When I tell people I’m a psychiatric and addictions advanced practice nurse, they are a bit surprised after I share with them my family origins. You see, I come from multiple generations of pharmacists, dating back to the turn of the 20th century when my great grandfather patented medicines around the world and maintained company with the founding fathers of Eli Lilly and Johnson & Johnson. My grandfathers, on both sides of my family, my parents, and numerous aunts and uncles also studied and practiced pharmacy.
Nevertheless, I ultimately decided my career path would include a deep understanding and respect for the role of the pharmacist, but I wanted to practice nursing and provide care to patients with psychiatric and substance use disorders. As an advanced practice nurse, I was able to incorporate prescribing into my practice as a master clinician in psychopharmacology.
My extensive connection to pharmacy and pharmaceutical agents, and psychotropic medications in particular, is why I have embraced pharmacogenetic testing for patients who present with complex diagnostic issues and for whom various trials of medications have failed to provide symptom relief and emotional stability.
Genomind’s Genecept Assay is a simple, in-office, cheek swab-based test that I offer to patients to assist with personalizing their psychopharmacological regimen; it’s painless and easy to perform. The assay explores key pharmacokinetic and pharmacodynamic genes, which affect how the patient’s body may metabolize medications and the potential impact the medication may have on the body. This information provides an understanding of whether a drug is likely to either work properly or produce adverse effects for a patient before he or she even tries it. The details provided by the assay also offer insights into the dosing of medications and potential drug-to-drug interactions based on their metabolism by the various CYP450 system enzymes located in the liver.
With this information, along with the patient’s symptom presentation; medical, psychiatric, and substance use histories; family history; and medication (including over-the-counter and supplemental medications) history, I am able to narrow down the pharmacological treatment options so patients can feel better, faster.
In 93% of patient cases, the Genecept Assay influenced clinicians’ decisions about medications. It helps reduce the trial-and-error approach, time, expense and struggle of finding the right treatment options. I think the results of the assay are especially helpful for patients who are frustrated after multiple medication failures when trying to find a medicine to alleviate their symptoms. As a clinician, the more information I have in my toolbox when working with a patient, the better.
An example of the beneficial results received as a result of using genetic testing occurred when I treated a woman who was in her early 60s and who said she had suffered from a lifetime of depression, dating back to her early childhood. The genetic testing helped me realize she was suffering from low dopamine levels, our pleasure enhancing and energizing neurochemical located in the prefrontal cortex of the brain, the area responsible for executive functioning, including motivation, attention, concentration and organization. This was an ah-ha moment for both my patient and me, as it explained why so many past trials of medications were either ineffective or contributed to adverse side effects.
Based on the results of the Genecept Assay and my patient’s history, I prescribed a psychostimulant, typically reserved for the treatment of Attention Deficit Hyperactivity Disorder. Once dosed to the appropriate level with guidance from the pharmacokinetic results of the assay, it revolutionized her life; the depression lifted and her quality of life improved dramatically for the first time she could recall. Now, at the age of 70, she remains free of depression and is catching up on the life that depression stole from her for so many years.
An important point to emphasize is that the test is neither directive nor diagnostic. For those prescribing advanced practice nurses and other clinicians who may feel challenged by interpreting the results of genetic testing, I can assure you it’s well within your ability to do so and that the companies who offer the testing have extensive clinical support teams to guide you through the results and pharmacological decision-making process. I will also point out that genetic testing to personalize medication decisions is not a new science, as oncology clinicians have been utilizing such reports for years to personalize chemotherapy regimens for their patients.
As health care and the disciplines of psychiatry and addictions continue to evolve, personalized medicine will become more and more the norm. Advanced practice nurses have an opportunity to serve in a critical and leading role during this emerging period by adding pharmacogenetic testing to assist in streamlining psychotropic medication options for their patients. Genetic testing is one of the keys to unlock the mysteries of prescribing psychotropic medications and should be added to the clinician’s arsenal of clinical tools in order to to maximize improvement in symptom relief and quality of life for our patients.
Perhaps you give CPR (cardiopulmonary resuscitation) almost every shift, and you consider yourself a code blue champion. Maybe you work on a med-surg unit or in a surgery center that rarely has to code a patient. Despite the ACLS (Advanced Cardiac Life Support) certification card in your wallet, you may find your skills need brushing up on. Below are some tips for ensuring that you are providing excellent CPR.
1. Get your hands on the chest quickly.
As soon as you notice that a patient is pulseless, place your hands on the chest to start compressions while yelling for others to help. Minimize interruptions to CPR.
2. Use your equipment.
If possible, use a stool so that the compressor is at the proper height, and also place a backboard or use the backboard setting on a mattress to get the proper resistance for compressions.
3. Go fast, but not too fast.
Occasionally compressors get so full of adrenaline that they compress at a rate of 120-150, which is too fast to allow for ventricular filling. The rate should be between 100-120. Tip: Music services such as Spotify actually have entire playlists created for the ideal rate of CPR!
4. Depth is important.
Get the proper depth to allow full recoil of the chest. The recommended depth for adults is 2 to 2.4 inches. Sometimes this may mean lifting your hands completely off the chest after each compression.
5. Too much of a good thing.
Pause for breaths without an advanced airway, but also be careful not to “overbag” the patient. Excessive ventilation can increase intrathoracic pressure and decrease coronary perfusion pressure.
6. Use end tidal to measure your compressions.
End tidal carbon dioxide monitoring can reveal the quality of your compressions. End tidal greater than 20 is associated with greater survival outcomes. Values of less than 20 indicate that you need to adjust your rate and depth. If end tidal suddenly jumps into the 40s, you likely have return of spontaneous circulation.
7. Switch compressors to combat fatigue.
Proper CPR is exhausting. Switch every two minutes, and you can give epi every two compressors.
8. Designate a CPR coach.
If you have extra eyes or hands, designate a CPR coach who will monitor the depth and rate of compressions and who will help ensure that compressors are switching appropriately and end tidal is appropriate.
High quality compressions lead to greatly improved patient outcomes.
While working in a NICU setting, we as staff get used to the long-term admissions, fragile 24-weekers, and the deer-in-headlights look from caregivers during those first few weeks. Feelings of inadequacy and lack of control can easily creep into our most experienced and knowledgeable caregivers when their baby is the patient. Much of this time, caregivers look to the medical team to provide care to their babies and can easily forget the power they have as a caregiver. Kangaroo care (skin-to-skin) holding gives back a huge level of control as caregivers are able to provide undeniable benefits to their baby that no nurse or doctor can provide.
What is skin-to-skin holding?
Kangaroo care involves direct skin-to-skin contact between the caregiver and infant. This type of touch stimulates the C-afferent nerves, which are packed under the sensitive skin on our chests. Research shows that activating these nerves with positive touch leads to a release of hormones that promote many positive benefits including: brain growth and development, digestion and weight gain, immune system benefits, reduced stress and crying, stability of heart rate and breathing, temperature regulation. These nerves send a message to the brain that produces oxytocin, which creates physiological and psychological benefits. All of these positive outcomes greatly affect an infant’s hospitalization as they are provided with real human connection with the people that love them the most.
For caregivers, this special time with their infants promotes bonding, positive coping, and emotional connection during this stressful time. Caregivers are empowered to make observations about their babies, engage in their daily care, and learn appropriate ways to stimulate their infant which increases collaborative care between caregivers and nurses.
What is a Kangaroo-A-Thon?
A Kangaroo-A-Thon is an event to promote this wonderful skin-to-skin holding between infants and caregivers! The event was held over the course of 13 days to allow for maximum opportunities for participation. Nurses were instrumental in being available, providing education, and supporting our caregivers to engage in the act of skin-to-skin care. Caregivers were encouraged to hold their infants skin-to-skin as long and often as possible (and was safe) during these 13 days. A plethora of prizes were raffled off to caregivers and nurses as the unit was decorated with kangaroos and hearts to support our “Heart-to-Heart” theme.
We had a tremendous response across all disciplines and especially with our caregivers. The number of families participating in the event increased over 50% from the week prior to the event and our total number of hours documented rose from 140 hours to just over 304 hours. Caregivers were asking more questions and becoming more confident and capable partners in their baby’s care. All in all, we had a very fun time promoting, supporting, and running this event. Skin-to-skin care is a simple yet extremely effective tool that turns even our most cautious caregivers into confident, knowledgeable, and competent partners.
The last time you walked into a patient’s hospital room, what was touching the floor? A purse or briefcase? A cell phone charger? The call button? The TV remote? A blood pressure cuff? Pulse ox? Water bottle?
I don’t know about you, but whenever I see high-touch items like these casually dropped or placed on the hospital floor, I cringe. Until recently, however, I didn’t have any data to back up my revulsion.
For better or for worse, I do now. Yes, bacteria and viruses really can get transferred from patients, to floors, and back up again to other patients, health care providers, and even visitors.
According to a recent study published in the American Journal of Infection Control, patient room floors in five Cleveland-area hospitals were often contaminated with health care-associated pathogens, and objects on the floor frequently resulted in the transfer of pathogens to hands.
Of particular concern, the study found that C. difficile (Clostridium difficile) was the most frequently recovered pathogen from patient room floors. The frequency of contamination was similar in each of the five hospitals studied and in patient rooms and bathrooms, alike.
How should this impact your day-to-day practice? Here’s what I think:
1. If you aren’t already educating patients and visitors to avoid putting personal items directly on the floor, start doing so.
2. If and when items land on the floor, make sure that patients and visitors have access to sanitizing wipes to clean those items, and remind them to do just that.
3. Educate your coworkers on the importance of using sanitizing wipes on items that have touched the floor.
4. Remind patients and health care workers to wash hands or to use hand sanitizers frequently and as per hospital policy, but also after touching items that may have been in contact with the floor.
5. Advocate for institutions to provide patients and visitors with more hooks for hanging up items that might otherwise end up on the floor.
6. Work with environmental services to improve the efficacy of your institution’s current floor cleaning. Does your hospital use sporicidal agents or ultraviolet-C room decontamination? Find out and voice concerns if you have them.
But the buck doesn’t stop on the floor.
According to a study in the Journal of Hospital Infection last year, patients’ nonslip socks are frequently contaminated with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). In fact, 85% of the nonslip socks tested were contaminated with VRE. Ick!
Here again I see a role for nurses in educating patients and caregivers to help prevent pathogen transfer:
- Teach proper doffing techniques for sock removal.
- Advise patients to refrain from touching socks with their hands unless necessary.
- Provide clean socks often.
- Provide hand-sanitizing opportunities throughout the day.
Likewise, similar research in World Journal of Microbiology and Biotechnology has suggested that wheelchairs could be a source of pathogen dissemination in health care facilities. Which, I venture, gives nurses a chance to remind patients and coworkers to clean their hands after taking wheelchairs for a spin. And it certainly couldn’t hurt to disinfect the wheels on a regular basis.
Finally, the ubiquitous smartphone: Recent research finds that mobile phones serve as reservoirs of infection in the health care environment. The study, published in the American Journal of Infection Control, looked at genetically identical strains of Staphylococcus aureus recovered from mobile phones and palms and fingers of users and multiple users. The results reinforce, yet again, the need for frequent hand washing or hand sanitizing throughout the day for patients and health care providers—particularly after touching common items like phones.
Spring is always a time for a fresh start and thanks to the research I’ve covered today, it seems we’ve got even more great reasons to clean up and clean often. Now, if only I could get my family to help by putting away their phones and picking their stuff up off the floors at home!
The preceptorship of a nurse or student has far-reaching effects, influencing everything from the safety of the patient, to the quality of care the patient receives, and the employment, retention, and job satisfaction of the new nurse. The preceptorship experience will be remembered long after the preceptee has left the facility. How the preceptor conducts both himself or herself and the orientation period will not only influence how the preceptee feels about the profession of nursing for years to come, but the quality of care his or her future patients receive.
Listed below are behaviors attributable to an ineffectual nursing preceptor. If you notice that they reflect your teaching style, then take advantage of preceptor education. Recognize that these behaviors can be changed and that the most successful preceptors do not exhibit these qualities. You are an ineffectual preceptor if:
- You are unclear about the goals of orientation.
- You do not ascertain the preceptee’s skill and knowledge level prior to the start of orientation.
- You do not question the preceptee to determine if there are any patient care areas in which he or she feels weak.
- You do not introduce the preceptee to fellow team members and do not help the preceptee feel like part of the team.
- You do not orient the preceptee to the unit so that he or she does not know where items or located or typical procedures to follow.
- The goals and expectations for orientation are unclear and are not stated in writing.
- The goals you establish are not measurable or achievable.
- You do not review the goals for the day or for orientation with the preceptee.
- You are inconsistent in your communication style.
- You do not allow the preceptee time to practice skills prior to attempting them.
- You do not build new skills upon current skill level.
- You delegate to the preceptee beyond his or her skill level.
- You do not seek out new learning experiences for the preceptee but instead allow the preceptee to find learning situations on his or her own.
- You fail to provide guidance in the completion of a new skill, assessment, or other nursing function.
- Your clinical skills and technique are not evidence-based or correct; you take shortcuts to save your time but in doing so may unknowingly endanger the patient. You pressure the preceptee to perform these skills as you do.
- You leave the preceptee to do the work that other staff do not wish to complete.
- You are continually rude to the preceptee, fellow staff, families and patients.
- You allow the preceptee to experience a lot of “down time,” for example by allowing him or her to “hang around” the nurses’ station rather than engaging in patient care or learning new skills.
- You frequently cancel scheduled meeting times with the preceptee, the unit manager, the unit educator, or faculty members, therefore fallowing communication to break down among all parties.
- You allow the preceptee to be utilized as staff prior to the end of preceptorship.
We know about the dangers of opioid prescriptions: A recent study linked opioid addiction to just one encounter with opioids for pain control, usually prescribed in an emergency department. (To learn more about safe opioid prescription medication patient teaching, read an article here.) The question is, how can you effectively manage pain without opioids? Pain requires frequent assessment and the setting of realistic expectations by a patient and his or her care team. Patients need to know that although it may not be possible for them to feel entirely pain-free, they are still entitled to some level of pain control. Below is a review of non-pharmacological methods for controlling your patients’ pain.
Heat it up or cool it down. Many of us neglect the value that a hot blanket or heating pad or a cold pack or bag of ice can have on our patients’ pain. It may not help with their chronic pain, but for acute pain, applying heat or cold can be very effective. Just monitor the patient’s skin for any burns or skin irritation at the site, and leave heat or cold on for no longer than 15 minutes at a time.
Guided imagery or relaxation. There are several guided imagery scripts you can find online that you can run through with a patient or even print off and hand to a family member at the bedside. Several institutions have caring or healing patient channels that provide relaxing music or imagery exercises.
Distraction. Can you help your patient turn on the TV, or bring them some magazines or books? When patients are lying in a bed with nothing to focus on but their pain, their perception of the pain can increase. Try to distract the patients with music, TV, art therapy, or books. These methods can help a patient alter their perception of pain.
Promote rest. Make sure your patients can get plenty of sleep. We all know that the hospital is ironically one of the worst places to get a good night’s sleep, but sleep deprivation decreases the patient’s pain threshold and increases their stress response. Excessive stimuli should be reduced for patients as much as possible, so take care to eliminate excess noise by closing doors, adjusting the room temperature, and decreasing harsh artificial lighting.
Fed is best. If your patient is able to eat, ensure they are getting adequate nutrition and enough food to feel full. Hospital food can be notoriously unappetizing, but a feeling of hunger can also exacerbate patient perception of pain. If possible, suggest to family or friends that they bring some favorite snacks or meals for the patient to enjoy.
Advocate. Frequent assessment and evaluation of patients’ pain and their response to pain interventions is crucial for our patients. Be sure you are re-assessing frequently and advocating to the physician if you feel that pain is being inadequately managed.