Teach back

Get your patients to “teach back” what you have taught them. Get them to repeat what you have taught them. You may be surprised at how little information your patient has absorbed from the education you have given. Using the “teach back” or “repeat back” method can help you gauge just how much information your patient is retaining.

With the “teach back” method, it’s exactly as it sounds. You get your patient to teach you what you taught them. This method is really effective for education that involves hands on training. Things like changing a colostomy bag at home, changing a wound dressing, giving tube feeds, doing peritoneal dialysis, etc all require a lot of teaching. These are thing you want to make sure your patient understands before they return home. When you get them to teach it back to you then you know that they have an understanding of the information they have received. As they are teaching it back, you can correct them if necessary and give them little hints to help them with the process.

“Repeat back” works well with information that may not require as much hands-on work. I found that it works well with my patients that are being sent home with multiple prescriptions, especially different inhalers. I had a patient with COPD and asthma (and yes, she still smoked, how did you know?) that had both Symbicort and an albuterol inhaler. She ended up on our unit from a bad asthma attack. When she started to get wheezy I took her the albuterol inhaler to help open her up and she refused. I couldn’t understand why. She said “that’s not the one I need for my asthma, I need the other one”. Confused, I asked her if she was referring to her Symbicort. She said yes, that’s the one she takes when her asthma flares up. She took her Symbicort whenever she felt tight or wheezy and took her albuterol twice a day. OH, nooooooow I know why you’re in here. I tried explaining to her that the Symbicort is for her COPD, not asthma. She argued with me for a good 10 minutes that I was wrong. I had to not only print out information on Symbicort but also have the doctor talk to her before she accepted that she has been using her meds wrong this whole time and that is why she was in the hospital. Upon discharge I made her repeat the education I had given her and show me which inhaler was her twice daily inhaler for COPD and which inhaler was for her asthma. I felt comfortable that she understood her meds upon discharge.

I think this teaching our patients about their health is where the medical system is lacking. Often, we are in such a rush to get people out so we can get people in that we just assume the patient understands because they didn’t ask any questions. Often, it’s the opposite. Some are embarrassed to say they don’t understand. Some can tell we are in a rush and don’t want to bother us by asking us to repeat what we have told them. It is up to us to make sure our patients are leaving with a full understanding of their health and their medications.

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TJC

So The Joint Commission is here this week…

Yay.

If you don’t know, TJC is an accrediting body for hospitals that makes sure we are doing things according to acceptable standards. In all honesty, it’s a good thing. It makes sure we are on our sh!t. I am okay with that.

However…

When TJC visits it turns every unit into chaos! What do I mean? Well, each hospital gets a “heads up” that TJC may be visiting within a date range. This sends every manager and compliance officer into a panic. Typically it goes a little something like this:

“Is this dated?”

“When does that expire?”

“Move this stuff out of the hallway and even though we have no true place to store it, FIND SOMEWHERE!”

“Do you know where the evacuation plans are for this unit?”

“Where are the fire extinguishers located?”

“How long does it take the purple wipes to disinfect?”

“What about the gray wipes?”

“And the red ones?”

“What is the temp on the fridge?”

“Where is the temperature log?”

“Where is the check sheet for the code cart?”

“Is there an expiration date on the Accucheck controls?” 

“All cups must have a lid on them or I am throwing them away!”

This continues for the entire week that TJC is in the hospital. All those things that we should have *technically* already been doing, we are going to do them all RIGHT NOW. I have been lucky. For eight years I worked 1900-0700. TJC is not in the hospital at night and neither is management so I avoided most of the shenanigans. Now I work days and evenings. I am now in the line of fire. I have been on my toes all this week just waiting to see the group of them come around the corner. So far I have avoided them. Let’s hope my luck continues!

So you have to send your patient to MRI…

So your patient needs an MRI. Maybe you can just send them down with transport, maybe you have to come down with them. Here are 10 tidbits to help make it easier or yourself and us.

  1. THE MAGNET IS ALWAYS ON. ALWAYS. 
  2. Because of #1, don’t bring anything you don’t need on your person. Majority of what you carry is not MRI compatible and you’re going to have to leave it somewhere away from the MRI room anyway.
  3. Also, don’t leave anything on your patient that they don’t need. The 4 blankets? Yeah, let’s consolidate that. The SCD’s? Leave those in the room. The stickers from their morning EKG? Take those off, they aren’t MRI safe. No, your patient can’t bring his/her phone with them. Your patient will need to be moved off of the hospital bed and onto the MRI safe stretcher, let’s make this easy on everyone.
  4. Coming down with your patient? Understand that you aren’t just going to walk into the MRI room when you get downstairs. You may be in a rush, we aren’t. Safety is our number one priority. We have to make sure you don’t have anything unsafe on you and we have to check the patient for the same reason.
  5. ICU nurses please note: your ECG leads and pulse ox are coming off once you get here so be prepared to replace those. We have our own MRI compatible monitoring equipment, your patient will be monitored using our stuff not yours.
  6. Take a look at what IV fluids you have hanging, are they necessary? Your IV pump is not compatible with the MRI machine. No, seriously, it’s not. You are probably going to have to add like 30 feet of extension tubing to your drips unless your hospital has the MRI safe pumps and there aren’t many hospitals that have them. Do you really need to bring the patient down on normal saline? Really? Can the TPN and lipids be paused for 30 minutes to an hour? Thinking of this while you are still on the unit is going to make the transition much easier. ICU nurses, take note because we are notorious for bringing down drips that could really be paused for this test. I’m not saying be unsafe to make it easier, just use your judgment.
  7. The magnet of the MRI interferes with the ECG monitor, you are NOT going to get a good rhythm while your patient is in the scanner. This, in particular, applies to my ICU nurses. Please understand that there is nothing we can do about that. The monitor is wireless and whenever the magnet begins scanning it disrupts the signal so the rhythm that we see on the monitor is garbage. In between scans you will see a normal rhythm but once the technologist begins the next part of the study you are going to see nothing but artifact. If your patient has been having unstable arrhythmias you may want to speak with your docs about the risk/benefits of coming down for the scan. You may want to wait until you can trust that they aren’t going to jump into some funky heart rhythm during the scan. That MRI of the foot can wait.
  8. Pacemakers no longer exclude a patient from having an MRI. It used to be having a pacemaker was an automatic “no”. That has since changed. There are now MRI conditional pacemakers and we are now scanning patients with MRI non-conditional pacemakers. That being said, let your physician know that an MRI on a patient with a pacemaker is NOT going to happen the day it’s ordered. Many steps have to be taken to assure we do this in the safest manner possible. We need paperwork from whatever company manufactured the pacemaker. We then have to set it up so that a technologist from the company can be there to put the pacemaker in “MRI-safe” mode.
  9. FYI: MRI safe mode does NOT mean we turn the pacemaker off for the scan! This was something I was not aware off until I became a radiology nurse. It’s the exact opposite. The pacemaker mode is actually changed from pacing only when needed to pacing continuously at a set rate determined by the doctors and set by the technologist from the company.
  10. Do not send your patient down if they are claustrophobic, altered, or in pain unless you have a plan. For a successful MRI, the patient MUST lie still for the ENTIRETY of the scan. If they move, that section of the scan must be restarted FROM THE BEGINNING! If you know they are claustrophobic, ask for something to help calm them. If they are altered and can’t hold still, ask for a sedative of some sort or reschedule. If they are in pain, please premedicate them. The MRI table is hard and uncomfortable, your patient won’t be able to tolerate the scan if they are already in pain.

Hopefully these 10 tidbits of info make your trip to MRI a tiny bit easier.

Full circle

I started working in a hospital on my birthday in 2007. In this particular hospital, there were two separate transportation teams. One did regular transports and discharges and the other only did transports to and from radiology departments. I started as a transporter in the radiology department. The hospital offered a free EMT-B course, all you had to do was pass. Of course I took up that offer! I transported for over a year and in the process started nursing school. That’s when I decided to become a tech. After graduation, I worked on that unit (med-surg) for two years. I hated it. I am not a med-surg nurse. I got frustrated very quickly with all the frequent flyers. I felt like I wasn’t making a difference. No matter how much teaching I did I knew I would see those patients in a month, maybe two. So I left the hospital to take an ICU position in a smaller hospital. It was hell for me to go from a teaching hospital where I was autonomous and a part of the care team to a community hospital where I was supposed to just do what I was told. Yeah, no. They got two years out of me as well before I took an ICU position in another teaching hospital. I loved it. I learned so much and got to be a part of things I had never experienced before. The only drawback was the commute. An hour and a half one way, and I was working night shift.  I managed to pull this off for three years. I kept telling myself I would move closer to the hospital but I never did. I love the city I live in right now. I love the diversity, something that was lacking in the area that particular hospital was in. So, I started the job search again. Guess what hospital and what department were in need of a nurse? Yep, my first hospital and the opening was in radiology! I jumped at the chance and luckily got the position.

Its been a bit surreal. Being back in the radiology department feels familiar and new at the same time. Most of the radiology techs and nurses were there when I first started. They remember me as a transporter from 11 years ago. Now here I am in their department as a clin 2 nurse! I’ve come full circle.  I am getting used to being the new kid without actually being a new kid. Maybe, just maybe this is where I was supposed to be all along…

 

Log off

Log off of your computer, nurse!

I know you’re just going to go into the room of your patient for a few minutes. I understand that you just need to go to the pyxis and grab one more med. Log off.

You have very personal information about your patient visible for anyone to see. EVS, the random med student, the family member/friend in the room (for those of you with bedside computers), they can all see this very personal information.

How would you feel if one of your friends found out that you tested positive for opioids on admission because your nurse left your labs open on the computer in your room? You’re sedated and intubated so you can’t remind the nurse to protect your personal information.

Doesn’t sound fun does it?

Your patient and their information deserve that same respect.

Even more importantly, it’s law. You have been given the responsibility to maintain patient privacy and you should take it very seriously. You’ve heard of HIPAA. You know just how important it is. Understand just how serious it is to your medical facility. Nurses have been written up, suspended, even fired over HIPAA violations.

Don’t be that nurse.

Get into the habit of logging of when you walk away from your workstation. It may seem tedious but it is your duty to protect that information.

That’s so gross

You would think the grossest thing that I have seen as a nurse would involve the patient.

Oddly enough, no.

I can say for sure the grossest thing I have seen is the patient’s family member(s) sleeping on the floor of the room.

DO YOU KNOW WHAT HAS BEEN ON THAT FLOOR?!?!?

I have walked into the room and nearly tripped over a family member sleeping peacefully on the floor. I was immediately freaked out. Like, what makes someone think sleeping on a hospital floor is safe or sanitary?

Oh, you have to get up off that floor honey.

There have been soiled linens, blood, body fluids that I can’t describe, EVERYTHING on that floor. Glare all you want but I’m not leaving you down there.

People think hospitals are far cleaner than they actually are…

Consent and ethics

Nursing is fully aware of consent. We know that we need to have documentation that the patient accepts this treatment. It’s a no brainer. But, what if the patient doesn’t want treatment and the power of attorney does?

Prime example, you have an elderly patient that is obviously letting the family talk them into surgery. To no one’s surprise, it doesn’t go well. They end up sick. They have to remain intubated. They need an art line, central line, pressors, the works. Even on the ventilator they are adamantly shaking their head no to all the things you’re trying to do. They are fighting. They keep trying to pull away. They don’t want this.

Their family does.

The POA is who the doctors decide to ask for consent to treat. They completely bypass the patient. They’re intubated, they can’t answer for themselves right? If course the family wants everything done… So, everything is done. Is that fair to the patient?

Shouldn’t the patient be allowed to say no without having someone else choose otherwise? What is the fine line that decides when a patient no longer has the capacity to make their own decisions? Does intubation automatically take away that right? Does having a POA take away that right? If a patient is clearly communicating, even in the vent, shouldn’t we respect their wishes?

The nurse in me says yes. The nurse in me says to respect my patient’s dignity.

The nurse that’s been at the bedside for almost 8 years knows that that is normally not the case.

I have seen advanced directives ignored because the patient is unconscious and the family isn’t ready to let go. I’ve seen cases like the one mentioned above. I’ve seen doctors watch as the family is almost forcing a patient to go along with treatment and the doc just goes along with it as well. I’ve had to be a part of “moral distress” meetings because nurses were stressed over the ethical dilemmas involved in certain cases. When do we stop?

“Do you have any allergies?”

How often do you ask your patients about their allergies? Better yet, do you clarify and ask about medication and any other allergies?

We get in the habit of trusting our doctors who order the meds and the pharmacy that verifies the meds. However, we may need to get into the habit of asking about food, medication, and “any other” allergies on admission.

When doing the admission database I used to always ask whether the patient was allergic to any medications. That’s all I figured I needed to know… until a patient was negatively affected.

Way back when I was a Med-Surg nurse there was a patient that needed a CT scan. No big deal, he tolerated the scan fine but his kidneys, however, did not. We started noticing his BUN and creatinine creeping up, his urine output decreasing, all for no apparent reason. He just didn’t look as good as he should. He said he has had a CT scan before and never had any trouble. He had no known allergies. He was not a renal patient. It didn’t make sense! One of our nurses happened to be in the room giving him a saline bolus to see if we could get his urine output to pick back up. He was questioned about his previous CT scans again and this time he mentions that one time they “put something in his IV “and it “made him sick and put him in the hospital” but “that was years ago.”

Oh really?

Well, guess who had a CT scan with IV contrast… Mind you, he said he had no allergies. Turns out because of his education level he only considered medications to be the pills he took at home so the IV contrast allergy didn’t register with him. I don’t think he even understood that his reaction was an actual allergy.  He didn’t really know what IV contrast was and since we only asked about meds, he didn’t see a reason to mention it.

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Looks like we found our problem guys.

Needless to say, that changed how I asked about allergies. I try to keep my patient’s education level in mind when asking questions. I want to make sure they understand what I am asking them. It is my job to keep them safe. As the nurse, we are often the last safety check before something reaches the patient. We block all the foolishness from getting to our patients because we are awesome.

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Charge

I’m a charge nurse on my unit. I actually wasn’t comfortable taking on that role but my coworkers thought I would do well so I said ok.

Some days I regret that decision.

Don’t get me wrong, I do enjoy having new responsibilities. I like seeing nursing from a different perspective. I rather enjoy the decision making that is left in my hands.

I do not enjoy the stupidity that I encounter. For instance, our OR and ER are fully aware that because of the way EPIC is set up, we need an admission order placed by the physician so that bed center can place the patient on our bed board. If the patient is not on our bed board then we cannot pull them onto our unit list and thus we cannot get into their chart once they arrive to our unit. If we can’t get into their chart then we can’t see their orders. If we can’t see their orders then we can’t carry them out. They know this. It never fails, however, the doc will call us to tell us they need a bed but not put in the order. Once they arrive to the unit, they want to look at us crazy because we can’t start carrying out their orders and draw admission labs. It is now to the point that if the admission order isn’t in then we just don’t take report. Why? Why do we have to go through this!

I also do not enjoy the micromanaging. There is a list that charge nurses have to carry out each night. I have to check and see if everyone’s admission database is done, whether each patient has an up to date blood band, whether each patient has ICU and blood consent, whether each patient with restraints has an up to date restraint order, and whether or not each patient has a daily weight. Because heaven forbid we hold nurses accountable for their patients! I understand some of the list. I know when I have patients I rarely check the admission database. There are typically too many other things taking place for me to worry about that at 0034 in the morning. Consents though? As the nurse, I should be checking those. I feel like it’s micromanaging. More importantly, how are nurses going to form the habit of checking for consents and active blood bands if I am always doing it for them? It is my least favorite thing to do and everyone knows it.

Overall, I am still glad that I decided to become a charge nurse. I have a greater understanding of why assignments are the way they are sometimes. I understand how difficult it is to decide who is getting the next admission. I understand the frustration involved with moving patients out just to make room to get patients in. I realize now that the reason I am just learning of the admit I am getting, because ER is on the phone to give me report, is because the charge nurse is just learning of the admission as well. Things that I used to take as a personal strike against me no longer bother me. I realize the charge nurse doesn’t have the time to spiteful. It’s too damn busy for all of that. Being in charge has given me a whole new perspective.

Gory Glory

I’ll admit it, I like the gory stuff that nursing involves. We recently had a crush injury admitted to our unit and when they took down the bandage I was all up in there! I wasn’t the only one. My coworkers were all up in it too.

The gory things never really bothered me. I have always been great at doing wound care. The bad wounds were the ones I really got into. I think that is why I really wanted to get into a trauma ICU at a true trauma center. I wanted to play in that fun stuff. Blood is just a part of the job. If there is blood coming out of the body I just need to replace. I can do that. Foot falling off? No problem. Blood spurting everywhere? Let me apply some pressure. Ribs cracking while I do chest compressions? Well, that just means I am doing a good job.

And then there’s mucus…

I HATE MUCUS. Nothing turns my stomach like the sound of a trach that needs to be suctioned. I don’t know why it bothers me so much. But that’s not the worst of it. When there are mucus bubbles popping up around the trach… Grossed_out

Before I go into suction I definitely have to take a moment to get myself together.

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