Patients require transportation for many reasons: to an increased level of care, a decreased level of care, a procedure, or for imaging. Katherine Stradling, BSN, RN, CCRN, TCRN discusses the science of transport, what it's like in the ambulance, and what bedside nurses can do to facilitate safe transport.

BLS v. ALS v. CCT

Note: Protocols differ by county and organization

The Science of Patient Transport

How the sending nurse can help facilitate safe transport

Tip: If you're saying to yourself "the patient should be fine", just remember that the ambulance has finite supplies and team members. It's just the RN and EMTs out there on the road or in a helicopter, so give them more medications and supplies than you'd think and get your patient as stable as possible before they go.

Relevant Links

Hands to Hearts is a volunteer organization who believes that no one should die of treatable medical emergencies due to lack of education and resources. The organization helps build the first response system and offer life support courses in developing areas across rural Mexico. 

Dialysis isn't simply hooking up a patients to a machine for 3-4 hours. Veteran dialysis nurse, Jameisha Rogers RN, talks us through what happens during dialysis starting from reviewing orders to decannulation.

Up My Nursing Game is partnering with VCU Health Continuing Education to offer FREE continuing education credits for registered nurses. Click here to obtain nursing credit (1.00).

What does dialysis do?

Dialysis eliminates waste, corrects electrolyte deficiencies, and corrects fluid imbalances.

Inpatient v Outpatient Dialysis

Inpatient

Outpatient

Different Types of Dialysis Access

Blood Pressure During Dialysis

BP can increase or decrease based on the patient's baseline, what/when medications were taken prior to dialysis, and the dialysis machine settings.

What is UF (ultrafiltration)?

Ultrafiltration is the mechanism for which fluid is removed from the blood during dialysis. Ultrafiltration occurs when fluid passes across a semipermeable membrane (the dialyzer) to an area of lower pressure (the dialysate).

A high UF volume means that a large volume of fluid will be removed from the patient. A high UF rate means that fluid will be removed from the patient quickly.

Strategies to increase BP during dialysis?

Anemia in ESRD

The kidneys play a primary role in RBC production by secreting the hormone erythropoietin. Patients will often receive exogenous Epogen, iron, and vit D to help stimulate RBC production on dialysis days

Miscellaneous

Q: When should we be taking off dialysis dry dressing? 

A: Around 4 hours after dialysis has ended (don't leave until the next day)

Q: Why are patients tired afterwards?

A: We are doing in 3-4 hours what the body does 24 hours a day -- fluid balance, removing toxins, electrolyte replacement to name a few.  The decrease in kidney function itself along with anemia and other comorbid issues contribute to fatigue.

Venous thromboembolism (VTE) prophylaxis is a core marker of healthcare excellence. Dr. Walter Cheng explains that almost every hospitalized patient is at an increased risk for developing a deep vein thrombosis (DVT) or pulmonary embolism (PE) and that nurses play a crucial role in preventing, assessing for, and educating our patients about VTE. 

Up My Nursing Game is partnering with VCU Health Continuing Education to offer FREE continuing education credits for registered nurses. Click here to obtain nursing credit (1.00).

Virchow’s Triad 

What are SCDs?

Sequential compression devices are a venous thromboembolism prevention strategy that works to stimulate circulation in the lower extremities through inflation and deflation one at a time to simulate the pumping effect of walking.

What are TED hose?

TED hose stands for “thromboembolism deterrent” hose, and are used as compression stocking for the prevention of venous dilation and therefore prevention of clots, as noted below. They work by applying continuous pressure from the calf to the thigh, thereby compressing the veins and preventing venous stasis. 

Quick Anatomy Rundown

Hypercoagulability

• Genetic causes of hypercoagulability: inflammatory diseases, infections, cancer, rheumatologic diseases, organ failure

Risk factors for VTE

Tips for explaining the need for SCDs, TED hose, and the Heparin/Lovenox 

Assessment findings of DVT/PE

Today, ICU patients seem to become sicker and more sedated. Sedation medications, such as Propofol, have become more accessible and can be hung up and left on a drip all day. Heidi Engel, PT, DPT argues that less sedation and more mobilization should be thought of as important as taking medications. In this episode, we discuss how nurses can play a crucial role in mobilizing our patients both in the ICU and on the floor.

Up My Nursing Game is partnering with VCU Health Continuing Education to offer FREE continuing education credits for registered nurses. Click here to obtain nursing credit (1.00).

Benefits of Early Mobilization:

When to Initiate Mobility?

• 48 hours is target for initiating mobility because it only takes 48 hrs to start developing diaphragm weakness

We must advocate for our patients who develop anxiety regarding getting out of bed

Strategies for coaching patients through anxiety

What are some chair and standing exercises RNs can lead with our patients while we’re in the room? 

GOAL: We want to normalize activities and being out of bed as much as possible. Getting out of bed is imperative for maintaining mental and physical health

Example of Early Mobility Initiative Success

Inner Mountain Health in in Salt Lake City is an institution that is very aggressive about early mobilization. They have the longest running, most vigorous, mobility program in the country. Patients, ventilated or not, are out of bed and walking twice a day, while getting uninterrupted sleep throughout certain nightly hours. A very high percentage of their ICU patients are able to leave sooner and go straight home after their hospital stay. Here are articles that explain how an initiative encouraged early mobility for a shorter hospital stay.

Last Notes:

Pregnant and breastfeeding patients aren't always hospitalized for obstetric reasons and can be placed throughout the hospital. Dr. Michelle Solone, OBGYN talks to us about how we can assess these patients, what to look out for, and how nurses can promote pumping and breastfeeding during a hospitalization.

Common reasons for non-OBGYN related hospitalization for pregnant patients:

Which floor does the Pregnant Patient receive care on?

Physiologic Differences of Pregnant Patients

Assessment ABC's of Pregnancy

Medications and Imaging in Pregnancy

Care of the Postpartum and Lactating Patient

Dr. Brandon Varr, an advanced heart failure and transplant cardiologist, provides insight into how heart failure is managed by diuretics and whether or not fluid restriction is important. 

Heart Failure (HF) Refresher

Heart Failure (HF) simple means that the heart is not pumping enough blood to adequately supply organs.

TYPES OF DIURETICS (MAIN 4):

Holding Parameters

How much do diuretics influence BP?

When are we justified in holding on diuretics?

Important Take-Aways

Think critically as to WHY your patient is here in the hospital. For example, a decompensated HF patient is in the hospital to lose weight, salt, and take aggressive diuretics to help them feel better. 

If a patient is hypotensive, look at their meds and think about which medication to hold (usually NOT the diuretic). Consider adjusting BP meds before holding a diuretic.

Nurses should hold other BP meds before holding diuretics if patient is hospitalized for fluid overload

Fluid Restrictions

I&Os v. Os & Weight

• More useful: Overall output for day and daily weights

Overview
Patients experiencing homelessness can add extra layers of complexities to emergency or inpatient care. Dr. Joe Mega provides some much needed perspective about the needs of our patients experiencing homelessness and how healthcare professionals can care for them more effectively.


Belongings

Pets

Substance Abuse

When people are in the throes of addiction, this is often their #1 priority and they live in fear of experiencing withdrawal

IF YOUR PATIENT IS BECOMING UNCOMFORTABLE DUE TO WITHDRAWAL SYMPTOMS AND WANTS TO LEAVE THE HOSPITAL

Ask questions like these:

Present the situation to the physician in a constructive way such as “I’m worried that the patient might leave, because they’re starting to feel unwell. What do you think about giving them something to help prevent withdrawal such as x, y, and z”

Food
It’s important to put it in the context of how easy it is, for someone with resources in home to access food, and then compare it to a person who doesn’t have a home. Just opening a refrigerator and getting access to some to what they want to eat is, is not a convenience that most people have.

Be Trauma Aware
The homeless have often experienced extreme trauma and horrible experiences that either contributed to their homelessness or resulted from it.

It’s important to be “trauma informed” and consider reframing your mindset from “What is wrong the patient” to “What happened to the patient?”

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Faiman Chow MS, SLP provides insight into safe swallowing practices, good oral care, the risk factors for aspiration pneumonia, and the use of artificial nutrition in advanced dementia.

We're a year into the pandemic and, as a nurse, I'm curious: what are the best practices for treating COVID in the hospital? I sat down with a returning guest, Dr. Cyrus Shariat, an intensivist, and asked him about COVID pathophysiology, management of respiratory failure, medications, and risk of thromboembolism. 

Dr. Megan Coylewright, interventional cardiologist, and Danielle Durfey, cath lab RN, sit down with me to talk about atrial fibrillation (AF) management including rate v. rhythm control, anticoagulants, the Watchman™ device, and give us a peak inside life in the cath lab.