Archive for August 20th, 2009

Documentation of Bedsores, comment

August 20, 2009

This is very true about the documentation of bed sores being incorrect. In the ICU where I work at, we actually document initially if there are any sores as soon as the patient arrives. It is located in the admission assessment. After that it is up to the nurses top document if there have been any changes in the skin integrity of the patient. Multiple time we see a skin assessment documented with a stage one/two pressure ulcer when reality is that it is incontinence associated dermatitis. Most time the IAD can resolved by either timely cleansing of the person, the insertion of a rectal tube and foley catheter (if not previously present) and some type of barrier ointment. In a way prevention is the best medicine for IAD and Pressure Ulcers, in companied with good core and forensic assessment skills. If the pt is having large loose stools, create a prevention to keep the skin intact.

Original Post
August 3, 2009
Title: Documentation of Bedsores, comment

The hospital where I currently work also includes documentation of existing pressure ulcers on admission of a patient. However, the protocol asks you to assess the patient’s skin then to document on paper what the ulcer looks like, stage, size, drainage, etc. The paper charting does not require a picture of the pressure ulcer that was found by assessment of the RN. I think this leaves a wide margin for error. It is probable that some ulcers will not be documented correctly. I believe that a photo would be advantageous to the medical record along with perhaps a computerized charting system where you can label with an X any area of the body that has breakdown and then attach a photograph to the document. Also the documentation I work with does not allow for updates on how the pressure ulcer heals or worsens. This also leaves room for criticism and error. I think my place of work would benefit from photo/computerized documentation of pressure ulcers.

Original Post:
July 31, 2009
Title: Documentation of Bedsores, comment

I found this post and other comments relative to my new nursing job. As an experienced ER nurse, we found little time to assess or document pressure ulcers. With the new CMS guidelines that came out this past October, Medicare will not longer be reimbursing for facility acquired pressure ulcers. My new nursing role focuses on prevention and education. I was very surprised how little I knew about pressure ulcers from working in the ED. Yet it is so vital that our assessment starts there. The photo proof documentation mentioned in this Post sounds like an excellent idea. One of the hospitals I work with, just installed a whole new soft ware program for nursing documentation. It is really easy to chart your skin assessments and pressure ulcers. With drop down choices, body diagrams. But the wound care nurse still has to validate the floor nurses documentation with her own patient assessment every month. I helped her with this, and it was very time consuming. It was double the work in my eyes. Yet we did find, many pressure ulcers that were resolved and many that were staged incorrectly, as well as several that were missed by the RN. Even though we have many different technologies to help us with our documentation and assessment, it still comes down to basic education.

Original Post:
June 17, 2009
Title: Documentation of Bedsores
Joint Commission and CMS (Medicare) has set a Patient Safety Goal of not allowing bedsores to occur during hospitalizations. My institution uses technology to document existing wounds at the time of admission assessment. We are a totally computerized charting hospital. When we identify an existing wound, we bring up a screen of the body and insert a photo of the wound into the patient’s medical record. This feature allows us to prevent lawsuits and receive the correct reimbursement of that patient’s hospitalization. Health assessment no longer has to rely on a verbal or hand written dictation to describe history and physical assessments!

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Patient Interaction with their Disease

August 20, 2009

Wouldn’t it be cool if patients who are admitted to the hospital for a chronic illness could be connected with an online program that teaches them about their disease? Maybe the patient could check out a laptop for a few hours and then there could be information given to them about their disease. Medications and the important information that goes along with them could be reviewed (this could be tailored specifically to the medications the patient is taking/will be sent home with). Also a little pathophysiology lesson could be given in an interactive exercise that reviewed anatomy and then changes at the cellular level due to the chronic disease. The program could then go into warning signs of an exacerbation of the disease and when to contact their health care provider or call 911. At the end it could talk about how the patient can work to control their illness at home. The program could include print offs of the medications and disease information. If the patient had questions they could take notes and ask their health care provider before their discharge. I think it is so important for a patient to feel that they can have control over their chronic illness. I think that if patients were better educated about their disease processes that hospital admissions/exacerbations would decrease. I firmly believe in educating patients about their illnesses and believe that a user-friendly computer program would greatly benefit patients.

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Abdominal Assessment

August 20, 2009

The type of assessment skills presented by the book and video clips is rapidly becoming a dying breed. Palpation is still used frequently (for hepato-splenomegaly, to feel for ‘the olive’ in pyloric stenosis, RLQ exam for r/o appy, etc) but percussion has definitely fallen of the clinical pathway. The use of CT scans and bedside ultrasound have replaced percussion for establishing +/- free fluid in the abdomen, liver size, masses, etc. These high-tech tools are fast and easy. Images are transferable to clinicians miles away within minutes, allowing for better clinical decision making for the benefit of the patient. However, with the loss of the hands-on skill come the increased cost of the test – which burdens our health care system even more.

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Scanning Patients’ Armbands

August 20, 2009

I miss scanning patients’ armbands. The hospital where I worked in the ICU we scanned armbands as a safety measure when administering medications. It was very helpful in the ICU because most patients were sedated and unable to give the nurse their name and birth date. It was very helpful. I felt safe in checking my patient’s armband at the beginning of my shift then scanning their armband later as an identifier. At the hospital I work at now you have paper charting, paper MARs, then you go into the patient’s room and ask them to identify themselves. Many patients are unresponsive or confused and it is not a reliable check. One time I was in a male patient’s room and it was semi-private and both men were sitting up in chairs and I almost administered an IV antibiotic to the wrong patient. The patient was confused and his armband was taped to his bed so it was very unclear. I ended up going to the other patient and asking him to identify himself because I could not get a clear answer from the first patient. It turned out that the second patient was the correct patient. It made me a little tachy for a while. It was scary to think that I could have wrongly administered a medication. I want to keep my patients safe and I really miss the scanner. I felt much more comfortable with it. It also scanned the meds to approve them as well instead of relying on human eyes to misread something. You could rely on your eyes AND the scanner.

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E-Learning

August 20, 2009

I have definitely used e-learning and the Internet to educate myself and my colleagues. I place peripherally inserted central catheters as one of my jobs. In that, the latest research show that mid-clavicular lines should be a thing of the past due to their increased risk for increased clotting/thrombosus, which was a simply 2 1/2 page online CEU I recently completed. This was not known by even experienced PICC nurses and was brought to their attention for a change in practice. I have encouraged the nurses I work with (as a second job in an ICU) to review their pt’s morning X-rays’s, to assess proper placement and to question the order that allows Mid-Clavicular lines to be allowed as practice. A simple X-ray assessment of the line could prevent a healthy lawsuit and more importantly save your pt’s life.

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Computerized Medication Reconciliation, comment

August 20, 2009

I agree with the post in that hospitals would benefit from computerized medication reconciliation forms. At the facility I work, the med rec forms are constantly lost or that handwriting is illegible or the doctor did not fill out the form correctly. If the form was online, I believe, there would be less room for error. Also I agree that it would be easier to review the form on a different floor if a patient was transferred if it was online. It is very hard to keep track of paperwork when a patient is transferred. With each patient that I receive from the PACU or ICU, I spend probably 15 minutes trying to retrieve the paperwork I need from the patient’s chart. I have previously worked at a hospital where the med rec form was online and the only time it was printed was when a MD wrote transfer orders then it was added to the chart and the MD had to check boxes to continue or discontinue a med. After the MD filled out the form it was faxed to pharmacy and then everything went back to being online. The nurses never had to bother with med rec paperwork. I definitely had less phone calls from the pharmacy with questions regarding the med rec form!

Original Post:
May 26, 2009
Title: Computerized Medication Reconciliation
I have recently seen a need for medication reconciliation to be computerized. In my current hospital, the patient’s meds are documented individually on paper at each floor they are admitted to. Problems arise in this system when papers get lost, each floor uses different charting, nurses do not complete the form, etc. In short, the patient ends up either answering the same question regarding their home meds repeatedly, the nurse at each floor must searches for the med list or the family must bring in the home med list more than once to appease the admission paperwork required of each floor and nurse. I see a much easier answer to be to computerize the medication reconciliation forms. The computerized form could then be checked at each floor if needed for completion. We could also solve the problem of incomplete forms through this means. The program could be designed to ensure that the form must be complete, for example, using a symbol such as a red exclamation mark to notify the nurse at each shift if it is not completed. I see this as using informatics to eliminate problems and ensure patient safety in home medication reconciliation.

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Nursing Assessment Meets Technology – Nursing Education, comment

August 20, 2009

I too work in a hospital with the "SIM" man, as he (the manikin) is known to us. This is a wonderful tool for everyone that comes in contact with patients. As an ICU nurse it is valuable to hone our skills and be able to react to the emergency at hand by using our nursing assessments and education. Shortly after using the SIM man during our mock code, I had to run a true code in which the MD was not available, she was at a another Code in the hospital. When I arrived to the code the pt was unresponsive still had a qrs complex on the monitor. I checked a pulse and it was absent, PEA. This simple and basic assessment was not previously done by the primary RN(disturbing I know.) However my code team mate and I began work immediately on the pt. Having the technology to train on, the nursing education and assessment skills allowed the team to complete the code and successfully resuscitate the patient. The MD was able to finally show up and thanked us for being able to use our nursing skills and quick reactions.

Original Post:
July 30, 2009
Title: Nursing Assessment Meets Technology – Nursing Education, comment
I work at an institution that received a federal grant to start up a simulation lab. This lab has three manikins that are very lifelike. One is an obstetric manikin and can simulate vaginal births. One is pediatric. The last manikin is an adult and we have sent over 1000 nurses thru this lab this year. We do ACLS scenarios and mock Code Blue. The program can be written to do anything. You can hear the lung fields and heart. When you feel the pedal area, you can even feel a pedal pulse. It is an awesome way to train students and new graduates as well as the experienced nurses. I am impressed that your institution was able to obtain a federal grant in this day and time of economic hardship to establish an innovative simulation lab. This technology is truly awesome in that it gives students who come into the nursing field having no idea about basic assessment skills, which have never experienced actually hearing a real heartbeat, or breathe sounds let alone participate in an actual code blue situation. This lab will allow the students to establish some level of comfort prior to entering the clinical area for their first encounter with real patients. Although I am sure this technology is as close to simulating a real patient as possible remembrance of those first day jitters in the clinical area is something that will stay with you for a lifetime.

Original Post:
June 4, 2009
Title: Nursing Assessment Meets Technology
I work at an institution that received a federal grant to start up a simulation lab. This lab has three manikins that are very lifelike. One is an obstetric manikin and can simulate vaginal births. One is pediatric. The last manikin is an adult and we have sent over 1000 nurses thru this lab this year. We do ACLS scenarios and mock Code Blue. The program can be written to do anything. You can hear the lung fields and heart. When you feel the pedal area, you can even feel a pedal pulse. It is an awesome way to train students and new graduates as well as the experienced nurses.

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My Favorite Aspect of Online Learning

August 20, 2009

My favorite part of online learning is that there are no stupid questions asked. I get very impatient in class when students ask questions that are relative only to them or that have already been answered earlier in the class. It seems that the people who ask the most questions are those that pay the least amount of attention. Often times the answer to their question has either already been reviewed or is located on a power point/email somewhere. It can be very annoying. It has been 2 and ½ years since I have been in school and I am about to rejoin the classroom setting; I am not excited for the "question students." This is why professors put together lectures and send out emails, to prepare students for the exams, quizzes, clinicals, etc. I hope that in graduate school the students read a little more carefully. To summarize, thank you Dr. Johnson for providing me with an advanced health assessment class that lacks obnoxious question sessions.

Online Advanced Health Assessment Course, Online Nursing Education

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Internet Education and a changing belief among traditional nurse educators, comment

August 20, 2009

I agree the comments made about the online student and educators. I currently work two different nursing jobs like various other nurses out in the world. Having to make time to show up to a class 5 days a week would nearly be impossible. For the online assessment class I currently am enrolled in, we had a lab portion in which we had to meet for a certain amount of hours to fulfill the hands on portion. This was very important sense we learned new skills (percussion) which is not taught in the BSN or ADN programs and is considered an "advanced practice" skill. Like the previous author I am in agreement that the access of the online course is wonderful but certain aspects where hands on learning is needed cannot be replaced. Would you want your surgeon cutting you open if he learned it on-line?

Original Post:
July 29, 2009
Internet Education and a changing belief among traditional nurse educators, comment
I personally have mixed feelings about online education. I feel there are a variety of pros and cons dealing with this issue. The pros are that the student has high flexibility are far as the time constraints go and the student has the ability to take test and complete work according to their work schedule. The main negative is that the student has very limited amount of instructor interaction. Therefore if the student is having issues or a problem they can’t figure out they may become more anxious about completing assignments.

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The pro’s of online learning in the nursing world

August 20, 2009

Nursing education and nursing students have changed. When deciding to take online nursing courses, other factors must be considered. What you need to participate in online classes varies with the sophistication of the tools used by the course instructor. Sending and receiving e-mail, participating in discussion groups, and viewing online syllabi require fairly simple technology. You need a computer with Internet access. It is important to investigate any technology issues in your area before undertaking a course. Access to the campus bookstore and library is critical, and journal articles must be available online. Some advantages of distance learning that I could come up with are: 1. Student-Centered versus Instructor-Directed Learning. Students take an active role in their own learning experience. 2. Flexibility. Students may work at their own computers on a weekend or the middle of the night, not having to worry about library hours or driving in bad weather. 3. Accessibility. Geographic proximity or time constraints do not prohibit students from utilizing these courses. 4. Student Interaction Increases. Students not only listen and take notes, but they also pose ideas to and ask questions of the instructor as well as other students in discussion groups. 5. Increased Sharing of Knowledge. In the traditional classroom, the instructor is the primary source of information. In distance learning, students have a greater opportunity to share their knowledge and experience, allowing the members of the group to learn from each other. 6. Immediate Access to Updated Material. Any material or announcements that have been changed can be distributed instantaneously. 7. Developing Technology Skills. Students are learning technology skills that they can apply later in their work setting. Online learning is being used by more and more educational institutions to provide both degrees and continuing education.

Online Advanced Health Assessment Course, Online Nursing Education

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