Weekly Review #15

I've worked in sites that use recorded shift reports - they're ridiculous: first you spend 10 minutes recording it, then I spend 10 minutes listening to it, and then we end up talking about it for another 10 minutes so you can answer my questions and give me updates. 30 minutes instead of just a 15 minute in-person handover! I've always hated them; but now I have some evidence to support my dislike for them: an article by Judymae Ofori-Atta discussing the superiority of person to person bedside reports (BSR). Bedside reports are given between nurses in the presence of the patient and family they've been shown to improve work flow and patient safety, as well as patient involvement and satisfaction: a win all round, and applicable to all nurses. Hopefully this helps you bury the voice recorder for good!

http://journals.lww.com/nursing/Fulltext/2015/08000/Bedside_shift_report__Implications_for_patient.20.aspx

There was an online article published in the Journal of Emergency Medical Services by Douglas Dixon and Darren Braude on managing the airway of bariatric patients. Nursing considerations of bariatric patients has become a recurrent theme here: last week I discussed a REBELCast review of the accuracy of the Broslow Tape in estimating weight in obese children, and a review from the Nurse Path post on surgical considerations in weekly review 8. This article focuses specifically on airway management. Dixon and Braude start with a brief overview of the epidemiology of obesity and the physiological changes that accompany it: a reduced functional residual capacity due to decreased chest wall compliance and reduced diaphragm movement. Because of these changes obese patients will more quickly become hypoxic and will need extra attention paid to optimizing their ventilatory effort. They make some suggestions on positioning (ramped, or reverse trendelenberg), discuss how three handed BVM ventilation may be necessary to maintain good mask seal and overcome increased airway resistance, how to provide apneic oxygenation with high flow nasal cannula, and how drug dosing for RSI may need to be adjusted from total to ideal body weight (the Nurse Path post has a great overview of this). This is a good starting point if you're looking for tips for bariatric patients, and a good reminder to attend to patient position, especially for nurses working in the ED where patients may not always be able to adjust the position of the cot on their own.

http://www.jems.com/articles/print/volume-40/issue-8/features/bariatric-airway-management-is-about-more-than-intubation.html?cmpid=jemsnowenl08202015&eid=288528567&bid=1157558  




There was a great mnemonic (MADE NICER) created by Anali Maneshi and Matthew Cherian posted on BoringEM this week. It's a mnemonic to help assess possible differentials for geriatric patients presenting with weakness:

Medication - Screen for medication causes: steroids, statins, antipsychotics, diuretics, insulin, opioids, and sedatives; assess for recent dosage changes,
Anemia - Either due to blood loss (overt or occult), or impaired production malignancy, nutritional deficiency,
Dehydration - Diarrhea, diuretics, or vomiting,
Endocrine - Hyper/hypoglycemia, adrenal insufficiency, hypothyroidism can all cause glucose/electrolyte derangement,
Neurological conditions - Acute (stroke, SAH) and chronic conditions (lesion, MS, Parkinsons, etc) can result in weakness,
                                 Infection - Any infection can result in weakness,
                                 Cardiac - Presyncope from cardiac cause, angina or atypical MI presentation (malaise), and CHF may present as weakness,
                                 Electrolyte imbalance
                                 Rheumatological - SLE temporal arteritis

The typical ED will see a large number of geriatric patients, they're less capable of tolerating challenges to their systems, may be multiply co-morbid, and may have medications masking or contributing to their physical findings; having a mnemonic to help work through differential causes for a common presenting complaint is useful for all ED nurses when attempting to triage a vague complaint.

http://boringem.org/2015/08/24/tiny-tips-weakness-made-nicer/

There's been an increasing number of deaths in Canada recently from intentional and unintentional use of fentanyl. There is starting to be some reaction from the medical community, as studies are showing a 4% mortality rate associated with prescribed large doses of opioids. However there is still a large volume of diverted narcotics that are finding their way into other recreational drugs. The news is likely not news for many; but it is an excellent segue to highlight some more research on low dose titrated naloxone for opioid toxicity in the ED. A summary and how to for titrated naloxone can be found in a post by ALiEM. Worth a read for nurses working in the ED, also worth remembering is that obtunded patients without a history of narcotic use may still have unintentionally ingested fentanyl. . 

http://www.cbc.ca/news/canada/edmonton/alberta-slow-to-react-to-sharp-rise-in-fentanyl-deaths-critics-say-1.3191075



There was a podcast by Brian Ericson on erNURSEpro posted this week discussing hyponatremia, one of the most common electrolyte imbalances seen in the ED. The discussion begins with a discussion about the difference between acute and chronic hyponatremia, classification and explanation of  the differences between hypo/hyper/normo-tonic and hypo/hyper/eu-volemic hyponatremia. There is a discussion about the causes of hyponatremia: pre-renal (excess sweating/diarrhea/burns etc); versus renal (CRF/addisons disease/etc), neurogenic causes (SIADH), treatment, as well as the complications associated with correcting sodium. Brian discusses the difference in acute vs. chronic hyponatremia, and offers a great clinical pearl on suspecting hyponatremia in seizing patients who are not responding to benzo's. This is a great podcast, a little too in depth to fully absorb while driving; but worth the 25 minutes when you have some time to dedicated to listening. 

http://www.ernursepro.com/#!podcast-episodes/c1enr

I came across a blog called Rescue Science) by Matthew Douma with some great posts that I'm looking forward to reviewing in more detail in coming weeks. There's some standout posts on dead space in IV extensions, methods for pushing adenosine, and a fantastic review of the role for external aortic pressure in junctional bleeds to check out. Some of these have been out for a while, but they're directly applicable to nursing practice, thorough and well written. An awesome resource, I'm looking forward to future posts.

Check out Injectable Orange this week for a review of Sketchy EBM. I would also like to congratulate Jesse on winning the Symplur Signals Research Challenge. 

Ian Miller from the Nurse Path has 28 step guide to hanging an IV that is pretty well spot on for your first shift back, as well as some tips for handling messy situations. I'm glad to see you up and running on Facebook again!

CriticalEd had a discussion about the role of a "nurse curator" in staff development: what it is, what the role would include, what to call it etc. An exciting idea to suggest a formalized role for FOANed in clinical practice. Give it a read, he's looking for feedback and suggestions if you have any.