101 Nursing Tips

Assess for Complications

Perform a full assessment at the beginning of your shift, recognizing potential problems.  Then choose the part of the affected system that is most likely to change first.  This is the area that does most of the work or is the most sensitive to injury. 

When you do your assessment, try to identify areas that could pose potential problems.  For example, if your patient had surgery and he has a wound, one of his potential complications could be infection.  You will do a focused assessment directed at the most common complication which is infection; assess the patient’s white blood cell count and his temperature, and not just for specific elevations, but also for trends.  Yesterday his white count was 7, today it’s 8.  It’s going up.  If at the same time his temperature is going up, there’s a good chance he is developing a wound infection.  That could be a normal post-surgical rise in WBC count, so our quick-check assessment will be to focus on the wound itself and look for wound drainage, redness, and swelling, at the wound site.  To put those three things together doesn’t take much time, but it does give you a pretty focused assessment looking for early signs of infection. 

Here is another: if your patient is at risk for pulmonary complications, assess the bases of the lungs in the back first.  The lower lobes of the lungs are likely to be affected before the rest of the lung and therefore will exhibit changes in lungs sounds in the bases in the back first.

Think of other ways that you can develop quick-check assessments so that you can find problems in your patients early on and decrease the potential for complications.

Download week29.mp3 

Best wishes,
David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.
www.Ed4Nurses.com
www.DWoodruff.com

Finding Dehydration

An increase in BUN and an increase in serum sodium indicate dehydration.  Look for other signs, like dry mucus membranes and tenting of the skin to validate your assessment.  When you assess your patient's labs and you find that the BUN and the sodium are both high at the same time, in a patient who also does not have a high creatinine level, it is probably because the patient is dehydrated.  You can validate this with your clinical assessment by looking for dry mucus membranes, tenting of the skin, assessing the intake and output and patient's weight.  If the patient's weight has gone down, chances are he has lost fluid and is dehydrated. 

Another great assessment is to look at the patient's jugular veins.  There has been some research in the last few years to validate the fact that assessment of the jugular veins is a good and accurate assessment of patient's fluid volume status.  If your patient is laying flat and has flat jugular veins (normally they would distend when the patient is lying in a supine position), then that would indicate that the patient is dehydrated.

What your patient needs is some free water, and what we call free water is tap water, so if he is able to eat and drink, we can have him drink some additional tap water.  If not, you will have to put that water in his tube feeding, or if all he can take is IV fluids, then you need to give him D5W.  When you administer D5W, the dextrose is metabolized, which leaves the water and it is going to help to dilute a high sodium and high BUN level.  You need to be careful with rehydration though, you do not want to rehydrate your patient too quickly because dropping the sodium can cause changes in the patient's water mass in the brain and that can lead to cerebral edema.

Download week28.mp3

Best wishes,
David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.
www.Ed4Nurses.com
www.dwoodruff.com

Enlist Champions

Enlist champions.  Those are people who have the power to make changes to help you resolve your issues.  Having the attitude that things will never change is a cliché that will be true without your effort.  Many times I have heard nurses sigh, “that’s the way it’s always been and that’s the way it’ll always be.”  That doesn’t have to be true. 

Many times nurses have tried to make changes in practice situations, and their efforts were unsuccessful.  Enlisting champions can help you to make the changes that you want to create in your workplace.  These are people who have the pull, the people who have the power, to make the changes.  There may be a physician you get along with fairly well who might be able to present your ideas to their committee.  Maybe there’s an administrator that you have a particular, connection with, or maybe your manager. 

Look for the people who have the power to make the change rather than just talking to the people who don’t have any power.  Frequently, we just talk to the other people who don’t have any power either, and we all end up being frustrated.  Look for the champions in your institution who can help you to make the changes that you want to see happen to provide better patient care.

Download week27.mp3

Best wishes,
David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.
www.Ed4Nurses.com

Listen first

Practice beginning every conversation by listening.  Everyone wants their agenda to be known and listening first will help to disarm defensiveness.  You have probably heard this a million times in a million different ways, but it is so important.  As Dr. Steven Covey says in his book The 7 Habits of Highly Effective People, “Seek first to understand and then to be understood”.  This is a very difficult concept to try to integrate into your practice and just into your life in general, but it’s very, very helpful. 

Take, for example, a situation where you have a patient that is coming up from the Emergency Room and needs to be admitted to your floor.  The Emergency Room nurse calls up and says, “We’ve got this patient down here.  We gotta get him up to the floor.  We need the beds.  We need the room.  We’ve got a lot of extra patients coming.  The squad just called and said they’re bringing in a bunch of trauma patients, and we have to bring this patient up to your floor right now.”  From your perspective, you’re saying, “Well, the bed isn’t ready.  We don’t have any place to put this patient.”  And, what usually happens in this kind of scenario is each person has an agenda.  The ER nurse is saying, “We have to get this patient out of here right now”, and that is their agenda period.  And then you are saying, “We don’t have a bed for the patient.  You can’t bring him up here because we don’t have a bed.” 

If you were the one who is receiving the call on the floor, if you listen first to what the ER nurse is saying, and  bottom line here is they’re busy and they don’t know how they’re going to take care of this patient.  And then, restate that in terms that show your understanding: “wow, you guys must be really busy down there today and it’s going to be really tough to try and take care of this patient with all those patients that you have coming in.”  Then, you can state your point of view and it will be more likely that you’ll be heard. 

If you state your point of view first and say, “The bed isn’t ready and you can’t send him up,” that immediately blocks the conversation and there is no communication back and forth.  Each person is trying to win the argument rather than trying to resolve the problem.  “Seek first to understand, then to be understood.”  Try this in your practice.  Try it when it’s not a crisis situation.  Try it in every conversation you have.  Get some practice with it and then, when you have a crisis situation; it will become a lot easier to do.

Download week26.mp3

Best wishes,
David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.
www.Ed4Nurses.com
www.dwoodruff.com

Set your monitor parameters to detect early changes

Reset the monitor alarm parameters to alert you of early changes in your patient.  Most alarms are set up to tell you that the patient is already in distress.  Take the pulse oximeter, for example.  If you have the pulse oximeter alarm set at 90 percent, is that really going be adequate for the patient that you’re caring for today? 

The point is that you want to try and set up our monitors so that you are going to get important information about that particular patient.  Using the preset values is going to miss some early warning signs in some patients.  The reason why you have preset alarm values is just so that if the patient gets into trouble, you will know about it; but in many of your patients, smaller changes in their parameters are going to give you important information that you want to know about.  Your alarms on your monitors are there to help.  Let them help you find those problems in their early stages so you can ward off complications in your patient.  Set them individually based on each patient’s baseline parameters.

Download week25.mp3

Best wishes,
David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.
www.Ed4Nurses.com