PARADIGM BYTES

Newsletter for Paradigm 97

September 16, 2014

PARADIGM DEFINED:1) an outstandingly clear or typical example or archetype.2) a philosophical and theoretical framework of a scientific school or discipline within which theories, laws, and generalizations, and the experiments performed in support of them, are formulated.

Our website...... http://paradigm97.blogspot.com/Please copy, paste, and bookmark it.

MISSION STATEMENT

We believe that nurses need each other for support during the "lean and mean" days to help survive them. We offer research results and other ideas to enrich the nursing experience.

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SNIPPET

From The Floor

Courtesy Counts in Nursing

Being busy is never an excuse for being rude

By Genevieve M. Clavreul, RN, Ph.D.

Nurses are constantly reminded that we are held to higher standards than people in other professions, both at work and in our personal lives. We are judged by how our patients and coworkers perceive us as well as how they perceive our nursing skills. People expect us to be not only competent, but also compassionate and caring.

Unfortunately, nurses often overlook the role that basic courtesy plays in our profession. When stress levels rise, good manners are often the first things to go out the window. We’ve all been there at one time or another when tired or overwhelmed. The consequences of that rudeness can be much more serious than you think. 　
WHEN CIVILITY FAILS When it comes to the workplace, politeness might seem like a very trivial issue, particularly in a profession as demanding as ours. Not so, says Pier M. Forni, Ph.D., a professor at Johns Hopkins University and the author of several books on civility and ethics. “Incivility is very costly,” he told David Zax of Smithsonian.com in 2008. “Incivility is both caused by stress and causes stress, and stress is not only a producer of human misery, but is also very costly in dollars.”

Discourtesy costs businesses and organizations a lot of money in the form of reduced productivity and higher turnover rates. Rude behavior in the workplace can make workers avoid each other when they should be collaborating, “tune out” when doing important tasks or even quit. Considering how many talented nurses become burned out, the latter is no small concern.

For healthcare workers, the stress caused by incivility is also bad news for patient safety. The Joint Commission’s 2012 report “Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation” notes that workplace civility is “[c]losely associated with, and perhaps a necessary precursor to, improving safety culture.”

Then there is the problem of lateral violence. Research has repeatedly demonstrated the terrible impact workplace bullying has on nurses and such bullying is all too common. Some researchers have estimated that as many as 85 percent of nurses suffer lateral violence at one time or another and up to 93 percent of nurses have witnessed it. Discourtesy isn’t the same thing as bullying, of course, but an environment in which coworkers are frequently rude to one another and to patients is one in which lateral violence can thrive. So, civility and manners do count and the lack thereof can and does have an impact on our workplace and in turn on our patients.

CHANGING THE ATMOSPHERE Common courtesy promotes a more positive work environment and allows for better relationships with the people you know and the ones you meet on a day-to-day basis. Good manners convey respect for those with whom you interact and encourage them to respond in kind. A more congenial workplace also makes it harder for lateral violence to take root.

Negativity feeds on negativity, but it is also possible to shift the atmosphere in a more positive direction. Sometimes, all it takes is a few people making the choice to be polite and pleasant.

I often share with people my experience of changing the negative milieu at a local county hospital — not as a nursing director or a nurse, but as a patient undergoing treatment. While the physicians at this hospital had the expertise to provide the treatment I needed, the downside of going there was the very high volume of patients: almost 100 a day. During my first few visits, it was apparent that while the nurses and auxiliary staff were good at their jobs, many treated the patients more like cattle than people.

WHY WEREN’T THE NURSES MORE HELPFUL? Patients were given little guidance on how to navigate the complex procedures for making appointments or about how to get labs and X-rays done prior to being seen by the doctor. Worse, the nurses seemed to be doing almost nothing to help. I realized that the reason the nursing staff wasn’t trying to making the patients’ lives easier was that no one had made any effort to make the nurses’ lives easier.

Seeing that, I decided to perform simple acts of courtesy like making eye contact, addressing nurses by name and offering a cheerful “hello” to the nurse in the intake line. When I noticed one of the nurses go out of her way to help a patient, I made a point of complimenting the nurse for her act of kindness, remarking that such acts are a fundamental part of our nursing function. I also brought in treats like homemade cookies for the nursing staff.

This reinforcement had a gradual but observable impact in how the nurses treated me. Over time, I also saw the nursing staff demonstrate a bit more kindness and consideration to other patients and even to one another. These were all small things, but they made the clinic a more pleasant place to be and in which to work.

A SMILE GOES A LONG WAY It’s easy for nurses to blame our lack of courtesy on having one too many patients, not enough ancillary help, being short-staffed and so forth. However, good manners and civility shouldn’t suffer just because we’re too busy.

I have a friend who’s now a plastic surgeon in France. She has a very outgoing personality and greets everyone who crosses her path with a warm “hello” or “good morning” regardless of where she is. As a result, people almost always respond positively to her. Even the curmudgeonly chief of service would find himself smiling (if for only a moment) whenever she entered the room.

Being polite to others is not a one-sided affair. People have a hard time ignoring someone who offers a kind word or other simple courtesies. Taking the time to make these small gestures will go a long way towards achieving positive outcomes in most if not all of our encounters.

Nurses face many challenges in our daily work, but civility and the practice of good manners shouldn’t be given short thrift in the name of efficiency. Courtesy never goes out of style even if people sometimes forget to practice their manners. Let’s make this one of the many areas in which nurses lead the way. 　

------10 Ways Nurses Can Be More Courteous

1. Be respectful. Respect is reciprocal. If you want respect from others, you must be prepared to show respect to them as well.

2. Appearances count. Make a point of coming to work in clean, pressed scrubs (or the uniform of the day) and make sure you wear your identification so it can be seen by coworkers and patients.

3. Politeness wins the day. Always say “please,” “thank you” and “you’re welcome” when interacting with your coworkers, patients and their families. It’s easy to forget in the hustle and bustle of the floor, but is always remembered by the people on the receiving end.

4. Voices carry. Whether interacting with coworkers, patients or patients’ families and friends, remember not to raise your voice, use foul language or slang or talk down to others.

5. Promptness is a virtue. There are times when you’ll be late due to some unforeseen circumstance beyond your control, but chronic tardiness is disrespectful and places an additional burden on your coworkers, which breeds resentment and hostility.

6. Gossip is never harmless. Talking or gossiping about a person who isn’t present is disrespectful and generally ends badly for all involved. It harms the person who’s the subject of the gossip and reflects badly on the one doing the gossiping.

7. Don’t ignore people in your presence. The clinical floor isn’t kindergarten. It’s rude to ignore or refuse to acknowledge people when they approach. A polite “hello,” a wave of the hand or a smile will go a long way.

8. Pay attention when someone else is speaking. Show interest, maintain eye contact and listen to what the other person is saying. It’s easy to get distracted when others are speaking, but making the effort to pay attention and show an interest in their thoughts and ideas helps to build a civil work environment.

9. Keep the common areas neat. When in the nurse’s lounge, staff lunch room or other common areas, be sure to clean and put away your dirty dishes. Don’t be a food thief and make sure you keep the refrigerator, microwave and other appliances neat and clean.

10. Use the correct name. Mangling someone’s name or calling someone by a unwanted nickname doesn’t engender positive feelings. If you’re not sure how someone wants to be addressed, ask them. If you’re not sure how to pronounce a name, ask the person to spell it for you (even if that means spelling it phonetically to help you remember the correct pronunciation!).

This list is by no means exhaustive, but these 10 basic tips will prove helpful in most situations.　　

Geneviève M. Clavreul RN, Ph.D., is a healthcare management consultant who has experience as a DON and as a lecturer on hospital and nursing management.

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Tracheostomy care: An evidence-based guide to suctioning and dressing changes (Permission granted by American Nurse to have the full article here)

Tracheostomy care and tracheal suctioning are high-risk procedures. To avoid poor outcomes, nurses who perform them—whether they’re seasoned veterans or novices—must adhere to evidence-based guidelines. In fact, experienced nurses may overestimate their own trach care competence.

Tracheostomy patients aren’t seen only in intensive care units. As patients with more complex conditions are admitted to hospitals, an increasing number are being housed on general nursing units. Trach patients are at high risk for airway obstruction, impaired ventilation, and infection as well as other lethal complications. Skilled bedside nursing care can prevent these complications. This article describes evidence-based guidelines for tracheostomy care, focusing on open and closed suctioning and site care.

Suctioning a trach tube

A trach tube may have a single or double lumen; it may be cuffed or uncuffed, fenestrated (allowing speech) or unfenestrated. Each variation requires specific management. For instance, before suctioning a fenestrated tube, you must insert a plain inner tube, because a suction catheter may puncture the small opening of the fenestrated tube. (See Trach tube positioning by clicking the PDF icon above.)

Regardless of the type of tube used, suctioning always involves:

assessment
oxygenation management
use of correct suction pressure
liquefying secretions
using the proper-size suction catheter and insertion distance
appropriate patient positioning
evaluation.

Also, be sure to keep emergency equipment nearby. (See Be prepared for trach emergencies by clicking the PDF icon above.)

When to suction

Suctioning is done only for patients who can’t clear their own airways. Its timing should be tailored to each patient rather than performed on a set schedule.

Start with a complete assessment. Findings that suggest the need for suctioning include increased work of breathing, changes in respiratory rate, decreased oxygen saturation, copious secretions, wheezing, and the patient’s unsuccessful attempts to clear secretions. According to one researcher, fine crackles in the lung bases indicate excessive fluid in the lungs, and wheezing patients should be assessed for a history of asthma and allergies.

Suctioning technique

Before suctioning, hyperoxygenate the patient. Ask a spontaneously breathing patient to take two to three deep breaths; then administer four to six compressions with a manual ventilator bag. With a ventilator patient, activate the hyperoxygenation button.

Experts recommend using suction pressure of up to 120 mm Hg for open-system suctioning and up to 160 mm Hg for closed-system suctioning. For each session, limit suctioning to a maximum of three catheter passes. During catheter extraction, suctioning can last up to 10 seconds; allow 20 to 30 seconds between passes.

For open-system suctioning, catheter size shouldn’t exceed half the inner diameter of the internal trach tube. To determine the appropriate-size French catheter, divide the internal trach tube size by two and multiply this number by three.

A #12 French catheter is routinely used for closed suctioning. Premeasure the distance needed for insertion. Experts suggest 0.5 to 1 cm past the distal end of the tube for an open system, and 1 to 2 cm past the distal end for a closed system.

Liquefying secretions

The best ways to liquefy secretions are to humidify secretions and hydrate the patient. Do not use normal saline solution (NSS) or normal saline bullets routinely to loosen tracheal secretions because this practice:

may reach only limited areas
may flush particles into the lower respiratory tract
may lead to decreased postsuctioning oxygen saturation
increases bacterial colonization
damages bronchial surfactant.

Despite the potential harm caused by NSS use, one survey found that 33% of nurses and respiratory therapists still use NSS before suctioning. Other researchers have found that inhalation of nebulized fluid also is ineffective in liquefying secretions.

Evaluation

When evaluating the patient after suctioning, assess and document physiologic and psychological responses to the procedure. Convey your findings verbally during nurseto-nurse shift report and to the interdisciplinary team during daily rounds.

Trach site care and dressing changes

Tracheostomy dressing changes promote skin integrity and help prevent infection at the stoma site and in the respiratory system. Typically, healthcare facilities have both formal and informal policies that address dressing changes, although no evidence suggests a particular schedule of dressing changes or specific supplies for secretion absorption must be used. On the other hand, the evidencedoes show that:

secretions can cause maceration and excoriation at the site
the site should be cleaned with NSS
a skin barrier should be applied to the site after cleaning
loose fibers increase the infection risk
the trach tube should be secured at all times to prevent accidental dislodgment, using the two-person securing technique described below under "Securing the trach tube."

Start by assessing the stoma for infection and skin breakdown caused by flange pressure. Then clean the stoma with a gauze square or other nonfraying material moistened with NSS. Start at the 12 o’clock position of the stoma and wipe toward the 3 o’clock position. Begin again with a new gauze square at 12 o’clock and clean toward 9 o’clock.

To clean the lower half of the site, start at the 3 o’clock position and clean toward 6 o’clock; then wipe from 9 o’clock to 6 o’clock, using a clean moistened gauze square for each wipe. Continue this pattern on the surrounding skin and tube flange.

Avoid using a hydrogen peroxide mixture unless the site is infected, as it can impair healing. If using it on an infected site, be sure to rinse afterward with NSS.

Dressing the site

At least once per shift, apply a new dressing to the stoma site to absorb secretions and insulate the skin. After applying a skin barrier, apply either a split-drain or a foam dressing. Change a wet dressing immediately.

Securing the trach tube

Use cotton string ties or a Velcro holder to secure the trach tube. Velcro tends to be more comfortable than ties, which may cut into the patient’s neck; also, it’s easier to apply.

The literature overwhelmingly recommends a twoperson technique when changing the securing device to prevent tube dislodgment. In the two-person technique, one person holds the trach tube in place while the other changes the securing device.

Review trach tube policy and procedures

To achieve positive outcomes in patients with trach tubes, keep abreast of best practices and develop and maintain the necessary skills. Every nurse who performs trach care needs to be familiar with facility policy and procedure on trach tube care. If your facility’s current policy and procedures don’t support evidencebased practice, consider urging colleagues and managers to conduct a patient-care study comparing different approaches to suctioning. Then follow the evidence by advocating for changes if necessary.

Selected references

Chulay M. Suctioning: endotracheal or tracheostomy tube. In: Wiegand DJ, Carlson KK, eds. AACN Procedure Manual for Critical Care. 6th ed. Philadelphia, PA: Elsevier Saunders; 2010:62-70.

Dennis-Rouse MD, Davidson JE. An evidence-based evaluation of tracheostomy care practices. Crit Care Nurs Q. 2008;31(2):150-160.

Edgtton-Winn M, Wright K. Tracheostomy: a guide to nursing care. Aust Nurs J. 2005;13(5):1-4.

Harkreader H, Hogan MA, Thobaben M. Fundamentals of Nursing: Caring and Clinical Judgment. 3rd ed. Philadelphia, PA: Saunders; 2007.

Klockare M, Dufva A, Danielsson AM, et al. Comparison between direct humidification and nebulization of the respiratory tract at mechanical ventilation: distribution of saline solution studied by gamma camera. J Clin Nurs. 2006;15(3):301-307.

Kuriakose A. Using the Synergy Model as best practice in endotracheal tube suctioning of critically ill patients. Dimens Crit Care Nurs. 2008;27(1):10-15.

Lewis SL, Dirksen SR, Heitkemper MM, Bucher L, Camera I. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 8th ed. St. Louis, MO: Mosby; 2010.

Smith-Miller C. Graduate nurses’ comfort and knowledge level regarding tracheostomy care. J Nurses Staff Dev. 2006;22(5):222-229.

Wiegand DJ, Carlson KK, eds. AACN Procedure Manual for Critical Care. 6th ed. Philadelphia, PA: Elsevier Sauders; 2010.

Betty Nance-Floyd is a clinical assistant professor at the University of North Carolina at Chapel Hill School of Nursing.

http://www.americannursetoday.com/Article.aspx?id=8022&fid=7986

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INTERESTING READING

Please remember that the REUTERS articles usually good for only 30 days

Needle that breaks after first use to be adopted in WHO mandate to curb infection spread

The World Healthn Organization is adopting a new mandate, the third in 60 years, to use needles that break after the first use to curb infection and death. ...

http://www.linkedin.com/e/v2?e=1p5190-hzygx7z1-3z&t=gde&midToken=AQFWR8JhbIKLxg&ek=b2_anet_digest&li=4&m=hero&ts=hero-disc-disc-0&itemID=5915803531469680640&itemType=member&anetID=2816581

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Respiratory Virus Hitting Kids in At Least 12 States

Health officials concerned about a wider outbreak, urge good hygiene to limit exposure

http://links.govdelivery.com/track?type=click&enid=ZWFzPTEmbWFpbGluZ2lkPTIwMTQwOTA5LjM1NzcwNjcxJm1lc3NhZ2VpZD1N

REItUFJELUJVTC0yMDE0MDkwOS4zNTc3MDY3MSZkYXRhYmFzZWlkPTEwMDEmc2VyaWFsP

TE2ODk2MDQ0JmVtYWlsaWQ9cm5mcmFua2llQGFvbC5jb20mdXNlcmlkPXJuZnJhbmtpZUBhb2wu

Y29tJmZsPSZleHRyYT1NdWx0aXZhcmlhdGVJZD0mJiY=&&&131&&&http://www.nlm.nih.gov/medline

plus/news/fullstory_148261.html

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The Role Telomeres play in our lives....A new study/ discovery
The tiny "caps" that keep our chromosomes from fusing together are also providing clues that could eventually lead to the achievement of one our nation's most important public health goals: extending good health well into old age.

To help understand the role telomeres play within the human body, it's useful to review some basic biology. All of the tissues within the human body are made up of individual cells. These cells contain chromosomes within their nuclei. Chromosomes are the packages that hold most of our DNA - the genetic instructions that tell the cell what to do.

Telomeres are repeating DNA sequences at the ends of the chromosomes. They do not contain any genetic instructions; they simply repeat a sequence of DNA over and over. When we are young, the telomeres are very long - they may contain as many as 20,000 base pairs of DNA. ...

http://www.agingresearch.org/content/article/detail/878

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This article is by : AJN Editor-in-Chief, E-mail: shawn.kennedy@wolterskluwer.com(she is also a member of Paradigm97)

For some children, the arrival of September means a visit with the school nurse. I can still recall my grammar school nurse, who checked our vision, our height and weight, and the straightness of our spines. She was the one who wrote to my parents to inform them that I was nearsighted and needed to see an eye doctor to get glasses. I don't remember her name; she only came in one day a week.

In most school districts, school nurse salaries and costs are part of the education budget—and when budgets are tight, many boards look to the school nurse position as a place to save money. They may cut the nurse's hours to part time, or abolish the position altogether, in which case teachers, secretaries, and other personnel often assume health care responsibilities. In a national survey of nearly 7,000 school nurses, conducted in 2013 by the National Association of School Nurses (NASN), 16% of respondents reported that school nurse positions in their areas were threatened. More than 5% said they'd been told that such positions would be filled by LPNs or aides. ...

http://journals.lww.com/ajnonline/Fulltext/2014/09000/Every_Child_Deserves_a_School_Nurse.1.aspx

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RANDOM TIDBITS
Dr. Rene Theophile Laenne invented the first stethoscope in 1816. He felt embarrassed if he had to listen to the heart beat of a young female patient by placing his ear directly on her chest, so he rolled up 24 sheets of paper to make a tube and placed one end on her chest and the other end in his ear. By 1855 a stethoscope similar to the one used during most of the 20th century became available.

The blood pressure cuff was invented by an Austrian physician named Samuel Siegfried Karl Ritter von Basch and first saw use in doctor's surgeries in the 1880's. An improved version of the cuff was unveiled by Italian physician Scipione Riva-Rocci in 1896.

Computed Tomography (CT) imaging is also known as "CAT scanning" (Computed Axial Tomography). CT was invented in 1972 by British engineer Godfrey Hounsfield of EMI Laboratories, England and by South Africa-born physicist Allan Cormack of Tufts University, Massachusetts. Hounsfield and Cormack were later awarded the Nobel Peace Prize for their contributions to medicine and science.

While studying the effects of passing an electrical current through gases at low pressure, German physicist Wilhelm Rontgen accidentally discovered X-rays. When Rontgen held a piece of lead in front of the electron-discharge tube, it blocked the rays, but he was shocked to see his own flesh glowing around his bones on the fluorescent screen behind his hand.

In 1948 George de Mestral, a Swiss mountaineer, and his dog went for a hike in the woods. When they returned both were covered with burrs. Using a microscope he examined the burrs stuck to his pants and discovered that the burrs had small hooks that clung to small loops of fabric in his clothing. This lead him to the idea of making one material with small hooks and the other material with tiny loops. He called his invention Velcro, a combination of the words velour and crochet.

English physician, Sir Thomas Allbutt (1836-1925) invented the first practical medical thermometer used for taking the temperature of a person in 1867. It was portable, 6 inches in length and able to record a patient's temperature in 5? min.

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Lystra Gretter: Public Health Advocate and Professional Reformer

By David Yates

When Lystra Eggert Gretter was inducted into the Michigan Women's Hall of Fame in 2004, she was honored for her "tireless" efforts in promoting nursing as a respectable profession in the late 19th and early 20th centuries. Gretter made many contributions to nursing. She shifted the model of nursing education from a one-year apprenticeship to a three-year academic pursuit. She created nurse-run hospital wards instead of allowing nursing students to run them. Gretter cut the work day to 8-hour shifts, to afford nurses and students more time to study and recreate. She wrote what is believed to be the first standardized textbook for nursing education and created one of the first professional nursing libraries. And Gretter was a founding member, at the end of the 19th Century, of groups that later became the American Nurses Association and the National League for Nursing. She established an early visiting nurses association. Noting that the public perception of nursing was that of "women's work," Gretter lobbied for more political power, including aligning nursing with suffragettes who sought the vote. And Gretter was "the moving spirit behind the creation of "The Florence Nightingale Pledge," an oath of ethics that many graduating nursing students still make today. Gretter also worked to advance public health generally. She established tuberculosis hospitals, lobbied for in-home nursing care and became a vocal public health advocate for Detroit's burgeoning poor and immigrant population. She also successfully introduced the first state-wide health inspections of school children and a free maternity/infant care clinic in Detroit. more...

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Quiz Time

Which drug would you expect the physician to order for a patient with disseminated intravascular coagulation?

a. Warfarin

b. Dabigatran

c. Aspirin

d. Heparin

See the answer at end of Newsletter

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This is from Sandy Summer's Newsletter: Truth about Nursing

Equally impressed and dismayed": Leah Binder's Wall Street Journal post highlights Truth's work

June 9, 2014 - Today Leah Binder, president and CEO of The Leapfrog Group, posted a strong piece on the Wall Street Journal site about the poor portrayals of nursing on television. "How TV Gets Hospitals All Wrong" points out that most recent television shows suggest that hospitals are staffed overwhelming by smart, attractive physicians. However, Binder notes, the fact is that "most of what hospitals do is deliver expert nursing care." When people are actually confronted with that fact in their own lives, it can shock them. Binder reports that a friend was "equally impressed and dismayed" that her life was in the hands of the nurses during a recent hospital stay. In other words, she was impressed by the nurses' knowledge and skills, yet understandably concerned that her life was entrusted mainly to a group of people she had been led to believe were low-skilled servants. Binder notes:

There’s a fascinating book about this, “Saving Lives: Why the Media’s Portrayal of Nursing Puts us All at Risk,”and a movement I support to pressure the entertainment industry to make some effort to acknowledge the actual work of nurses.

The link from "movement" is to the Truth's main page. Binder concludes by arguing that the gap between image and reality plays a role in the ongoing nursing shortage, which of course threatens patients. We thank her for another helpful piece about the need to improve public understanding of nursing. see the article...http://blogs.wsj.com/experts/2014/06/09/how-tv-gets-hospitals-all-wrong/

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An outbreak of a flesh-eating infection at Children's Hospital New
Orleans that caused the deaths of at least four children in less than
a year sent the hospital on a recent defensive public relations
campaign to explain itself, and caused the CDC to reexamine the
hospital's policies and laundry procedures.
http://tinyurl.com/meobyt5

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NewsCAP: Nurses write a new guide on catheter-associated urinary tract infections (CAUTIs)

Nurses write a new guide on catheter-associated urinary tract infections (CAUTIs), which are among the most common health care–associated infections. The Association for Professionals in Infection Control and Epidemiology has released a new guide (http://bit.ly/1syFer5) on many aspects of these infections, including causes, prevention, and surveillance.

AJN, American Journal of Nursing:

September 2014 - Volume 114 - Issue 9 - p 17

doi: 10.1097/01.NAJ.0000453740.03572.27

In the News

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Managing risk during transition to new ISO tubing connector standards

Tubing misconnections continue to cause severe patient injury and death, since tubes with different functions can easily be connected using luer connectors, or connections can be "rigged" (constructed) using adapters, tubing or catheters. This is why new ISO (International Organization for Standardization) tubing connector standards are being developed for manufacturers. Through an international consensus process, the standards are being developed, tested and approved to assure reliable designs and processes. The phased implementation of redesigned tubing connectors that are the result of these new ISO connector standards begins now. The Joint Commission urges health care organizations to be vigilant and begin planning for the upcoming period of transition, which will introduce changes and new risks into the health care environment. Download the PDF to read more.

Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences

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Hint 1: Keep your fridge germ free by a simply doing this...
Wiping the inside of the fridge with vinegar helps prevent mildew because acid kills mildew fungus.

Hint #2: Don't pay lots of money for Windex. Wait until the gallon size Windshield Washer fluid for cars goes on sale, and stock up. Refill the Windex bottles you have, and save!

Hint #3:Can you believe that just a dab of toothpaste can remove scuff marks from your favorite pair of leather shoes? It's simply amazing! Just dab a little on the scuff marks, rub the area with a soft cloth, and then wipe clean with a damp cloth. You will make them look like new!

Hint #4:Another unique use for Q-Tip cotton swabs is to dip the ends in soapy water. Then, use the ends to clean the dirt
and grime from the fins of furnace and air conditioning ducts.

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HUMOR SECTION

One night, a police officer was stalking out a particularly rowdy bar for possible violations of the driving under the influence laws. At closing time, he saw a fellow stumble out of the bar, trip on the curb, and try his keys on five different cars before he found his. Then, sat in the front seat fumbling around with his keys for several minutes. Everyone left the bar and drove off. Finally, he started his engine and began to pull away.

The police officer was waiting for him. He stopped the driver, read him his rights and administered the Breathalyzer test. The results showed a reading of 0.0. The puzzled officer demanded to know how that could be. The driver replied, "Tonight, I'm the Designated Decoy."

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A woman went to a pet shop and immediately spotted a large beautiful parrot. There was a sign on the cage that said $50.00.

"Why so little," she asked the pet store owner.

The owner looked at her and said, "Look, I should tell you first that this bird used to live in a house of prostitution, and sometimes it says some pretty vulgar stuff."

The woman thought about this, but decided she had to have the bird anyway. She took it home and hung the bird's cage up in her living room and waited for it to say something.

The bird looked around the room, then at her, and said, "New house, new madam." The woman was a bit shocked at the implication, but then thought "that's not so bad."

When her two teenage daughters returned from school the bird saw them and said, "New house, new madam, new whores."

The girls and the woman were a bit offended but then began to laugh about the situation.

Moments later, the woman's husband, Keith, came home from work.

The bird looked at him and said, "Hi Keith."

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CEU SITES---(CME and CNE)

Those that are-----Free and Otherwise..........
Go to www.sharedgovernance.org for access to a just released, free continuing education module about shared governance, written by Robert Hess, Forum’s founder, and Diana Swihart, Forum advisory board member.
Please follow me on Twitter as Dr Robert Hess.

Pay Only $34.99 for a full year of CONTACT HOURS
www.nurse.com for CNE offerings.

Free CEs http://www.myfreece.com/welcome.asp

https://nursing.advanceweb.com/CE/TestCenter/Main.aspx

This site was sent in by FNPMSN@aol.com (Cindy) http://cmepain.com/ !

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WEBSITES/ LINKS

Always on the lookout for interesting websites / links. Please send them to:RNFrankie@AOL.com.

This is an excellent nursing site, check it out:http://nursingpub.com/

Robert Hess, RN, PhD, FAAN (856) 424-4270 (610) 805-8635 (cell) Founder, Forum for Shared Governance
info@sharedgovernance.orgwww.sharedgovernance.org

Decubqueen's website: www.accuruler.com

http://www.thebreastcancersite.com/clickToGive/home.faces?siteId=2

http://www.nationalnurse3.blogspot.com/

The Nursing Site http://thenursingsite.com .

http://www.thebreastcancersite.com/clickToGive/home.faces?siteId=2

http://www.snopes.com

http://www.solutionsoutsidethebox.net/ Raconte's website

http://www.theanimalrescuesite.com/clickToGive/home.faces?siteId=3

If you're buying a used car, it is recommended having a mechanic inspect it first. And screen the car's VIN through the free database at carfax.com/flood

Rozalfaro's website: http://www.alfaroteachsmart.com/articles.htm

Metric conversion calculators and tables for metric conversions

http://www.metric-conversions.org/

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MEDICAL RECALLS

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Soliris (eculizumab) Concentrated Solution for IV Infusion by Alexion: Recall - Visible Particulates

Alexion Pharmaceuticals, Inc. announced that it is initiating a voluntary recall of certain lots of Soliris (eculizumab) 300mg/30 mL concentrated solution for intravenous infusion. The administration of particulate, if present in a parenteral drug, poses a potential safety risk to patients in two general areas: immune reaction and blood clots. Particulates could cause blockage of flow of blood in vessels, which could be life-threatening. The single affected Soliris lot is #10007A. Although these lots currently remain in specification, Alexion is including the following remaining lots, which were produced with the same process component during vial filling, within the scope of the U.S. recall: 10002-1, 00006-1, 10003A, 10004A, 10005A, 10005AR, 10006A and 10008A.

BACKGROUND: Soliris is approved as a treatment for patients with paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS), two ultra-rare and life-threatening disorders. Alexion and its distributors typically ship Soliris to healthcare providers in small quantities, which are timed to individual patient infusions, with the product being consumed before more is shipped. As product from the identified lots was last shipped on October 30, 2013, there is anticipated to be little, if any, material from these lots still remaining in commercial distribution.

http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm399536.htm

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Medical Device Safety and Recalls: Fresenius NaturaLyte Liquid Bicarbonate Concentrate (Part Number: 08-4000-LB)

The U.S. Food and Drug Administration has issued a recall for the NaturaLyte Liquid Bicarbonate Concentrate, 6.4 Liter Bottle (Part Number: 08-4000-LB). The product may develop higher than expected bacteria levels during its shelf life. Lab testing identified the bacteria as Halomonas (species 1, 2, 3), a gram negative bacteria typically found in water with high salt concentration. The FDA has received one report of death and two reports of injury that may be related to use of this product. The use of affected product may cause serious adverse health consequences, including sepsis, bacteremia, and death. ... http://www.fda.gov/MedicalDevices/Safety/ListofRecalls/ucm399124.htm

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Gemstar Docking Station by Hospira, Inc: Class I Recall - Potential for Error or Failure to Power Up

Hospira, Inc., announced today a nationwide medical device correction of the GemStar Docking Station (list number 13075), used in conjunction with the GemStar infusion pump. When the docking station is used in conjunction with a GemStar Phase 3 pump (List 13000, 13100 or 13150) the potential exists for the GemStar Phase 3 pump to fail to power up while connected to the docking station. When a GemStar Phase 3 (List 13000, 13100 or 13150) or GemStar Phase 4 pump (List 13086, 13087 or 13088) is used in conjunction with both a docking station and an external battery pack accessory (List 13073), there is a possibility that the GemStar pump will display error code 11/003 and give an audible alarm, indicating excessive input voltage from the external sources. If the GemStar pump detects what is perceived to be more than 3.6 Volts as measured on the external voltage input, the pump will stop the infusion. This will trigger an audible alarm and the device will display alarm code 11/003.

If a GemStar fails to power up or the 11/003 error code stops an infusion, a delay of therapy may occur. A delay or interruption in therapy has a worst case potential to result in significant injury or death.

BACKGROUND: The GemStar Docking Station is a separately sold accessory to the GemStar infusion pump and provides an alternate power source to the GemStar pump. The products impacted by these issues are identified in a table in the Firm Press Release. http://go.usa.gov/kM9d

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Fisher and Paykel Healthcare, Ltd., Infant Nasal CPAP Prongs

A recall has been issued for the Fisher and Paykel Healthcare, Ltd., Infant Nasal CPAP Prongs. Fisher and Paykel Healthcare received 24 reports in which the device has malfunctioned. There were zero injuries and zero deaths. The firm received reports of the affected prongs detaching from the nasal tubing during use, especially when mucous and/or moisture are present. When the affected prongs detach from the nasal tubing, therapy is likely to be interrupted. This may cause low blood oxygen (hypoxemia). The detached prongs may enter an infant’s mouth and present a potential risk of choking and airway obstruction. The use of the affected product may cause serious adverse health consequences, including death. For more information, please see http://www.fda.gov/MedicalDevices/Safety/ListofRecalls/ucm398631.htm

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DISCLAIMER: The intent of this PARADIGM BYTES Newsletter is to provide communication and information for our members. Please research the hyperlinks and information provided by our members. The articles and web sites are not personally endorsed by the editors, nor do the articles necessarily reflect the staff's views.
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THOUGHT FOR THE DAY

"The worst thing about medicine is that one kind makes another necessary."

Elbert Hubbard.

(1856-1915), American writer, publisher, artist, and philosopher, mostly known as the founder of the Roycroft artisan community in East Aurora, New York, an influential exponent of the Arts and Crafts Movement.