GFR

Now that I am in the radiology department I spend a lot of time focusing on GFR and kidney function. Why? Good question!

In MRI and CT we give contrast to a lot of patients. In CT the contrast is iodine based. In MRI the contrast is gadolinium (metal) based. Both types of contrasts are filtered out through the kidneys and thus the reason kidney function is so important in this department. The way we assess kidney function is by checking a patient’s creatinine level in their blood. Luckily for us we have machine called the i-Stat that can test the blood and give a result in two minutes. The result transfers into Cerner (our EMR) and the computer then uses that result to calculate the GFR. Great… except I didn’t really have an understanding of why we were checking the creatinine, what GFR really was, or why there is a GFR result for African Americans and non-African Americans. I decided to do a little reasearch and I figured, since this is a nursing blog and all, why don’t I share what I have learned?

What is “GFR”?

GFR stands for glomerular filtration rate. Basically, the GFR tells you the flow rate of fluids through the kidney. Your glomeruli are the capillaries in your nephrons inside the kidney. Blood is filtered across the capillary membranes helping to remove waste that can ultimately be excreted through the urine. Taking you back to anatomy and physiology in nursing school aren’t I? *shudders*

A simple google search will bring up lots of GFR calculators. Typically the GFR calculator takes into account serum creatinine, age, gender, and race (African American versus not) and then it will give you the estimated GFR. A GFR >60 indicates a generally healthy kidney. Less than 60 can indicate potential kidney disease. Less than 15 can indicate full on failure. Here is a little infographic that is patient centered.

Why creatinine?

Why does the GFR equation use creatinine? In the most basic terms, creatinine is a waste product of creatine. Creatine is used by the muscle cells for energy. Your kidneys help filter the creatinine out of the blood to be excreted in the urine. Low creatinine typically indicates good kidney function (which makes sense, healthy kidneys will filter out creatinine effectively). High creatinine indicates the opposite, kidney function is probably on the lower end because the kidneys are unable to filter out the waste product. Creatinine is primarily filtered out through the kidneys which is why it is a pretty good indicator of kidney function.

Why is the result different based on race?

Many, many times I have looked at my labs and wondered why the GFR had a result for African Americans and then essentially everyone else. It wasn’t until I started working here and paying attention to the GFR that I decided to look it up. Turns out studies show we have “higher than average” muscle mass so we generate higher levels of creatinine. Higher creatinine levels lead to higher filtration rates. The difference in results account for this.

Now I can actually explain to my patients why I am taking blood after I start an IV. I like to be able to asnwer my patient’s questions so of course I had to do a little learning on my end. Hopefully some of you will also find this information useful! (Also here is a great reference for frequently asked questions from the National Kidney Foundation because, why not!)

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Look at me when I’m talking to you!

I am going to vent for a moment so bare with me okay?

I ABSOLUTELY HATE WHEN MY PATIENT DOES NOT LOOK AT ME EVEN ONCE WHEN I AM SPEAKING TO THEM!

This has nothing to do with eye contact. I know for some people, eye contact is uncomfortable or unusual in their culture. I get that. However, when I call someone into my IV chair and they can’t bother to put their  phone down long enough to raise their head and answer my questions it burns me up! I just feel like it is so disrespectful! Is that how they converse with everyone? No, I highly doubt it. I think *that* is what bothers me the most. I am simply trying to provide care within my environment. I didn’t force them to come to this hospital, nor did I force them to make an appointment for whatever reason they are here. I feel like the least someone can do is acknowledge that a human being is standing in front of them providing care.

There have been times when I am trying to go over information with a patient and they are so engrossed in whatever is happening on their phone that they have a hard time answering my questions. Typically this statement will get me the acknowledgment I prefer: “Let me know when you are done on your phone and then I I’ll continue.” After that I take a step back and wait. Patients will typically put the phone down and pay attention.

In all honesty, I don’t need their undivided attention the entire time they are in my care. Since I am the radiology nurse, I am going to be the one to go over the contrast questionnaire with the patient and then I will obtain vascular access. This isn’t dramatic stuff here. I really only need the patient to pay attention when I am asking them questions, after that I actually prefer they occupy themselves because most often it means they’ll focus on their phone and not on the 20g I am about to stab them with.

I don’t know, maybe I’m just getting old or something but a little acknowledgment wouldn’t hurt.

Uniform… Acceptance…

The hospital I work for has a uniform policy. As nurses we wear ceil blue and/or white. I hated the idea of uniforms… At first.

Now, I kind of like the fact that each department in our hospital has a uniform.

Yeah, it surprised the hell out of me too!

It helps me know who I’m talking to or who just walked into my patient’s room. I’ve often had patients say, “the doctor said I can have something to eat!”, however I haven’t seen the docs come onto the unit. Now I’m trying to figure out who my patient was actually talking to so I can find out what was actually said. With everyone being in uniform I can ask my patients “what color uniform were they in?” I cannot tell you how many times I’ve asked that question and then find out it was xray technician that came in to do the morning portable chest xray that the patient talked to! For a lot of our patients, anyone in scrubs is a doctor.

The fact that I can identify a department just by their scrubs is a real help and as much as I hate to admit it, uniforms made things a lot easier. I only have one big complaint, THESE COLORS!!!!

I despise the ceil blue/white combo. I would really prefer a darker color. Something like a hunter green or a navy blue would work for me but it is what it is.

So tell me, what policy did you initially hate that you’ve learned to accept and perhaps even like?

I’m a nurse, and the worst patient

I am a nurse. I am very proud of that, I mean, I have a whole blog dedicated to being a nurse!

However, I am the worst patient.

Lately I have had to be a patient far more than I want to be. (Here is a link to my blog post on why I have had to be a patient frequently.)

I don’t know how to stop being a nurse and sit back and be the patient. I don’t know how to shut up and listen. I want to talk. I want to tell the doctor what I know. I want to be in charge of my care. I want to be the nurse.

I don’t like not running the show when it comes to my own care. However, this situation is aggravated by the fact that I don’t even know what is going on with my health. I feel completely helpless… and humble. I now understand the fear my patients have when they are coming to get scanned. As you all know, I work in radiology and a majority of the patients I work up are there to get scans to either see if they have cancer or to see if their cancer has spread. They are coming in dealing with the unknown. The fear, the anger, the tears, the blank stares, I understand why my patients exhibit so many emotions. It’s the unknown. I am going through it now and I am pretty sure I have gone through a lot of those emotions. I am blessed to not have cancer but having to go from seeing a family doctor, to a pain specialist, and now to neurologist, all because I have spreading neuropathy is scary. I don’t know what is wrong with me and as a nurse that drives me nuts.

I am a nurse, I help people get as healthy as they can. My job is to literally fix people and yet here I sit unable to fix myself because I don’t even know what’s wrong. I feel so helpless. I want someone to say “This is what is wrong and this is how we fix it”. I want to fix myself like I fix everyone else. I want to nurse myself back to health.

I don’t even know where to begin so friends I ask: do you have any suggestions for not going crazy as I work through this?

Dear administration

Dear hospital administration,

Hi, I’m just a lowly nurse here in your hospital but may I make a suggestion?

Please, PLEASE include the staff that will be working in a new area in the design of that new area!

I know you think you, the architect, and the contractor know what’s best but you don’t. YOU DON’T. You all look at what looks good. I mean, everything looks great on paper. What you aren’t paying attention to is whether or not the area will function for staff.

I cannot tell you how many times I’ve walked into a new area and immediately started picking out what doesn’t work, what needs to be moved, and what needs to be completely redesigned. I’ve seen areas opened and then closed so it could be “remodeled”.

Stop it!

You could save money, time, and stress by doing it right the first time. Let us be a part of the planning process. Let us be a part of the “walk through”. Talk to us and find out what we do and don’t need in the new area. Talk to US! It will benefit everyone in the long run, I promise…

The kids are alright

This is my last week of shadowing in the PACU. I’m ending my week in pediatric pre and post op.

😒

I have been a grown up nurse my whole career. Med surg, small ICU, STICU, that’s what I know. I know how you fix an adult. I know nothing about children.

I am not good with kids. I’m uncomfortable around them. I’m not used to kids. I am out of my element.

I feel so freaking awkward!

I am so useless in here. It’s not because the nurses aren’t teaching me. The PACU nurses have been amazing. I just don’t know how to handle kids. I have none of my own. I don’t want any. I have no maternal instinct. I have little patience for crying. I’m just not good with kids and I’m well aware of that.

So here I sit, on my phone, typing up this blog while on lunch, hoping I survive a few more hours so I can go back to my adults in radiology on Monday…

OR 4

I’ve been shadowing in the pre and post op unit for the last week. I am still a radiology nurse but I’m up here learning a few things. In MRI we give some of our patients propofol to sedate them so they can tolerate the scan and then we recover them afterwards. My department has me floating in PACU to evaluate how PACU recovers patients to see if there are things we need to bring back to our department. I’ve been enjoying myself so far. Today I am following the sedation nurse. We are in OR 4.

OR 4 is where they are doing all the abortions today.

I wasn’t prepared.

I have no children and have never been pregnant. I have no desire to have kids. Honestly I’m not fond of them. I am pro-choice. I consider myself pretty liberal. I don’t judge women who choose to have an abortion.

I was still not prepared.

I’ve read about abortion. I know people that have had them. However, I have never actually seen an abortion and after today I don’t need to see anymore.

It’s emotional.

One was because of fetal deformity. Most were not. The reason didn’t matter. You could see the anguish in some of the faces of the patients. Some were stone faced and I couldn’t really tell how they were feeling. A 16 year old seemed not to really have a full grasp of what was really happening. One lady cried and expressed her feelings of guilt the whole procedure.

It’s was a lot to deal with.

The procedure itself was different than I expected. Mentally I has to steady my nerves to watch how the fetus was removed. Typically I stayed at the head of the table with the patient for their comfort… And my own. I tried to focus on the patient and not the procedure so I could keep my emotions out of it.

This is definitely something I could not do on a regular basis, if I could ever do it at all. This experience is something I definitely won’t forget.

I still remain pro-choice even after today. Now I understand what women go through not just physically but emotionally when having to make this choice. It’s so much deeper than what I understood.

The complainer

Don’t be the complainer.

You know the one, nothing ever goes right for this nurse. They are the ones that come in and start complaining before they even clock in. They always have the worst assignment. They always have the worst shift. Everything is always wrong.

Two total care patients that only really need repositioning? “OH MY GOD WHY DO I HAVE TWO TOTAL CARE PATIENTS????”

Four walkie talkie patients that are self care? “GREAT THEY ARE GOING TO DISCHARGE SOMEONE AND I’M GOING TO GET AN ADMISSION!”

Float to an easy unit with cool ass staff? “WHY IS IT MY TURN TO FLOAT???”

Go home.

Why are you even here? Why are you even a nurse? What did you expect from the health care field? No, our jobs are not a roses and sunflower fields every shift. Sometimes our jobs suck, horribly. Honestly though, if every shift is your worst shift ever and it’s like that no matter where you work… I hate to be the bearer of bad news but it’s not the job, it’s you.

I mean, you’re the common denominator here. It’s time for you to face the facts: you’re miserable at your job because you’re just miserable as a person. Maybe you should work on that…

ABG’s, what do they mean?

Arterial blood gases… Chances are if you work in a progressive care or intensive care unit you have seen ABG results or you will.

If you’re like me in the beginning, you have no idea how to interpret the results. For the longest time I had no idea what I was looking at. I knew the pH was indicative of acidosis or alkalosis, and that was the end of it. Once I started working in an ICU I wanted to really understand what the results meant. I made one of our respiratory therapist teach me how to understand the results (he was awesome and was happy to help). It turns out ABG results are not too terribly difficult to interpret. You are trying to obtain three key pieces of information:

  • Is the patient acidotic or alkalotic?
  • Is this a respiratory or a metabolic issue?
  • Is the body fully compensating, partially compensating?

While there is plenty of information on the ABG slip (or in the chart if your unit doesn’t have an ABG machine available) you can come up with the answer by looking at three key results: pH, paCO2, HCO3.

One of the ECCO learning modules I did had this handy little chart that made it easier to interpret the results. I thought I would share it with you all in case there is someone out there confused like I was, but may not have a quick resource available.

That’s it. This little handy chart has helped me a lot. It took what was, for me, a larger amount of overwhelming information and broke it down into something I could use. Here’s how to use it:

Look at the pH, is it <7.35 (you’re acidotic) or >7.45 (you’re alkalotic) or is it normal? Circle which side of the chart your value falls in. Then look at the PaCO2. We are looking at carbon dioxide in the blood here. Repeat the previous steps and circle where your value falls. Then look at your bicarb, HCO3. Circle where that value falls.

Remember pH tells you if they are acidotic or alkalotic. Now that you’ve figured that part out, it’s time to figure out if this is respiratory or metabolic. Look at your chart, is the CO2 circled on the same side as the pH? If yes, it’s respiratory. Is the bicarb circled on the same side as the pH? If yes, then it’s metabolic. Now, are we compensating? If you are partially compensating then you will have one value on the other side of the grid. If you are fully compensating then your pH will actually be normal.

I’m a person that needs to see something in action so let’s do a couple of examples:

Note let’s break out the chart:

pH is low so we know the patient is acidotic. The CO2 is on the same side as the pH. The bicarb is on the opposite side of the grid so the body is trying to compensate. We have respiratory acidosis, partially compensated.

Let’s do one more:

Bust out the handy dandy chart!

The pH is high so we know it’s alkalosis. The bicarb is on the same side of the chart as the pH but the CO2 is on the opposite side. Here we have metabolic alkalosis, the respiratory system is partially compensating, that’s why the CO2 is high.

I would like to mention one thing, if all your values are on the same side of the chart then it most likely means the one of the systems of the body aren’t compensating.

Hopefully this post is able to help someone out. If you have any other hints, tips, tricks let me know!

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.