The Challenges of Working with Intoxicated Patients

The Challenges of Working with Intoxicated Patients

There are times—especially around the holidays—that nurses find themselves in situations in which they have to work with intoxicated patients. This isn’t easy by any means. And it’s probably not something that you learned about in nursing school.

With New Year’s Eve right around the corner, we asked Rebecca Schwuchow, RN, CFRN, Education Coordinator, and Tom Syzek, MD, FACEP, VP of e-Learning Solutions for The Sullivan Group (a company that helps reduce patient errors and increase patient safety) about the best ways to deal with patients who are intoxicated.

During the holiday season, nurses may be faced with working with patients who are intoxicated. What are the most important things to keep in mind when working with these patients?

Intoxicated patients should be considered “high-risk” when they appear in an Emergency Department. Their intoxication often masks other concomitant medical, traumatic, overdose, and behavioral conditions that can be easily overlooked if the care team focuses solely on the immediately apparent drama of intoxication and ignores the need for a careful, thorough evaluation.

The safety of the intoxicated patient, as well as the staff caring for the patient, are the paramount concerns.

What should nurses be aware of with these patients?

They should not assume that alcohol is the only cause of intoxication and must consider the presence of other legal and illegal substances that cause intoxication—including opioids, sedatives, hallucinogens, and even poisons.

Emergency physicians and nurses are presented with additional medicolegal issues regarding intoxicated patients. Frequently, these patients are combative and disruptive, and may even refuse care. Other times they present with an altered level of consciousness. Determining who is simply drunk, and who may be suffering from a co-morbid illness, such as head injury, co-ingestion, or sepsis, represents a challenging diagnostic dilemma for the health care provider. The emergency department nurse and entire team must be extremely diligent in providing the highest quality of patient care in diagnosing coexisting, life-threatening disorders, and, at the same time, protecting patients’ constitutional rights.

What can they do to size up how to approach assisting them?

The ED nurses and entire staff should have a coordinated, teamwork approach to the management of intoxicated patients that insures the safety of the patients and staff. These patients can easily and suddenly become combative during their ED visit, and plans should be made in advance how to provide safety and security for all involved—while at the same time performing adequate medical evaluation and treatment. To ensure patient and staff safety, the ED staff must be prepared to apply physical or chemical restraint when warranted.

Intoxicated patients warrant a thorough history and physical. A full set of vital signs, including a core temperature, is essential. It is imperative that these patients be undressed to view all body surface areas for injury.

Nurses, physicians, physician assistants, and nurse practitioners caring for intoxicated patients must be aware that they may present with a wide variety of life-threatening conditions including:

  • Trauma
  • Hypoglycemia
  • Hypothermia
  • Sepsis
  • Electrolyte abnormalities
  • Ethanol withdrawal
  • Wernicke-Korsakoff syndrome
  • Co-ingestions

Furthermore, chronic alcoholics may suffer from low magnesium and other electrolyte abnormalities, clotting disorders, hepatic encephalopathy, or untreated infections.

What do nurses need to watch out for? What problems can come up?

As mentioned above, nurses need to insure a safe environment for the patient and themselves while caring for intoxicated patients. Second, nurses must work with the entire care team to evaluate for all potential threats to limb or life in patients who are intoxicated. For example, the intoxicated patient who has blunt head trauma should be considered to have an intracranial bleed until proven otherwise. The drunk patient with neck pain has an unstable cervical fracture until proven otherwise. The bottom line: assume that the intoxicated patient is hiding some potentially life-threatening pathology until proven otherwise.

What additional information is important for nurses to know about working with intoxicated patients?

Emergency Departments have become the “drunk tank” and the health care safety net for society. Intoxicated patients found in alleys, along roadways, and wandering the streets are brought to the ED for evaluation. This burden, whether emergency physicians and nurses like it or not, has become routine. The reasoning behind it is simple—intoxicated patients are high-risk. Thus, management of these patients can be both complicated and frustrating.

Nurses and the entire care team should be keenly aware of their own potential for cognitive and affective bias towards the intoxicated patient which can easily get in the way of appropriate clinical decision making. Regardless of their own objections, intoxicated patients warrant rapid, meticulous evaluation and aggressive treatment when indicated. Physicians, physician assistants, nurse practitioners, and nurses must not assume that intoxication is the etiology of a patient’s altered mental status.

There is little debate about the management of the patient with a severely altered level of consciousness or in a comatose state. Attention to the ABCs (i.e., airway, breathing, and circulation) is the first priority. The team should recognize that intoxicated patients are a high-risk group for serious injury and should make these patients a priority.

Finally, it is difficult to detect every traumatic injury, coexisting medical problem, or co-ingestion during the initial evaluation of an intoxicated patient. A period of observation may be necessary to identify hidden or subtle problems before a patient can be safely discharged.

This highlights one area in emergency medicine where physician/nursing teamwork is critical: the entire staff must recognize the intoxicated patient as a high-risk situation.

Nursing Leadership in Wound Care

Nursing Leadership in Wound Care

Do you love patient care but long for some autonomy in your nursing practice? Perhaps a leadership position in wound care nursing is the answer. Wounds are often the domain of one or more wound care nurses, as they are especially problematic for nursing departments, particularly those acquired during a hospital or facility stay. A wound care coordinator supervises these nurses, providing organizational leadership and management.

What Additional Certifications Are Required?

Wound care nurses focus solely on prevention and healing. The coordinator holds specific certifications in wound, skin, and ostomy care and is responsible for supervision of the wound care nurses. Wound care nurses may also have advanced certifications in this area, but their task is solely the everyday management, assessment, and treatment of wounds as ordered by the physician.

Wound Ostomy Continence Nurse (WOCN) certification is the highest available to registered nurses. It is obtained through the Wound Ostomy Continence Nurses Society, which requires completion of a formal WOC program. These require a bachelor’s degree or higher, at least one year of clinical experience following RN licensure, and clinical experience within five years of beginning the WOC program.

The Certified Wound Specialist (CWS) certification is sponsored by the American Board of Wound Management and is available to Registered Nurses and several other non-nursing health professions. Certification requires that the candidate have a bachelor’s degree and three years’ experience in wound care, or completion of at least a year-long fellowship that has been certified with a credentialing organization.

The National Alliance of Wound Care and Ostomy offers the Wound Care Certification (WCC) to RNs and LPN/LVNs, as well as NPs and other allied health professions with an active unrestricted license. This certification requires completion of an education course that meets the Alliances criteria but does not specifically require a bachelor’s degree.

What Are the Responsibilities of a Wound Care Coordinator?

Wound care coordinators evaluate the success of treatment modalities, discuss nutritional needs with dieticians, and consult with medical directors, physicians, and plastic surgeons on healing progression and complications. Wound care coordinators develop and implement programs that focus specifically on skin and wound care. They also conduct interdisciplinary rounds with other departments whose areas of expertise intersect and potentially affect the patient’s potential for wound healing. Wound care coordinators and nurses usually meet regularly with the administration and nursing to update on the status of wounds as well.

How Do Patients Benefit?

Wound care nurses and the coordinators who manage them elevate the level of care for wounds by making that their sole focus. Without the full responsibility for a patient’s overall primary care, wound care nurses and coordinators are better able to focus on bringing their patient to an optimum state to facilitate healing. That’s a win for the facility, the physicians, the nursing department, and especially the patient.

Learn more about wound care nursing here.

Nurses’ Attitudes Key To Infection Control

Nurses’ Attitudes Key To Infection Control

Changing perceptions of risk could improve compliance with infection-control measures

It’s often said that knowledge is power. But a new study finds that when it comes to nurses’ compliance with infection-control measures, it’s more appropriate to say attitude is everything.

The study, published in the American Journal of Infection Control, examines the relationship between infection-control compliance, knowledge, and attitude among home healthcare nurses. Researchers surveyed 359 home healthcare nurses in the U.S., and evaluated their knowledge of best practices in relation to their compliance with infection-control measures.

Over 90% of nurses self-reported compliance for most of the measured behaviors. The researchers also found there was not a direct correlation between knowledge of infection-control practices and compliance with those practices. However, there was a relationship between the level of compliance and the participants’ favorable attitude toward infection control.

“This study tells us that knowledge is not enough,” said one of the lead authors, Jingjing Shang, PhD, of Columbia University School of Nursing in New York City. “Our efforts to improve compliance need to focus on ways to alter nurses’ attitudes and perceptions about infection risk.”

Common Hurdles

The authors suggest that efforts to improve compliance with infection-control practices should focus on strategies to alter perceptions about infection risk. Changes should start on an organizational level, and seek to create a culture of positivity in relation to infection-control compliance.

Among other takeaways from the study:

  • Protective equipment lapses: While most of the participants reported compliance on most issues, many reported lapses when it came to wearing protective equipment; only 9% said they wear disposable face masks when there is a possibility of a splash or splatter, and 6% said they wear goggles or eye shields when there is a possibility of exposure to bloody discharge or fluid
  • A culture of “presenteeism:” Presenteeism, coming into work despite being sick, has become a patient safety issue over the last few years, especially as it relates to infection control; only 4% of participants felt it was easy for them to stay at home when they were sick, which could be a major contributor to rates of infection
  • Hand hygiene is still an issue: 30% of respondents failed to identify that hand hygiene should be performed after touching a nursing bag, which could transport infectious pathogens as nurses travel between patients

“Infection is a leading cause of hospitalization among home healthcare patients, and nurses have a key role in reducing infection by compliance with infection-control procedures in the home care setting,” Shang said.

This story was originally posted on MedPage Today. 

Hunting the Elusive Work-Life Balance in Nursing

Hunting the Elusive Work-Life Balance in Nursing

Work-life balance is a hot concept in the nursing profession. We hear we need it. We want to achieve it. But does it really exist?

That question has piqued the interest of Adele A. Webb, PhD, RN, FNAP, FAAN, senior academic director of workforce solutions at Capella University in Minneapolis.

“People think they need it,” she said. “But do they? Can you ever have it? Or are people chronically dissatisfied because it’s like a unicorn … they’re chasing something that doesn’t exist.”

Balance Vs Satisfaction

Webb plans to study and delve into the concept of work-life balance and nurses. She said recent conversations with nurse executives, including those at HealthLeaders Media 2017 CNO Exchange, left her realizing that the idea needs to be better defined.

“Years ago, I read an article called Balance is Bunk!, and [the point] was you never have 50% this and 50% that. Sometimes work takes more, sometimes family takes more,” she recalled.

For example, if a nurse must take off from work to stay home with a sick child, on that day, family needs more focus than work. And there are times, especially for those who work weekends or holidays, where work will eclipse family.

Still, Webb said she understands the desire behind the idea of work-life balance.

“What does work-life balance really mean? It means you’re happy. Well, what does happy mean? Happy means you’re satisfied with what you’re doing,” she said. “I think what people really want is life satisfaction. They can be satisfied at home and satisfied at work even if it’s not balanced.”

Generational Differences

Another question Webb said she is pondering is, “How then do we address or encourage satisfaction and what does that mean?”

She said she has noticed, even among her own family, that different generations of nurses crave different things.

“I have a daughter and a granddaughter who are nurses. My granddaughter is definitely a Millennial. She’s 24, new in her career, and what she wants is opportunity,” Webb said. “She’s always reading, trying to better her skills, and to learn something new.”

This drive to further their skills and their careers is a trait often tied to the Millennial generation. However, it can also be a factor that contributes to their workplace turnover. According to the RN Work Project, almost 18% of newly licensed RNs leave their first employer within the first year.

“We have the job to educate these younger nurses on opportunities to find satisfaction in the job they’re in. So when you want more, you can sign up for a committee. You can look at policy in your community or state. There are opportunities outside of leaving your unit that can meet your needs,” Webb said.

“How exciting it would be for a young nurse to have the opportunity to be on the quality committee at a hospital. Or to have the opportunity to contribute to care algorithms or standards or care or policies?” she added. “They would learn [so much] from it [and] they could contribute so much.”

While baby boomers are more likely to stay in their positions, they, too, have a need for life satisfaction and often value time and self-fulfillment, said Webb.

For example, offering tuition assistance to pursue a master’s degree may give this generation a sense of satisfaction. Or they may find fulfillment in sharing the knowledge they’ve garnered over their years of experience.

“[Give them] the opportunity to be involved, and be on a budget committee at the hospital and understand the finances and the contributions they make,” Webb suggested. “Train them to be preceptors. Let them share that knowledge with the younger generation.”

What’s Next?

Webb is in the early stages of reviewing published literature for existing information on work-life balance and satisfaction, and plans to interview nurses about their insights. Once she has a working thesis, she plans to connect with nursing professionals through presentations and conferences to see whether her definition and evaluation of work-life balance or work-life satisfaction rings true.

This story was originally posted on MedPage Today. 

What to Expect During Your First Holiday Season as a Nurse

What to Expect During Your First Holiday Season as a Nurse

Your first year working as a nurse is challenging, and your first holiday season is even more so. Oftentimes, the last thing you want to do is put on your scrubs and drive into work while your friends and family are celebrating without you. Unfortunately, every nurse has to work some holidays—it’s just part of the job. Here are eight tips to help you cope successfully with your first holiday season as a nurse.

Get ready to work at least some holidays.

Different facilities run their schedules differently, but one thing is for sure: You’re going to have to work at least some holidays throughout the year. At some hospitals, if you normally work that day of the week, then you work the holiday–period (unless you find someone gracious enough to swap shifts with you, of course). Other facilities pair holidays together—Thanksgiving with July 4, Memorial Day with Christmas, etc.—and you work one day and get the other off, alternating year over year. However, almost no nurse gets all the holidays off each year, so mentally prepare yourself to work on at least some of these days.

If you want to make swaps, do them in advance.

No one likes that coworker who tries to swap a holiday shift only days in advance, so don’t be that person! If you really want a particular holiday off, look into your facility’s shift-swapping protocol and reach out to your coworkers well in advance. It’s a big ask to request that someone else works on a holiday, so you might have to be willing to work a different special day. For example, you take their Thanksgiving shift while they pick up your Christmas one. And of course, it never hurts to sweeten the deal with some Christmas cookies while you’re at it.

Plan your schedule wisely.

Some nurses figure that if they have to work on a holiday, they might as well do three 12-hour shifts back-to-back and get their week over with. While this may sound tempting, be honest with yourself if this is something you can and want to do. Nursing is a tough profession emotionally and physically, and it can be even more so over the holidays–especially if you’re away from your family. If working three consecutive twelves is going to compromise your nursing work, or simply make you exhausted and sad, try to leave yourself some downtime in between shifts so you can spend time with friends and family. Take care of yourself, even if you can’t celebrate the day of the holiday.

Know how to get in touch with senior leadership.

Senior leaders often take or get off the holidays, so they won’t always be around to assist you in case of an emergency. Ask your supervisor what the protocol is for contacting out-of-office leadership in case a situation does arise. Make sure you know who will be quickly accessible and keep their contact info in an easy-to-reach place, such as your nursing bag, at all times. Hopefully nothing will happen, but staff is often spread a bit thin over the holidays and you want to be prepared ahead of time.

Ask others for help and minimize your commitments.

If you already have a holiday routine, it can be difficult to make the adjustment during your first holiday season as a nurse, especially if you’re usually the one doing all the work: cooking the big festive meals, gift shopping on other people’s behalf, hosting the annual holiday party, etc. But trying to do all that during your first year as a nurse will only make you tired and prone to burnout. Don’t be afraid to ask friends and family members for help or to back out of your usual activities. Be upfront about the demands of your nursing career, and give people plenty of heads up on what you can and can’t do. Of course, this isn’t to say you have to completely give up on everything. You can still make a side dish to bring to the party (for example), rather than hosting the entire thing.

Be prepared that your family might not understand.

Non-nurses don’t always understand the rigors of the work schedule, and this is especially true for those who work a regular 9-to-5 job and get holidays off. As soon as you know your holiday schedule (which should be pretty far in advance), communicate it to your family, explain why you won’t be able to join them the day of and offer to coordinate an alternative celebration either before or after the holiday itself. If they give you pushback, explain that everyone in your unit has to work some holidays each year without exception. More senior nurses will have gone through this routine many times, so don’t be afraid to turn to them for advice and encouragement on this matter.

Focus on the incentives.

Almost no one wants to work on a holiday, but the situation isn’t all negative. Many facilities provide overtime pay for working on a holiday, including Thanksgiving and Christmas, and they may offer other perks (such as a free meal in the cafeteria) as well. Put that extra money to good use by scheduling a fun activity after your holiday shift, such as a massage or art class, so you have something to look forward to and a way to reward yourself for all your hard work.

Don’t forget other people are missing the holidays, too.

Obviously, being away from friends and family during the holidays can be tough, but you’re not the only one. Up to a quarter of all Americans are required to work at least one winter holiday.  Many other hospital staff, EMTs, firefighters, police officers, restaurant workers, and retail workers will put on their scrubs or uniforms and clock into work over the holidays. (And of course, your patients are missing the holidays as well and they’re sick and in the hospital on top of that.) If nothing else, remember that you’re not alone and that you’re helping other people—and possibly even saving lives—in the process.

Your first holiday season as a nurse may not be fun, but you can make it a lot less painful by preparing ahead of time. Follow these eight must-know tips to successfully weather the holidays as a working nurse for the first time.

NPs Can Now Prescribe MATs to Opioid Addicts

NPs Can Now Prescribe MATs to Opioid Addicts

According to Joyce Knestrick, PhD, C-FNP, APRN, FAANP, President of the American Association of Nurse Practitioners (AANP), Congress recently passed and President Trump signed “a comprehensive package of anti-opioid bills into law with a key provision permanently authorizing NPs to prescribe Medication-Assisted Treatments (MATs), further expanding patient access to these critical treatments.”

This passage is extremely important to those fighting opioid addictions as well as those health care workers who are treating them. “Recognizing the ongoing impact of the opioid crisis, Congress and the President moved quickly to get this critical legislation across the finish line. We applaud their actions, which acknowledge the vital role nurse practitioners play in treating patients with opioid use disorder with Medication Assisted Treatments (MATs),” says Knestrick.

What does this mean for the health care community? Knestrick answered questions to explain.

Why is this important—both for NPs and for opioid addicts?

First and foremost, for the millions of American families struggling with addiction today, passage of this legislation ensures patients continuity of care, knowing that their NPs can continue to provide their loved ones access to MAT treatment.

Second, knowing that NPs are now permanently authorized to prescribe MAT, we anticipate significant growth in the number of America’s NPs who will become waivered to prescribe MATs—which will help turn the tide of opioid addiction in communities nationwide.

How will this help more opioid addicts?

As primary care professionals, NPs really are on the front lines of combating the opioid epidemic. Tragically, eighty percent of patients addicted to opioids don’t receive the treatment they need, due in part to health care access challenges, stigma, cost, and other factors. Thanks to advances in Medication-Assisted Treatment—which combines medications that temper cravings with counseling and therapy—and this new law granting NPs permanent authority to prescribe MATs, the opportunities to reach and treat patients struggling with addiction are better than ever before.

In addition to helping addicts, will this make the process more cost-effective? If not, how else will it be beneficial to health care facilities and/or treatment centers?

We do know that treating people with addiction to opioids and other substances is costly—in part because of the need for in-patient treatment and more frequent hospitalizations. Yet, most people in need of treatment simply don’t receive it. As a nation, we are facing significant shortages of specialty treatment facilities for addiction, and this makes it all the more important to ensure that NPs and other primary care providers have the tools to meet the patient need for MATs

AANP has formed a collaborative with the American Society of Addiction Medicine and the American Association of Physician Assistants to provide the 24-hour waiver training for NPs and physician assistants. We invite NPs to visit AANP’s CE Center at https://www.aanp.org/education for more information.

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