Tuesday, 21 August 2018

Early in my career as an ICU nurse, I was lucky enough to have a preceptor who helped me develop a solid morning routine I have carried ever since. Because my experience is primarily Cardiac ICU, this routine mirrors what I do in that area of practice, however, it can be tailored to meet the needs of any ICU patient.

Nurse Career, Nursing Responsibilities, Nursing Certification

While the following list may look like a lot, pending any instabilities or interruptions with the patient, it can be completed within 30-90 minutes (depending on experience level) for each patient after a few months of experience.

Of note, this routine is completed simultaneously with a thorough head to toe assessment. The steps for a head to toe assessment are not included in this post. The purpose of this is to incorporate parts of a morning routine that are often missed, but when completed, can make your day much smoother.

This is how I do it but, make sure to follow your hospital's protocol or previous training.

The following comprises the 20 integral steps that have worked for my personal routine as an ICU nurse.

1) Upon arrival to the unit and after receiving your assignment, breeze past both patient’s rooms and glance at the patients and monitors. Make sure nothing needs your immediate attention, and if the patients are restrained, make sure the restraints are tied properly.

2) Take bedside report – it is evidence-based practice to receive report at the bedside. Encourage your peers to partake in bedside report as well.

3) Do a quick check of orders, medications, and the morning chest X-ray. Also, trend pertinent labs. Looking at the trend of labs is very important. For instance, you can note if a hemoglobin is dropping or a white blood cell count is trending up. Whereas, if you just look at the morning set of labs, you will not know if your patient’s condition is worsening or improving.

4) Go into the room of the most critical patient first.

5) Check drip concentrations, confirm the weight programmed into the IV pump matches the patient. Confirm infusion rates, and patient name on IV bags.

6) Check monitor alarm parameters. Alarm parameters should be patient specific. For example, if your patient lives with a heart rate of 50, you will want to set the high alarm around 70 and low alarm around 45. But if your patient has a heart rate of 70, the parameters might be set 50-100.

7) Check the IV access on patient. Flush all peripheral IVs and central access with a normal saline flush to ensure proper functioning. I always make a note of the functionality of my access and think, “if my patient were to code, where could I push code drugs?”

8) Check for an accessible ambu bag in case of emergency, trach supplies and obturator if warranted, and ensure one suction apparatus is set up and functioning.

9) Check ET tube size, length, and vent settings, including peak pressure.

10) Check settings on any device and insertion sites: CRRT, IABP, LVAD, ECMO, PA cath etc. Level, zero, and flush all tranducers, note waveforms.

11) Note the feeding tube length and securement, check residuals and placement if applicable (tube dependent and per hospital policy.)

12) Note the date on central line dressing and all dressings. Change per hospital protocol.

13) Complete urinary catheter care and make sure there are no dependent loops or kinks in tubing.

14) Make sure all chest tubes, cords, IV tubing, drains are operating properly (either hooked to suction or not per order, canisters aren’t full, tubing isn’t under patient, etc.)

15) Note the patient’s skin, particularly the bottoms of heels and behind the ears. Prop heels on pillows, change draw sheet and chucks pad, note sacral region for breakdown, turn patient.

16) TALK to the patient and develop a plan for the day, also let them know what you are doing during your morning routine and why. The ICU strips so much control away from patients. By giving them the opportunity to develop a plan, you are providing better patient-centered care.

17) Make sure the patient’s call light is in place and the TV is on their chosen channel. You can also put on music for your vented patients.

18) Complete the CAM-ICU delirium scale or delirium scale per your hospital protocol. 

19) Throw away old supplies, Cavi wipe surfaces, move any chairs or tables out of the way that might be blocking a path to the patient or cluttering room.

20) Repeat with next patient. 

What is your morning routine for your specialty? As an ICU nurse would you add anything to the above list?
Question Of The Day, Anxiety Disorders
Q. A nurse notices that a client with obsessive-compulsive disorder washes his hands for long periods each day. How should the nurse respond to this compulsive behavior?

A. By setting aside times during which the client can focus on the behavior
B. By urging the client to reduce the frequency of the behavior as rapidly as possible
C. By calling attention to or trying to prevent the behavior
D. By discouraging the client from verbalizing his anxieties

Correct Answer: A

Explanation: The nurse should set aside times during which the client is free to focus on his compulsive behavior or obsessive thoughts. The nurse should urge the client to reduce the frequency of the compulsive behavior gradually, not rapidly. She shouldn't call attention to the behavior or try to prevent it. Trying to prevent the behavior may frighten and hurt the client. The nurse should encourage the client to verbalize his anxieties to help distract attention from his compulsive behavior.

Monday, 20 August 2018

Q. A 28-year-old client with an Axis I diagnosis of major depression and an Axis II diagnosis of dependent personality disorder has been living at home with very supportive parents. The client is thinking about independent living on the recommendation of the treatment team. The client states to the nurse, "I don't know if I can make it in an apartment without my parents." The nurse should respond by saying to the client:

A. "You're a 28-year-old adult now, not a child who needs to be cared for."
B. "Your parents won't be around forever. After all, they are getting older."
C. "Your parents need a break, and you need a break from them."
D. "Your parents have been supportive and will continue to be even if you live apart."

Correct Answer: D

Explanation: Some characteristics of a client with a dependent personality are an inability to make daily decisions without advice and reassurance and the preoccupation with fear of being alone to care for oneself. The client needs others to be responsible for important areas of his life. The nurse should respond, "Your parents have been supportive of you and will continue to be supportive even if you live apart," to gently challenge the client's fears and suggest that they may be unwarranted. Stating, "You're a 28-year-old adult now, not a child who needs to be cared for," or "Your parents need a break, and you need a break from them," is reprimanding and would diminish the client's self-worth. Stating, "Your parents won't be around forever; after all they are getting older," may be true, but it is an insensitive response that may increase the client's anxiety.

Sunday, 19 August 2018

Question Of The Day, School-age Child
Q. An 8-year-old child is suspected of having meningitis. Signs of meningitis include:

A. Cullen's sign.
B. Koplik's spots.
C. Kernig's sign.
D. Chvostek's sign.





Correct Answer: C

Explanation: Signs and symptoms of meningitis include Kernig's sign, stiff neck, headache, and fever. To test for Kernig's sign, the client is in the supine position with knees flexed; a leg is then flexed at the hip so that the thigh is brought to a position perpendicular to the trunk. An attempt is then made to extend the knee. If meningeal irritation is present, the knee can't be extended and attempts to extend the knee result in pain. Cullen's sign is the bluish discoloration of the periumbilical skin caused by intraperitoneal hemorrhage. Koplik's spots are reddened areas with grayish blue centers that are found on the buccal mucosa of a client with measles. Chvostek's sign is elicited by tapping the client's face lightly over the facial nerve, just below the temple. A calcium deficit is suggested if the facial muscles twitch.

Saturday, 18 August 2018

Q. When assessing for pain in a toddler, which of the following methods should be the most appropriate?

A. Ask the child about the pain.
B. Observe the child for restlessness.
C. Use a numeric pain scale.
D. Assess for changes in vital signs.




Correct Answer: B

Explanation: Toddlers usually express pain through such behaviors as restlessness, facial grimaces, irritability, and crying. It is not particularly helpful to ask toddlers about pain. In most instances, they would be unable to understand or describe the nature and location of their pain because of their lack of verbal and cognitive skills. However, preschool and older children have the verbal and cognitive skills to be able to respond appropriately. Numeric pain scales are more appropriate for children who are of school age or older. Changes in vital signs do occur as a result of pain, but behavioral changes usually are noticed first.

Friday, 17 August 2018

Q. A parent confides to the nurse that their 8-month-old infant is anxious. Which of the following suggestions by the nurse is most appropriate to help the mother lessen her anxiety about her infant?

A. Limit holding the infant to feeding times.
B. Talk quietly to the infant while he is awake.
C. Play music in his room for most of the day and night.
D. Have a close friend keep the infant for a few days.

Correct Answer: B

Explanation: Infants are sensitive to stress in their caretakers. The best way to handle an anxious infant is to talk quietly to him, thereby soothing the infant. Limiting holding of the infant to feeding periods interferes with meeting the infant's needs for close contact, possibly compromising his ability to develop trust. Playing music in the room for most of the day and night will make it difficult for the infant to differentiate days from nights. Having a friend take the infant for several days will not necessarily take care of the problem because when the infant returns to the mother the same behaviors will recur unless the mother makes some changes.


Thursday, 16 August 2018

Question Of The Day, The Nursing Process
Q. A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of:

A. Nursing informatics.
B. Electronic medical records.
C. Telemedicine.
D. Computerized documentation.


Correct Answer: A

Explanation: Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. A specific application of nursing informatics is the use of PDAs in the clinical setting. The devices are less likely to be used to perform documentation or to constitute client records. Telemedicine involves the remote provision of care.


Tuesday, 14 August 2018

Q. When giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of:

A. 15 degrees.
B. 30 degrees.
C. 45 degrees.
D. 90 degrees.




Correct Answer: D

Explanation: When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when administering an intradermal injection. A 30-degree angle isn't used for any type of injection. The nurse may use a 45- or 90-degree angle when giving a subcutaneous injection.

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