Skin Assessment

 Skin Assessment should be performed during admission and discharge to/ from the hospital, every shift, if Pt. conditions change, and at the emergency department. 

Complete assessment of the skin head to toe, paying attention to bony prominence because there can be the site for a pressure injury, aka bed sore. those are the most frequently bony prominences: 

*Sacrum/coccyx

*Buttocks

*Ischium

*Heels

Braden scale: Braden scale is a standardized and validated tool to determine pressure injury risk, It contains 6 items, sensory perception, moisture, activity, mobility, nutrition, and friction and shear. These helps in the decision-making and plan of care.

Assessing pressure related changes like temperature, cooler, warmer, blanch response, and pain or discomfort. Signs of pressure injury may include blanchable erythema, and or changes in tissue temperature or consistency.

"Blanchable" refers to an area of skin redness that turns white when pressure is applied, meaning the color disapears with pressure, while "non-blanchable" means the redness persists even when pressure is applied, indicating potentialtissue damage and often a sign of developing pressure ulcer. in dark skinn colors apply a wet wipe and use a tangential lighting, use a penlight to detect suspected erythema or color changes. 

Complete skin assessment include 

Skin Tones:  

*Pallor (paleness)

*Erythema (redness)

*Ecchymosis (bruising)

*Jaundice (yellow)

*Cyanosis (blue)

*Mottling ( spotty white)

Turgor:

When skin on the back of the hand is pinched, it should immediately return to normal. A variation of this may be indicative of dehydration or aging.

Temperature

Moisture

Skin Integrity:

* Intact

*Breakdown: open areas (skin tears, pressure injuries)

* Rash (fungal, bacterial)

*Moles, Freckles, variation in skin color or texture

Braden subscale: Sensory Perception

1) Completely Limited : unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body. Ex : comatose, sedated and intubated patient

2) Very Limited : responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body. Ex: Spinal cord injury below the waist, stroke with hemiparesis.

3) Slighly Limited: responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR has some sensory impairment which limits the ability to feel pain or discomfort in 1 or 2  extremities. Ex: Patient has diabetes and has neuropathy (can't feel pain in their feet)

4) No Impairment: responds to verbal commands. has no sensory deficit to feel or voice pain or discomfort.

Braden Scale Mobility: 

1) Completely Immobile: Does not make even slight changes in body or extremity position with assistance

2) Very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3) Slightly Limited: Makes frequent though slight changes in body or extremity position independently.

4)No limitations: makes major and frequent changes in position without assistance.

Avoid : Egg mattresses, turning pacient onto a body surface that is still red from a previous episode of pressure loading.

Braden Scale Activity: bedfast, chairfast, walks occasionaly, no impairment. Avoid: long periods sitting, donut-type devices.

Braiden Scale Moisture: completely moist, very moist, slightly moist, rarely moist. Avoid hot water, plastic underpads, multiple layers of linens under patient, briefs in bed.

Recommended Interventions: turn and reposition every 2 to 3 hours, if unable to tolerate full turns, frequent micro turns every hour until stable. Heels if reclined, elevate off of footrest. Sacrum/lowe buttocks:consider application of multilayer foam dressing with silicone adhesive. Support surface: consider reactive overlay (specialty bed) or "sand bed" 

Braden scale Nutrition:

1)Very Poor: never eats a complete meal . Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly.. Does not take a liquid dietary supplement OR is NPO and or maintained on clear liquids or IVs for more than 5 days.

2) Probably Inadequate rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding.

3) Adequate eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutricional needs.

4)Excellent eats most of every meal never refuses a meal Usually eats a total of 4 more servings of meal and dairy products. Occasionaly eats between meals. Does not require supplementation.

Recommended Interventions: consult dietician if: NPO for more than 48 hrs, presence of stage 2 or greater pressure injury.

Braden Risk Category: Friction and Shear

Friction: occurs when the skin moves against another surface. Ex pulling a patient up in bed, pulling linens/tubes out from under patient, using elbows to push self up in bed.

Shearing: the pulling of two adjacent tissues in opposite directions,often resulting in tissue destruction Ex: High risk of shearing when HOB>30 degrees. Tissue and superficial fascia remain fixed against the bed linens while the deep fascia and skeleton slide down toward the foot of the bed causing deeper tissue injury.

Probem, potential problem, no apparent problem Avoid greater than 30 degrees head of the bed elevation.

Final notes: this entire presentation is from the mandatory courses provided by Ascension Seton, they are all standard tools to follow. The computer Cerner charting, program will give the score imediately when data is entered during charting. The only purpose of this presentation is educational purpose only.

 

How is a typical day of a nurse/ Brazilian nurse/ International nurse working at the IMC Intermediate care and Trauma MedSurg in the Hospitals in the USA

0615 Arrive at the Hospital. Go straight to the break room and put the lunchbag in the fridge, backpack in the locker, get flash light pen, pen, eraser pen, and stethoscope littmann out in the pocket or in the fannybag.

0621 Find the assignment with 4 to 5 patients assigned, go to the computer, quickly read the main reason for Pt. being in the hospital, procedures done, medication times, and antibiotics next dose, next pain medication dose, allergies, past medical history,

0639 Clock in, get report from the night nurse, ask to spell out the abbreviations, ask again if he or she speaks too fast, write down really quickly everything. X4 X5 Shift change meet and greet Pt. update the board with the date, nurse, PCT, patient care technician, charge nurse names, phone numbers (work phones) plan of care, pain control, goals of the day, etc

0720 to 0930 Pass medications of the 7, 8, and 9 hour medication, Synthroid first is given 2 hours before breakfast. Insulin short-acting following the sliding scale, first need to know from PCT how much was the last glucose results, Insulin Glargine Lantus is long-acting and it is usually given by prescription certain units.

Beta-blockers (Metoprolol, Carvidelol) Always check blood pressure and apical pulse before administering, if lower than 50 hold, some recommend to hold if pulse is lower than 60 and Systolic pressure lower than 100, Digoxin hold if Pulse is lower than 60. Hold heparine and betablockers if there is surgery or call the anesthesiologist to ask first. Some medications are held before hemodilalysis, usually hypertension medication. 

Narcotics Oxycodone step one and step 2, Dilaudid, morphine, Tramadol after pulling from the BD Pyxis (an automated medication dispensing system) YOU HAVE 30 MINUTES TO ADMINISTER the narcotics, if waste get a nurse witness to witness, if Pt. refuses pain medication return medication back to Pyxis BEFORE THE 30 MINUTES. Pain scale must be moderate to severe and POSS score must be completed  1 for awake and alert, 2 for slightly drowsy. 

Antibiotics double check if it's the initial loading dose which is usually given in 6 minutes, maintenance dose is given over 2 or more hours. For Vancomicin runs for 4 hours, when trough level is due, collect blood for lab from a fresh vein, 30 minutes before the next dose. Laboratory says it's normal 10 to 20mcg/mL that number can vary depending on each hospital 

Heparine or Lovenox is given SC usually on the lower abdomen.

Tip: wake up Pt, do a quick assessment head to toe, ask about pain, if constipation, numbness and tingling check arms and leg strength, pulses, eyes, level of consciousness pulses, heart, lungs, sensibility on operated leg toes, arms fingers, color temperature. Ask pt. his/her name and date of birth, scan medication, give medication unwrapped in the medicine cup, explain each and what it is, its side effects, open the chart begin charting the assessment, Cerner or Meditech select only a few items of charting, just to set the time and register important information, charting completely after passing all medication is better so they dont't  get too late.Check orders constalty, refresh your screen every 15 minutes. Get help from your PCT with perineal care comfort care, check the skin while wiping with warm sponges no rinse sponges dry with towel,  turning Pt with two-person assistance, mornings go by very quickly.

1110 finish charting on Cerner or Meditech

1200 Pass noon medication rounding every room again, collect blood for lab studies, check lab results, eletrolytes results, administer Potassium if level is low, following the sliding scale the Potassium PO dose must be given with meals. 

1230 bathroom break drink water.

1100 or 1300 meeting with the interdisciplinary team.

8000 to 1230 answer calls and texts from work phone, if there is a surgery get informed consent signed by the Pt for surgery, explain risks, and consent for blood transfusions if needed and risks sign as witness, if Pt, needs further instructions doctoe can explain procedure again. All procedures are written without abbreviations, put it in the binder, delegate CHG bath.

13:30 take your lunch break, yes, finally another bathroom break warm up in the microwave, relax enjoy your lunch.

1400 pass medication, finish charting, discharge or admission.

1500, 1600, 1700 1800 rounding educating teaching Pt & passing medication fluids. collecting blood if necessary.

1800 Ins and outs. fluids, charting of food and beverage, urine output, and last bowel movement are usually done by the  PCT, nurses can do it too, beverage and urine output empty measure cup, , chest tube drainage, mark with sharpie pen last measurement on the device, JP drainage, on drains section.

1800 pass medication if any

1900 give Pt. report to the night nurse. see here an example of a bedside report.

!930 to 1945 clock out, go home, and get some sleep. You made it woohoo!

#MedSurg  #Progressivecare  #Nurse  #Braziliannurse  #Intermediatecare

 #TraumaMedSurg

Chipped Tooth

Thanksgiving week and the stores, particularly the grocery stores are well stored with all kinds of yummy traditional Thanksgiving food, it's beautiful to see so much abundance. Around this time of the year is the only time you will find eggnog, pumpkin drinks and pies, shaved beef, extra thin chicken breast, pork ribs, lots of green beans, and bags of cranberries.

Thanksgiving is one of the United States most important holidays, family and friends gather together to cook and share typical dishes to celebrate the end of the harvest and grattitude for everything.

Typical dishes are: 

Green bean casserole

Mashed potatoes

Turkey and Baked Ham

Cranberry sauce

Gravy

Buttery rolls

Corn

Pumpkin pie

Sweet potato casserole

Mulled wine or Spiced wine

Etc.

I went shopping this morning, actually at noon, and upon arriving at home I put all the groceries away,  soon I noticed an item was missing and checked the receipt it was paid for.  I ate some walnuts, and than I grabbed a handful of corn kernel put some in my mouth, and started looking for the missing item again while anxiously chewing which chipped my wisdom rotten tooth. I spat a piece of it while in the car putting the seat belt on, on the way to go back to the store to claim the missing item. I looked at the piece of tooth is really small and then while touching the hole with my tongue I felt the hole bigger, I wondered if I swallowed any piece.

Upon arriving at the store I went straight to check out 13 (I usually try not to get into this number) anyway, the young lady was still there and I waited for her to finish with her last customer and approached and I said: 

-'Hi! I was here earlier shopping  and I have a missing item",

She remembered me. I was wearing a  teal shorts and a pink jacket, and she said:

 -"Oh yes, your item is by the guest area", which was the same area of the returns and customer service.

  At the customer service I explained twice about my missing item while touching with my tongue the bigger hole on my wisdom tooth. The customer service lady said:

- I'm going to see with the checkout lady,13 right?" I nodded yes.

She went there and quickly returned and said:

-" I  can refund you now or you can go inside and get another one"

 As I was going inside I decided to just let it be and get the refund which was quick and easy. The item is a belt wallet which was supposed to be a gift for a family member and she's already gotten a lullulemon fanny bag, she's happy with it so I thought I might as well just get my money back.

The chipped tooth is supposed to be extracted any time soon, now after a piece is gone it's actually better to clean than before. Food would get trapped in the hole, now the hole is bigger and easier to clean until getting a dentist appointment.

Introduction To ECG

 ECG has been for me a mystery and then I thought "Ok I need to decypher ECG language for the love of God" I've been watching videos, reading books, writing notes, and drawing. So I thought that another good way to memorize and share as educational purposes is writing a post about ECG. 

The ECG shows the electrical activity of the heart in the form of waves on a tiny orange squared striped paper. The orange stripes are divided into blocks of five tiny squares. On the horizontal represents time the measure of each tiny square as 0.04 seconds, thus a block of five is 0.20 seconds. So far so good, right? 

The vertical strips measure the amplitude in millimeter or mm or electrical voltage in millivolts or mv each tiny square is 0.1 mv, thus a block of 5 is 0.5 mv. 

The letters that make the ECG are P,Q,R,S,T,and U.

Before getting to know better each letter, important tips about placing the leads of each ECG pad is necessary for a good reading of the electrical waves. ECG devices come in 3, 4, 5, or 12 leads. Now let's talk about the 5 lead, mostly used and called telemetry you need to make sure you place each pad on the intercostal space between the bony ribs, never on bony areas or you won't be able to see the waves properly. If the skin is oily you can wipe it down or if it's too much hair shave the hair off .

White RA, right arm

Black LA, left arm

Brown C,chest

Green RL, right leg

Red LL, left leg 

Nmonic to help you remember the pads placement is:

 White (clouds or snow)  over Green ( tree or grass)

Black (smoke)  over Red (fire)

Brown (chocolate) close to the heart

P wave means to FIRE from SA (Sinus Atrial) node the impulse that generates a P wave with amplitude 2 to 3 mm high and time duration of 0.06 to 0.12 seconds.

PR interval is the tragetory of the impulse from the atria SA node through the AV (Artial Ventricular) to the bundle of His, and finally right and left bundle branches with duration is 0.12 to 0.20 seconds.

The QRS complex means ventricular depolarization or in other words the ventricules contract and creates a pulse. QRS amplitude is 5 to 30 mm high and duration 0.06 to 0.10 seconds.

The ST segment represents the end of ventricular depolarization ( contraction) and the beginning of ventricular recovery or in other words repolarization. This very place is also known as J point. Normal amplitude is 0.5 to 1.0 mm. If  ST segment is depressed, inverted 0.5 or more below the baseline may be myocardial ischemia or digoxin toxicity. If ST segment is elevated more than 1.0mm above the baseline might be myocardial injury.

T wave means ventricular recovery. Amplitude is 0.5 mm to 10 mm. If  the T wave is bumpy a P wave might be hidden in it. A tall T wave might be hyperkalemia, myocardial injure. Inverted T wave might be myocardial ischemia.

QT interval Prolonged QT might be a dangerous arrhythmia called Torsades de points. Short QT interval might be digoxin toxicity or hypercalcemia.

U wave if present represents the recovery of the Purkinje fibers.

The colors on this classic ECG is just a way to memorize, Fire as stimulation or depolarization, green as recovery or repolarization a plant in a vase to remember it's resting quietly. The purple looks like a tight dress to remember the ventricular contraction. The brown means just brown I couldn't think of something. Next post I'll try to improve the drawings as I'm planning on drawing the Arthytmias and their interpretation.

The wonderful sources of material for this post using the paraphrasing technique is a book called"ECG Interpretation Made Incredible Easy" Third edition Lippincott Williams & Wilkins. The pictures are from Dynamic Health and/or Healthstream, the use is for educational purposes only.

Workplace violence and bulling in nursing

Workplace violence and bullying is sometimes not clear to identify and at the same time this type of harassment happens frequently. Usually the victim happens to be new hires and the perpetrator is someone who has been doing this harm occasionally and has never been caught and reported. What is even possible is that the perpetrator does not realize it is harsh comments, gossip, a piece of information made up and not true, and this behavior is called UNCONSIOUS BIAS.

Unconsious bias is PREJUDICE which means a preconceived opinion that is not based on reason or actual experience (definition from Oxford languaged).

Workplace violence is not tolerated in big retail stores the same thing inside hospitals or healthcare facilities. All new hires and  all employees must go through mandatory training courses and must report this type of violent behavior to the open doors, and the theme for that is called "If you see something say something.

What are some of the situations that are considered violent?

"Intimidating or undermining employee by demeaning their work standards, not giving them credit, setting them up for failure and constantly reminding them of old mistakes" 

"Threatening employee personal self-steem and work status. Isolating employees from opportunities, information, and interaction with others" . Source: Google Search "What are the bully tactics at work?'

"Examples of bullying in the workplace:

Constantly criticising someone's work

Spreading malicious rumors about someone

Constantly putting someone down in meetings

Excluding someone from team-workload then everyone else  

Deliberately giving a heavier workload than everyone else

Excluding someone from team social events" Source: Google search

Gossip is related tp parrots, if has been dreams with those birds it is a sign someone might be gossiping about you. Look up spiritual meaning of dream with parrots. 

The best is to address with the perpetrator if he or she keeps saying these malicious comments he or she will be reported. 

Finally, I'm going to end this post by quoting some wise quotes by Florence Shinn:

"There is a supply for every demand".

"There is a place that you are to fill and no one else can fill, something you are to do which no one else can do". 

"The first start toward success is to be glad you are yourself"

"Every person is a golden link in the chain of my good"

"Gratitude is the law of increase and complaint is the law of decrease"

"What is really yours? The blessings you bring to yourself through your spoken or silent words, the things you see with your inner eye".

Forgive it, realiase it, and  move on, if that looks like a not very  welcoming enviornment, let it go. Something greater and much better is been prepared. 

What is malignant hyperthermia?

 Malignant hyperthermia is an emergency that needs to be recognized during the assessment and notifying the doctor and/or immediately stop surgery also stop the anesthesics agents and start treatment with Dantrolene 2.5mg/kg  

What are the signs and symptoms? The earlier symptom is a sudden increase of the CO2,  jaw rigidity, rise in skin temperature and rise in the core body temperature, acidosis (when arterial blood pH is lower than 7.35 nEq/L), increase in heart rate, cyanotic skin, mottled skin, intense diaphoresis.

How does Malignant Hyperthermia happen? It is an inherited muscle disturbance that unfolds a hypermetabolic cascade when the patient is exposed to triggering substances in certain inhalation anesthesic and depolarizing muscle sbstances or breaking down muscles, (aka rhabdomyolysis).so the combination of muscle rigidity, acidosis, and hyperthermia causes cell death. Muscle rigidity is caused by the calcium that escapes from the skeletal muscle cells, ATPase starts off metabolic activities, use up all available  O2. From these activities can occur internal bleeding, cardiac arrest, failure of vital organs such as the kidneys. Pre-operative assessment is important questioning the history of sudden death during surgery of a relative, is important to know the history of high temperature and dark urine(coca-cola color) after anesthesia procedures, including dental anesthesia. (this does not rule out a present crisis of malignant hyperthermia. There are tests available called caffeine halothane it's a contracture test, the classic signs and symptoms followed by exposure to the triggering anesthesic agents are the important clues.  While using Dandtolene avoid calcium channel blockers. Max titration dosage of Dantrolene is 10mg/kg.  Sodium bicarbonate is also used to treat acidosis. Another important plan of care is to monitor urine output, both color and volume.

#malignanthyperthermia #rhabdomyolysis  #anesthesiology #criticalcare  #Hyperkalemia

Sources: Wikipedia and HealthStream

What does it look like shadowing the nurse?

 Often times when applying for a job as a nurse it usually starts with shadowing the nurse during her/his day.

Shadowing means following the nurse being her shadow for 2 to 4 hours, or even for 12 hours just watching everything with no interference, no hands-on, just observe, unless he/she asks for help, please help, it feels amazing. All paperwork, kardexes, or notes you wrote down regarding the Pacient of his or her care must be thrown away at the end of the day in a proper place that's designed to shred into tiny pieces - the papers with sensitive information,  information like name, date of birth, lab results, and diagnostics. All information that is confidential, regarding HIPAA rules.

What is HIPAA? HIPPA means Health Insurance Portability and Accountability Act it is a law enacted in 1996 that protects the client's privacy, it's a law regarding healthcare, health plans, healthcare insurance, electronic signatures, electronic transactions, the client's health information, so HIPAA ensures the privacy of individual information.

Do you get paid for shadowing the nurse?  Sometimes yes, sometimes no. It is all very worth it, it's a lot of new information you will have the chance to learn, so it is always a very positive experience!

To get ready for the shadowing day, wake up a little earlier have breakfast first, and take your phone and a small thin wallet with you in your pocket, I recommend that because you're always ready to go anywhere including going on luch and buying your lunch at the cafeteria, the locker rooms are usually locked and it needs someone to open it for you to access your bags, having your items with you saves you time if you have only your essential belongings with you.

Good luck on your first day shadowing the nurse.