospital discharge, despite LTAC utilization. Probably not too surprising, given the acuity level of the patients studied. The study did not include patients coming from non-ICU care, although such patients are cared for in LTACs.

However, the question of whether LTACs serve as a more cost-effective method of delivering care to patients and families not ready to give up and die is asked, but not well explored. It would be interesting to see a study delineating survival rates only for non-DNR/DNI patients utilizing LTACs.

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A Sedation Alphabet

A is for Ativan and anxious

B is for benzodiazepine and barbiturate

C is for central line

D is for dopamine receptors

E is for Equanil

F is for frontal lobe

G is for glutethimide

H is for Haldol and Halcion

I is for intravenous and IJ line

J is for JCHAO

K is for Klonopin

L is for lorezepam

M is for mitts and morphine

N is for neuroleptic

O is for obtunded

P is for Propofol and Precedex and Prozac and paradoxical reaction

Q is for quiet

R is for restraints and Restoril

S is for sitter/safety companion and sedative and Security

T is for tardive dyskinesia and tricyclic antidepressant

U is for understanding

V is for Valium and Versed

W is for waking

X is for Xanax

Y is for y-site compatibility

Z is for zzzzzzzzzzzz…

1:1 Patient Sitting Survival Tips

CNAs often are called upon to serve as patient sitters, particularly in the acute care setting. Sitters are an alternative to increased sedation and/or restraints for combative patients. Facility policy may dictate the use of a sitter (“safety companion”) if a patient has expressed suicidal ideation.

When dealing with an agitated, combative patient, using a soft voice, dimming lights, and providing a calm, restful setting can go a long way toward minimizing the amount of action going on. If a patient is fidgeting in the bed, but not actively trying to pull out their central line (that would be a BAD THING), peripheral IV, or fourth (ouch) Foley that day, heck, let’em fidget! If the patient is given some opportunity to get rid of excess energy through some, ah, bed mobility, chances are good they might be able to settle down and even get some rest.

Cloth tape may be your BFF for keeping leads, IVs and sat probes on/in your patient. You can use a square of cloth tape over tele leads to make them more likely to stay on, and if you have the pulse ox probe on a toe, use cloth tape to secure its cable to the top of the patient’s foot.

Distraction is another valid approach to use with the agitated patient. Try telling stories, singing or employing other entertaining methods to help the patient get his/her mind off being in the hospital.

What kinds of survival supplies will help you have a more enjoyable shift as a sitter (assuming you’re not spending an entire shift doing everything you can just to keep the patient in bed, that is)?

Here’s a list:

-book to read (can be a textbook)

-smartphone with Netflix – many programs are close-captioned so you can watch without waking your patient, or you can play Words with Friends (scrabble game), Facebpook, text, etc.

-snacks, bottled water

-cards/stationery so you can catch up on correspondence

-portable reading light (so you don’t wake your patient)

-cell phone charger

Happy sitting!

Post-mortem care – prep for the journey

CNAs, whether working in hospital or long-term care settings are called upon to assist with post-mortem care.  If you’re not clear on this going in, perhaps a different career choice would be best.  Just sayin’.

Yes, death gives darn near everyone the heebie-jeebies, yours truly included.  Everyone’s reaction to death and corpses is individual.  What can be standardized is a competent, professional response to the practical need to prepare the body for 1.  family to spend time with the departed and 2. need to get things settled/cleaned/straightened before rigor sets in.  We’ve certainly come a long way since the time of the Black Death.

In the hospital, the nurse may supervise this care, or it may be performed by a couple of CNAs working together.  A CNA may also perform this duty solo, but usually this doesn’t occur, for the practical reasons that positioning is more safely accomplished with two or more workers, and that post-mortem care does an emotional/spiritual number on even the most grizzled, seasoned health care worker. 

Sometimes, the nurse needs emotional support.  He or she has supported the patient through efforts to save his/her life, then through hospice or “comfort care” and then the dying process.  The nurse has to be supportive of family/loved ones as well, and their reactions to the dying process.  Last but not least, the nurse is responsible for final charting, finding out which funeral service the family would like used, dealing with belongings, and supervising/performing post-mortem care according to facility policy.

So, what’s our role as the CNA in all this?  There are three areas:  rules of behavior/etiquette, rules of gathering supplies, and rules of post-mortem care.

1.  Rules of behavior/etiquette:

  • Watch your mouth! It is said that hearing is the last sense to go.  So keep it proper!  Plus, many hospitals only have a curtain between you and family members lingering outside the room, other staff, management, and passers-by.
  • It’s not about you, it’s about the consumer!  (Best business advice ever, courtesy of Joe Dirt.)  Nobody wants to hear how you handled the death of someone in your family.  They are having their own experience, save the stories and advice for another time and location. So STFU.
  • Be discreet!  If the family will be coming back into the room post-mortem to spend time with their departed loved one, put the body bag in a drawer or cupboard.  Bag up extra non-needed medical wastes (catheters, lines, drips, etc.) and get’em out of the room.  Lower the lights so things don’t look so stark.
  • Be realistic about time frames.  Post-mortem care can take 15-30 minutes to accomplish with a team of two or more, depending on how much there is to remove/clean, and how much bleeding/oozing is going on.  Keep the family informed so they don’t freak out on you.

Rules of gathering supplies:

  • 10 mL syringe for removing Foley cath
  • 60 mL Luer-lock syringe for removing stool/fecal management system (excellent product video from Bard – select the removal procedure video)
  • plenty of chux
  • paper tape (less damaging to skin)
  • drain sponges/gauze (needed along with tape for securing holes where lines used to be)
  • surgical scissors (find in procedure cart as needed) – needed for removing sutures holding in PICC, central, art lines (these are too tight to get at with trauma shears, which have blunted leading tips)
  • body bag with tags (usually 3 – for body, outside of body bag and for belongings) – to use per facility protocol (LTC – usually the funeral service brings this item)
  • bags for belongings if not already taken by family – don’t forget to tag them
  • clean gown
  • clean bed linen
  • basin
  • soap
  • water
  • wash cloths/towels
  • comb
  • EMPTY garbage cans with plenty of liners (don’t forget the biohazard bags – you’re gonna need ’em) – it just plain sucks to start post-mortem care with every waste can in the room chock-full!
  • did I mention – plenty of chux? OK.

Rules of post-mortem care:

Hopefully you had a good CNA textbook that covered this topic and you read it during your CNA course.  If not, might be a good idea to review it before taking a new position.  I highly recommend the following article:  Post-Mortem Care

Remember to put a chux down under orifices (or is it orifi?) on the side you are rolling the body to, because drainage happens.  This one piece of advice will hopefully save you a few post-mortem linen changes.

Remember, this is the patient’s (and their family’s) last experience with your facility, so make it a professional one.

2009 National Nursing Assistant Survey

Just in case you were wondering, there is a study that supports the common knowledge that the nursing home CNA position is not a high-paying position.  (Really?) 

Excerpts from This Study’s Discussion Section:

…CNAs are low-income workers (GAO, 2001) and add that years of experience do not translate into substantially higher wages. Although the median hourly wage is above the federal minimum wage, total family incomes for CNAs nationally indicate that more than half are within the 200% poverty level. Previous studies indicate that low wages do contribute to turnover and the need to work additional jobs or overtime (Harris-Kojetin et al., 2004). Moreover, working long hours may contribute to mistakes, affecting resident safety and quality of care. Strategies that increase CNA income and also meet growing care demands, such as career lattices that enable CNAs to take on additional responsibilities and receive higher wages or career ladders through which CNAs can advance in a career path (e.g., pursuing a nursing degree), may help stabilize staffing and increase the supply of licensed nurses.

Receipt of Public Benefits

A substantial proportion of CNAs are poor or near-poor. This study finds that one third of CNAs reported receiving some kind of means-tested public assistance. Moreover, our results indicate that CNAs access public assistance at higher rates than the general population…These findings may suggest that the use of public assistance is supplementing low wages for at least some working CNAs. Additional descriptive information from the NNAS allows for assessment of which CNAs are receiving which types of public benefits. For example, controlling for age, children, and wages could provide greater insight into CNAs’ receipt of benefits.

Health Insurance

Uninsured workers can adversely affect nursing home staffing stability. More than 40% of the uninsured CNAs in this study did not participate in their employer’s plan because they could not afford their share of the premium.

Injuries

Our study and others have found that more than half of CNAs incurred at least one work-related injury within the past year, rates that exceed those for almost any other profession (Hoskins, 2006). Although three quarters of the injuries in this study did not result in loss of work time due to the injury, the difference in mean and median number of injuries and time lost suggest that there is a small subgroup of CNAs with a much higher injury rate and/or more severe injuries. High injury rates and insufficient or no health insurance and sick benefits may jeopardize CNAs’ financial stability and commitment to their job or field; it may also adversely affect nursing home staffing stability…Lack of equipment (e.g., for lifting and transferring residents), lack of training on the proper use of equipment, lack of training on managing resident behaviors (e.g., combative or aggressive residents), and working short staffed are some of the reasons for CNA injuries.”

Link to the PDF document for further reading:  http://aspe.hhs.gov/daltcp/reports/2009/NNASeb.pdf

Hey, if that CNA gig doesn’t work out. . .

…perhaps you should consider working for Press Ganey.

In all seriousness, it’s nice to know that their Client Improvement Manager, Jackie Weaver, has a CNA background. 

If you haven’t considered the impact of PG scores on how acute health care is delivered, might be a good time to learn more.  Many hospitals use PG to gather statistics from patients on the perceived quality of their hospital stay/visit.  It’s interesting that many of the items measured relate to areas within nursing staff control, such as the time taken to have a call bell answered, for example.

You can download the WebEx presentation, “Improving Patient Flow: Improving Patient Satisfaction” here  (Includes a link for installing WebEx Player).

Since census drives staffing, which in turn drives the extent to which nursing staff are called off or placed on standby, it’s interesting to learn a bit about the factors that drive patient flow and thereby staffing.

The presentation takes about 47 minutes to run – just long enough to give yourself a good pedicure! (Just one great multitasking suggestion. . .)

 

How can the CNA help spot skin breakdown?

OK, so a big part of the CNA’s job involves butt-wiping.  There, I said it!  Although both nurses and unlicensed assistive personnel (uh, aides and CNAs) will often receive derision from others not working in health care concerning this aspect of providing patient care, perineal care butt-wiping ain’t no joke, friends and neighbors.  Allow me to trot out the evidenced-based, well, evidence:

In *Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Chapter 12 discusses Pressure Ulcers: A Patient Safety Issue:

Pressure ulcers remain a major health problem affecting approximately 3 million adults.1 In 1993, pressure ulcers were noted in 280,000 hospital stays, and 11 years later the number of ulcers was 455,000.2 The Healthcare Cost and Utilization Project (HCUP) report found from 1993 to 2003 a 63 percent increase in pressure ulcers, but the total number of hospitalizations during this time period increased by only 11 percent. Pressure ulcers are costly, with an average charge per stay of $37,800.2 . . .Given the aging population, increasingly fragmented care, and nursing shortage, the incidence of pressure ulcers will most likely continue to rise.

Preventing pressure ulcers has been a nursing concern for many years. In fact, Florence Nightingale in 1859 wrote, “If he has a bedsore, it’s generally not the fault of the disease, but of the nursing”4 (p. 8). Others view pressure ulcers as a “visible mark of caregiver sin”5 (p. 726) associated with poor or nonexistent nursing care.6 Many clinicians believe that pressure ulcer development is not simply the fault of the nursing care, but rather a failure of the entire heath care system7—hence, a breakdown in the cooperation and skill of the entire health care team (nurses, physicians, physical therapists, dietitians, etc.).

CNAs are on the front lines of this battle in long-term care facilities everywhere, and while we are outnumbered by RNs in the acute-care setting, our role in detecting skin abnormalities is no less vital.  So how can we best help our residents/patients avoid developing pressure ulcers?

  1. Be vigilant about skin issues when caring for patients with:  diabetes mellitus, peripheral vascular disease, cerebral vascular accident, sepsis, and hypotension.
  2. There’s no “one and done” – a pressure ulcer, according to this source, can develop in 2-6 hours – so keep watching out for skin changes at each peri-care session and/or brief change.
  3. Avoid using hot water, and use only mild cleansing agents that minimize irritation and dryness of the skin.
  4. During skin care, avoid vigorous massage over reddened, bony prominences because evidence suggest that this leads to deep tissue trauma. Skin care should focus on minimizing exposure of moisture on the skin.
  5. Follow turning/repositioning schedules as delegated.

This publication also addresses the incidence of pressure ulcers in more darkly pigmented skin: 

**The Stage I pressure ulcer may be more difficult to detect in darkly pigmented skin. A quality improvement study in several nursing homes found that by empowering the nursing assistants with education (skin assessment), use of pen lights to assess darker skin, mirrors, and financial reward, the researchers were able to reduce the Stage I pressure ulcers in residents with darkly pigmented skin.

So how about it?  Share your comments, including your skin integrity promotion techniques below!

*Hughes, R. G. (Ed.). (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: US Department of Health and Human Services Agency for Healthcare Research and Quality.

 **Rosen J, Mittal V, Degenholtz H, et al. Organizational change and quality improvement in nursing homes: approaching success. J Healthc Qual. 2005;27(6):6–14. 21, 44. (41 ref) [PubMed: 17514852]