With the aging baby-boomer population, one of the largest patient populations a nurse will encounter in the field is the geriatric population. Care of elderly people presents several significant challenges, especially patients with impaired communication or cognitive status deficits. It takes a special health care team to give this unique population the care that they both need and deserve. Here are five tips to keep in mind that will help you provide the compassionate and competent care they are hoping to receive.
1. Meet the patient where they are.
Cognitively speaking, many geriatric patients are not completely intact. They may experience confusion, disorientation, or even delusions and hallucinations. Providing competent and compassionate care requires that you assess the patient for these deficits before providing care. Educate your aides about what a patient’s deficits are so that they can provide the best care possible. While you may be able to successfully reorient some patients, others are not able to be reoriented. These patients may require you to be understanding and compassionate of their orientation level, choosing not to challenge their beliefs and assumptions while providing care. If the patient is calm and relaxed in their disorientation, it may be a safer place for them than if you were to challenge these beliefs.
2. Assess for sensory deficits.
A patient who cannot hear or see well may become agitated when care is being provided simply because they do not understand what is going on. Imagine resting peacefully in bed with your eyes closed and having someone start to roll you or manipulate your body…what sort of reaction would you have? You would probably be startled and attempt to fight back. Taking the time to gently notify the patient that you will be providing care, and making the attempt to communicate through words, motions, or even written words, will help the patient be comfortable and confident in what to expect as you provide care. If the patient normally wears glasses or hearing aids, make sure they are in place before you start. The more a patient feels in control, the better their experience will be.
3. Engage with the patient.
Most health care professionals and ancillary staff know what it feels like to be overwhelmed and exceptionally busy. It often feels like there is little time to stop and converse with our patients before we need to move on to our next task. For a patient who is alone in a room all day, however, a bit of conversation may be what they are craving. Take a few moments before leaving the room to show interest in the patient. Be empathetic if they need to talk or complain. Do not patronize or assume they have little to offer conversationally. Many of these patients have so much to say and great stories to share…you may even learn something surprising about them! A few minutes of genuine, engaged conversation may be the bright spot in that patient’s day and it takes so little of a nurse’s shift, and is certainly worth the effort it takes.
4. Manipulate the environment to enhance comfort.
Harsh lighting and loud noises can be frustrating or even upsetting to patients with sensory deficits. If a patient seems resistant to care and easily upset, try altering the environment by decreasing background noise, eliminating distractions, and providing distance between yourself and the patient when you speak. These simple interventions may seem inconsequential but can be very effective in calming an anxious or agitated patient.
5. Involve the patient in their care.
Perhaps the biggest complaint you will hear from geriatric patients is that they feel they aren’t kept informed about what is going on with their health care. Whether it is a cognitive deficit, communication barrier, or perhaps even a lack of education to understand terminology, the geriatric population often feels powerless over the care they are receiving. Nurses can help this situation by taking time to ask their patients what they understand of their diagnosis and plan of care. Do not assume that they don’t have an interest in what is going on. Allow them to be front and center in their course of treatment by educating them at their level of understanding. Make sure they have an opportunity to ask questions. If they are able to read, written materials can go a long way in helping the patient to understand what is happening to them.
As nurses, we want to empower our patients and give them a positive experience. The geriatric population certainly presents challenges to providing our best care, but by incorporating some of these simple interventions you will likely make a big difference in the patient’s perception of their care.
It’s that time of year: almost everyone is being discharged from hospital visits with an antibiotic. From pneumonia to skin infections to strep throat, there are a myriad of reasons your patients may leave with an antibiotic prescription. With microbial resistance on the rise, and because of the many complications of antibiotic use (C. Diff comes to mind), nurses play a crucial role in ensuring medication compliance and proper home use. Below are some tips for making sure you are teaching your patients correctly about their medications—from penicillin to Cipro and beyond.
1. Make sure your patients know to take their antibiotics with food, preferably at mealtimes.
Many antibiotics can upset the stomach or cause gastritis, so avoid taking them on an empty stomach. (The only antibiotics that should be taken on an empty stomach are ampicillin, dicloxacillin, rifabutin, and rifampin.) A heavy meal is not necessary, but a small snack can prevent indigestion.
2. It is imperative that the patient take the full bottle or dispensed amount, even if they start feeling better before completion.
In fact, it is very likely that the patient will feel better before the prescribed amount is finished. Even so, feeling better is not an indication that the bacteria are all gone. Patients who do not complete their entire prescription help promote antibiotic resistance, because any bacteria not killed yet can go on to reproduce with genes that allow them to avoid destruction by common antibiotics. Sometimes, emphasizing to patients that future antibiotics may not work for them can be an effective way to ensure compliance.
3. If the patient has a reaction to an antibiotic he or she needs to call their doctor immediately.
Several antibiotics can cause rashes or hives, or more seriously, an anaphylactic response. It is important to teach your patients to be on alert if it is a medication they’ve never taken before or if they have had reactions in the past.
For some specific classes of antibiotics, some additional teaching is required.
Fluoroquinolones, such as ciprofloxacin, levofloxacin, or moxifloxacin, can cause tendon injuries. Specifically, patients may experience peripheral neuropathy that can have permanent effects. Caution patients to immediately report any symptoms of pain, burning, pins and needles, or tingling or numbness. Rupture of the Achilles tendon is possible even with short-term use of these drugs.
Antibiotic–associated diarrhea is an overgrowth of usually harmless bacteria that live in the GI tract, most usually Clostridium difficile. In severe cases, C. diff can be life-threatening. The antibiotics most likely to cause a C. diff infection are fluoroquinolones and clindamycin, but diarrhea remains a risk when taking any antibiotic. To help prevent cases of C. diff, patients can take an over-the-counter probiotic or eat yogurt with live and active cultures (but yogurt must be ingested three times a day to be effective).
Certain antibiotics, such as tetracyclines (doxycycline) and fluoroquinolones, need to be separated from divalent cations—found in dairy products, antacids, and vitamins—by at least two hours. These antibiotics can also cause gastritis, so it is important to still eat them with a small meal to decrease this effect.
It’s no wonder our patients can be overwhelmed when taking antibiotics—there is a lot of information to remember! But proper patient education can help nurses play a role in preventing microbial resistance and ensuring safe medication compliance.
You receive your daily assignment and see that it includes a patient discharge. Do you think “Wow, I am so fortunate to be the person today who provides this family with a smooth transition from the NICU to home” or “Ugh, I have a discharge today”?
In our large, Level IV NICU that serves a population that is both high risk and low socioeconomic status resulting in several barriers to discharge, many nurses would answer with a resounding “Ugh.” This response is due to the stress, frustration, and even dread associated with all the moving parts of a NICU discharge. To address these feelings, our NICU team applied the Lean hospital approach to our discharge process.
How did we do apply the lean hospital approach to our discharge process?
Step 1: We reviewed the idea of standard work.
A multidisciplinary team from the NICU formed and participated in a Kaizen (Japanese term for continuous improvement) event focused on the discharge process. The team acknowledged the three elements of standard work: task time, inventory, and work sequence. The team also acknowledged the shared goal of identifying and documenting a “best way” or standard work for our discharge process. This new standard would provide a foundation for process stability and continuous improvement.
Step 2: We defined the current practice.
The team met at the Gemba (Japanese term for where the work occurs) and interviewed stakeholders; mapped out the current process; and highlighted inefficiencies in the discharge process, including: communication issues, a silo mentality of caregivers, batching of tasks, repetition of tasks or rework, and common barriers.
Step 3: We identified our best way and future standard work for our discharge process.
The multidisciplinary team defined the three elements of standardized work as follows:
- Task time: 5-10 minutes
- Inventory: We revised an existing discharge checklist in the EMR in order to standardize documentation.
- Work sequence:
- During a weekly conference, NICU multidisciplinary team discusses and identifies patients appropriate for discharge within 14 days.
- Case Manager flags these patients in the EMR so a best practice advisory (BPA) for the discharge checklist tool will fire once per shift for those health care workers entering the patient chart.
- All health care providers receiving the BPA for the discharge checklist must update and acknowledge the checklist.
- Using the discharge checklist, patients predicted to be discharged within the week will be discussed in a huddle format at the end of patient rounds. Outstanding task will be assigned with expected completion date noted.
Using the Lean hospital approach helped to identify and eliminate discharge process inefficiencies, thereby improving workflow and providing more time for purposeful patient care. Furthermore, applying the lean hospital approach helped to define a new best way or standard work for our discharge process. After all, don’t we all want more time to do our best work?
March 19th is Certified Nurses Day, the time to specifically honor nurses who have earned certifications. According to the American Association of Critical-Care Nurses, more than 768,917 nurses in the United States and Canada held certifications in 2016 (so said data collected by the American Board of Nursing Specialties).
Ever wonder why you might think about earning a certification? We asked Denise Buonocore, MSN, RN, APRN, ACNPC, ANP-BC, CCNS, CCRN, CHFN, an acute care nurse practitioner for Heart Failure Services at St. Vincent’s Medical Center in Bridgeport, Connecticut and the Chair-Elect of the AACN Certification Corporation board of directors for her thoughts on the matter.
What follows is an edited version of our Q&A.
How long have you been in the nursing field, and what certifications do you hold?
I’ve been a nurse for 38 years, with 25 of those years as an advanced practice nurse. I first became CCRN certified after working as an RN in critical care for two years. After completing graduate school and a post-master’s certificate program, I took certification exams for adult nurse practitioner (ANP-BC), acute care nurse practitioner (ACNPC), and clinical nurse specialist (CCNS). My subspecialty is heart failure, so I felt it was important to become heart failure certified (CHFN).
Why do you think it’s important for nurses to get certifications? What does it do for them? For the field?
It is important to become certified because it demonstrates to you, patients and families, and employers and teammates that you have the knowledge, skills, and abilities to meet national standards. Becoming a certified nurse is a mark of distinction and demonstrates excellence. Your RN license demonstrates entry-level competency. Certification validates specialty knowledge. Many employers—especially those on an excellence journey such as Magnet or Beacon—look to hire certified nurses or expect that nurses will become certified as part of the organization’s efforts to build an environment of professionalism and culture of retention.
On a personal level, being certified shows your deep commitment to your profession, lifelong learning, and personal improvement. By becoming certified, nurses may position themselves for appropriate recognition and advancement. As a certified nurse, you are a role model for professional practice and commitment to your team members, and it demonstrates dedication to patient safety and improving patient outcomes.
What’s the difference between board certification and being certified in a specialty?
Board certification is certification that meets the accepted criteria for state licensure. Examples of this are advanced practice exams. Specialty certifications are not required for licensure, but are important in demonstrating the knowledge in that specialty area.
How do you know you’re ready to become certified?
Start by reviewing the qualifying criteria for the certification you want to achieve. Most exams have a clinical practice requirement in the area of specialty before you can apply to take the exam. Then assess where you are on your personal learning journey in your specialty. I believe it is never too early to begin to study for the exam. I think the best part is finding out what you don’t know or what you need to improve on, formulating a plan for learning new information, and then applying new learnings in your clinical practice.
Do you need additional education to become certified? What are the requirements to apply?
RN specialty certifications such as CCRN and PCCN, or subspecialty certifications such as CMC and CSC, have core curriculum knowledge requirements in addition to practice hour requirements. There are many ways for you to gain this knowledge—attending conferences such as AACN’s National Teaching Institute & Critical Care Exposition, taking a live or online review course, reading review books or articles, and taking practice exams to build on your current knowledge and build confidence.
If you want to be certified as an advanced practice nurse (ACNPC-AG, ACCNS-AG, ACCNS-P, ACCNS-N) you will need to graduate from an accredited graduate-level advanced practice education program, and meet specific curriculum and clinical practice criteria to take the exam. The exam qualifying criteria can be found in the certification section of AACN’s website.
What does it take to maintain your certification?
Passing your certification exam is not the end of the road but rather the beginning. Recertification is just as important as your initial certification. It is the mark of true long-term commitment to lifelong learning and improvement. Each certification has specific renewal criteria. Most certifications require a combination of continuing education and professional activities that demonstrate your continuing competency.
What have been the greatest rewards for you that happened because you earned your certification?
The greatest reward for me personally in becoming certified was the validation of my knowledge and a deep sense of achievement and commitment. After I passed the CCRN exam, I remember feeling more confident in my ability to care for critically ill patients. I also felt connected to the community of certified nurses and potential certified nurses. I was fortunate that I had a few colleagues support and encourage me when I was considering taking my first exam. In turn, I have paid that forward to mentor and encourage the next group of potential certificants. That first certification was a catalyst to further my education eventually becoming a nurse practitioner and clinical nurse specialist.
What would you say to someone considering becoming certified in any field?
Do your homework! Look at the test plans, set aside specific time to study, determine how you want to study, and sign up for the exam. If you set up a test date, you are more likely to work toward it. Just do it!
I would make a wager that most nurses don’t see themselves as innovators, even though we innovate all the time. In fact, nurses are probably some of the most creative, quick-thinking people in the workforce. Whether it’s determining the best way to move a patient, the best way to decrease the number of steps you’re taking, or working out how to prioritize sixteen different orders on four different patients, nurses are constantly analyzing and problem solving. From scrub designers to app designers, nurses are often the brains behind many of health care and technology’s latest developments.
Nurses are authors, musicians, engineers, podcast writers, and inventors. We are a creative bunch who are always trying to make life easier for our patients—and for ourselves. From innovative wound dressings to re-purposing gloves or hospital socks for off-label uses, we are always thinking outside the box. We just never realize it.
Because nurses work at such an individual level it is sometimes difficult for us to see how we could affect change at the system level. And it’s not our fault, either: The infrastructure to scale our solutions to the system-at-large is very underdeveloped. There aren’t many ways for us to showcase our ideas to help bridge gaps in health care. We need design-thinking workshops that let us develop our creative thinking and empower us to innovate. We need to highlight our diverse backgrounds, our unique work environments, and our drive to improve patient care delivery.
In your own nursing unit or department, you could start by thinking of a problem. What irritates you every day? Is there a flow issue in your unit? Do you see any glaring areas for improvement? For example, think about how many steps you take per shift. Could resources be shifted or moved so that you and your colleagues can take fewer steps? Imagine what you need to be more efficient. After all, necessity is the mother of invention—and innovation, too. All ideas are potentially valuable: trust yourself and feel empowered to share your thoughts and innovations with others. The future of health care depends on it.
If you are interested in learning more about health care innovations, the Smithsonian’s Lemelson Center for the Study of Invention and Innovation is hosting a free program on March 16th with a panel of innovative problem solvers. If you are in the DC area, you can attend the event (and find more details here). If you aren’t a DC local, you may visit the Lemelson Center online to find program highlights or to explore multimedia content.
Opioid addiction is an epidemic in every US state. A new study in the New England Journal of Medicine has linked opioid-addicted patients to the very first provider who prescribed the medication. The researchers found a correlation between the pain-prescription habits of emergency room physicians and the frequency of their patients becoming opioid-addicted. (You can read an article in the New York Times about the research here.) The bottom line? The risk of opioid addiction begins with a single exposure to narcotic pain medications—which frequently occurs during an emergency room (ER) visit.
Naturally, prescribers are in the most control: They can limit the quantity of pills prescribed after an incident, or change their prescription habits to restrict the instances warranting their use. For example, instead of patients leaving the ER with a prescription for 30 oxycodone tablets after a sprained ankle, they can prescribe 5 pills. Better still, they can prescribe ibuprofen, ice, and rest; if that becomes insufficient for pain control at home, pharmacologic methods can then be addressed.
Although physicians and advanced practice providers write the prescriptions, it is the nurses who most often provide medication education to patients at the time of discharge. It is therefore the nurse’s responsibility to ensure adequate patient education and to stress the dangers of taking opioids to their patients—even before they ever start taking the medication. Now more than ever researchers are discovering that a single exposure to these dangerous medications is enough to put opioid-naive patients at risk for addiction.
Set expectations. Patients may have a right to pain control, but they also have a right to know just how many risks opioids bring. After an injury, many patients seem to think they will be instantly pain free. It is important to manage expectations that some degree of pain after an injury or illness is normal, as their body heals and recuperates. It is when the pain become unbearable that they should turn to pharmacological relief.
Discuss alternatives. After a musculoskeletal injury, other methods of pain control can be useful. Consider teaching patients to RICE (rest, ice, compress, and elevate) their injuries, and offer other methods of pain control such as distraction, positioning, massage, heat, and ice.
Lay out the risk of addiction. Narcotic drugs are very risky medications. Teach your patients that they are dangerous and may cause addiction even in small uses. Tell your patients to take the medications very sparingly, and be firm with your language. Patients trust nurses, and their cautious attitudes can affect patient perceptions and behaviors.
Review the unpleasant side effects. Opioid pain medications have a number of serious side effects and complications. Emphasize that your patient may experience sedation, constipation, dry mouth, tolerance or dependence, confusion, nausea, dizziness, or itching as a result of using the drug. Remind them that they cannot drive while taking the medication. Teach also that they may experience withdrawal symptoms after use.
Teach the symptoms of overdose and addiction. If the patient feels like they need more of the pills to feel normal or relief, this is a sign of increasing dependence and tolerance on the drug, and they should seek medical advice. If the patient has slurred speech; feels lethargic, foggy, or confused; is difficult to arouse or has loss of consciousness; or experiences a decreased respiratory rate, small pupils, or cold clammy skin, they may be experiencing an overdose and need immediate medical attention.
Nurses may think that since they do not prescribe the medications, they have no contribution to the opioid epidemic in this country. However, as some of the most trusted professionals in health care, it is the nurse’s role to properly educate, set realistic pain management expectations, and relay the serious risks of taking these medications.