Wednesday, December 17, 2014

December PARADIGM BYTES Newsletter

                                         Merry Christmas / Happy Hanakkuh to all.
PARADIGM BYTES
Newsletter for Paradigm 97
November 18, 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
This is a repeat but essential information from Wendie Howland (A member):
ABGs Made Simple

You want simple ABGs? Piece o' cake. People who have seen this before, well, just scroll on by. Newbies who want a brief ABG's refresher, take out your pencils and a piece of paper, cuz you'll need to do a bit of drawing .

I taught ABG interpretation for yrs in a way that made it pretty foolproof. You will make your own key to interpret ABG's, and will be able to reproduce it from memory any time you need to with very little trouble if you learn a very few **key concepts**, labeled **thus**..

Take a piece of paper. Make a big box on it, then draw vertical and horizontal lines on it so you have four boxes. I will try to make this come out, but...you should have

AB
CD

where the four boxes a,b,c,d are such that a is above c and b is above d. You don't need to label the boxes a,b,c,d, just get them in the right alignment. (This is WAY easier with a whiteboard bear with me).

*Inside* each of the 4 boxes write the following, down the left edge:
pH
CO2
Bic

Now, OUTSIDE the big box do the following: above the "A" box write "resp"; above the "B" box write "metabolic"

To the left of the "A" box write "acidosis" and to the left of the "C" box write "alkalosis"

Now you have a "resp" column and a "metabolic" column, an "acidosis" row and an "alkalosis" row. So you have respiratory acidosis and alkalosis boxes, metabolic acidosis and alkalosis boxes.

With me so far?

Now, you're going to label the PRIMARY DERANGEMENTS, so later you can tell what's the derangement and what's the compensation. OK? In the respiratory column, underline CO2's. In the metabolic column, underline the Bicarb's. That's because in **respiratory disorders, the CO2 gets messed up**, and in **metabolic disorders, the Bicarb is messed up**. You knew that, or could figure it out pretty quick if you thought about it, right? Thought so.

Now. You are going to put upward-pointing and downward-pointing arrows next to the pH, CO2, and Bicarb labels inside every box. Ready?

pH first. In the "alkalosis" row, make up arrows next to pH, because **pH is elevated in alkalosis (by definition)**. Put down arrows in the acidosis row's pHs, because **acidosis means a lower that nl pH**.

Remember that **CO2 is (for purposes of this discussion and general clinical use) ACID** and **Bicarb is ALKALINE** (this is the end of the key concepts. Not too bad, huh?). (oops, I forgot: **nls are generally accepted as pH 7.35-7.45, CO2 35-45 (nice symmetry there), bic 19-26**)

Now go to the box that is in the respiratory column and the acidosis row. Figured out that CO2 must be elevated? Good. Put an up arrow next to that CO2. Go to the respiratory alkalosis box. Figures that CO2 must be low to cause this, right? Put a down arrow next to that CO2.

OK, now go to the next column, the metabolic one. I think you can figure out what happens here: in the metabolic alkalosis box, put an up arrow next to the Bic, because high bicarb makes for metabolic alkalosis. Put a down arrow next to the Bic in the metabolic acidosis box, because in metabolic acidosis the bicarb is consumed by the acids (like, oh, ASA) and is low.

You are now going to put arrows next to the blank spots in your boxes that show compensatory movements. Ready? OK, what does your body want to do if it has too much acid? Right, retain base. Yes, of course if your body has too much acid it would like to get rid of it...but if it can't do that, then retaining bicarb is the compensation. So for every elevated CO2 you see, put an up arrow with its bicarb.( Chronic CO2 retainers always have elevated bicarbs, and this is why.) You will find an up arrow next to the CO2 in the resp/acidosis box.

So if your body is short on acids, what does it do? Right, excrete base. So put a down arrow next to the bicarb in the resp/alkalosis box, because chronic low CO2 makes the body want to get back into balance by getting rid of bicarb. However, remember that it takes a day or two for the kidney to do this job, and if you have nonfunctioning kidneys they won't do it at all.

Likewise in the metabolic/alkalosis box, a high bicarb makes your body want to retain acid, increasing CO2 being the fastest way to do that because all you have to do is hypoventilate, to bring your pH back towards nl. Put an up arrow next to the CO2 in the met/alk box. See the pattern here? Put a down arrow next to the CO2 in the met/acidosis box, because if your body has too much acid in it (think : ASA overdose? DKA?) it will want to get rid of CO2 to compensate, and the fastest way to do that is to hyperventilate. This is why patients in metabolic acidosis are doing that deep, rapid breathing thing (Kussmaul's respirations).

OK, I hear you wailing: but how do I know whether that elevated or decreased CO2 or Bicarb in my ABG report is primary or compensatory?

Well, now you have your key. So take your ABG reports and look at them. Say, try these. (Notice that O2 levels have nothing to do with acid-base balance ABG interpretation) (OK, if you are VERY hypoxic you can get acidotic...but you see that in the metabolic component, not the O2 measurement, because it's lactic ACID your body is making if it's working in an anaerobic way)

1) pH = 7.20, CO2 = 60, Bic = 40.

First thing to look at is the pH. 1) is acidosis, with a low pH. Look at your acidosis choices (you have two). Find the acidosis where both CO2 and Bicarb are elevated, and you find your answer: respiratory acidosis with metabolic compensation. This is what you see in chronic lungers who have had high CO2's for so long their kidneys have adapted to things by retaining bicarb. (It takes about 24 hrs for your kidneys to make this compensatory effort, so you can tell if your resp acidosis is acute (no or little change in bicarb) or chronic)). (Remember, your lungs' first and most important job is not getting oxygen in, it's getting CO2 out, and when chronic lungers have CO2 retention, they're really getting bad. People with acute bad lungs will often have low oxygens and low CO2's , because their ability to gain O2 goes first, and while they're trying to deep breathe their way back to a decent PaO2, they hyperventilate away their CO2. ....but I digress....)

2) pH = 7.54, CO2 = 60, Bic = 40
pH here? This is alkalosis, with a high pH.
The only box where pH is high and CO2 & Bic are both elevated is metabolic alkalosis with respiratory compensation. Sometimes you'll see this in people who have a bigtime antacid habit. Really. (You can get a short-term metabolic alkalosis with rapid severe vomiting, because the body's nl balance between acid and base has been disrupted due to a sudden loss of acid. Things will equilibrate pretty quickly, though, all things considered.)

So even though you have identical abnormal CO2's and Bicarbs, you can look in your boxes, find the match, and see what you have. Remember you underlined the primary disorder in each box?

Wanna try another one?

3) pH = 7.19, CO2 = 24, Bic = 12. Bingo, you found it: an acidosis where the CO2 and the Bic are both abnormally low. Only fits in the metabolic acidosis box, so you have a metabolic acidosis with a respiratory compensation effort. Incidentally, this is what you see in diabetic ketoACIDOSIS, when they come in huffing and puffing to blow out that CO2 because their ketosis is so high. Also you see this picture in ASA OD's, because this is acetylsalicylic ACID they ate, and the fastest way to get rid of acid is to blow it off via hyperventilation. Increasing your bicarb takes 24-48 hrs. Another quick way to get a metabolic acidosis is to poop out a lot of diarrhea, because you lose a lot of bicarb that way. Another classic place for this is in mesenteric artery thrombosis, in which you have a lot of ischemic bowel sitting in there screaming for oxygen and making lactic acid when it can't have any.

I know this is LONG, but trust me, you'll never go wrong with it, and you can recreate it anytime. It doesn't really even matter how you set up your boxes, so long as you have a metabolic and a respiratory axis and an acid/alkaline axis. Rotate your paper and you'll see what I mean.

Why don't I care about PaO2 here? Well, because ABG's mostly tell you about A/B balance and CO2 and Bicarb, that's why. Probs with them can be serious probs without any abnormality in oxygenation at all.

Remember that PaO2 (arterial oxygen, measured in torr or mmHg) is not the same as SpO2,( hemoglobin saturation, a percentage of red cells carrying oxygen). if you think they are, your pt could be in serious trouble before you do anything. There is a nomogram that shows you the relationship between arterial oxygen and saturation, which I regret I cannot reproduce here. But you can sketch out a basic version...

Draw a graph where sats are on the vertical (left) axis and PaO2's are on the horizontal (bottom) axis. Draw little shaded band across the top at the 95%-100% sat areas. That's your normal saturation. Draw a few dots there indicating a line of PaO2's of 80-100, because those are normal PaO2's.

Now draw a dot for SpO2 of 90 and PaO2 of about 75. Now, another dot showing SpO2 of 85 and PaO2 of about 60. Another dot: SpO2 of about 80 and PaO2 of about 55. Connecting all these dots should give you a sort of S curve, indicating that while the top is pretty flat in the PaO2 80-100, SpO2 95-100 range, PaO2 drops off like a shot at decreasing SpO2 levels.

Your pt with a sat of 85 is not doing OK, he's in big trouble. While a PaO2 of 75 torr isn't too bad at all, a SAT of 75% is heading for the undertaker unless dealt with.

Here's my very favorite ABG of all time: pH = 7.11, PaO2 = 136, PaCO2 = 96, bicarb = 36.

What happened to this lady? What will happen next?
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LETTERS TO THE EDITOR
Please write in...your workplace ideas/problems/suggestions. Let's get a thread started.
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INTERESTING READING
Please remember that the REUTERS articles usually good for only 30 days
U.S. introduces menu calorie labeling fight obesity
(Reuters) The U.S. government will publish sweeping new rules on Tuesday requiring chain restaurants and large vendin machine operators to disclose calorie counts on menus to make people more aware of the risks of obesity posed by fatty, surgary foods.
"Obesity is a national epidemic that affects millions of Americans," Food and Drug Administation Commissioner Margaret Hamburg
told reporters on a conference call on Monday.
"Strikingly, Americans eat and drink about a third of their calories away from home." ...
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'Tis the season for giving! During the month of December, NursingCenter will be celebrating the holiday season by offering you a special discount or offer every week! All of these offers will be good through January 2, 2015. This is our way of celebrating you and saying thanks for a wonderful year. We hope you continue to use NursingCenter for all of your professional and clinical needs in the new year.

Be sure to spread the cheer and share this email with your colleagues so they, too, can benefit from these special offers!
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Researchers discover 'pre-cancers' in blood
Many older people silently harbor a blood "pre-cancer" - a gene mutation acquired during their lifetime that could start them on the path to leukemia, lymphoma or other blood disease, scientists have discovered. It opens a new frontier on early detection and possibly someday preventing these cancers, which become more common with age. ...
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Infectious bugs are getting stronger and more resistant to drugs. Because of that, a British government-commissioned review released Thursday says these "superbugs" could lead to more than 10 million deaths and a $100 trillion global economic impact by 2050.

The Review on Antimicrobial Resistance states about 700,000 people die from antimicrobial resistant bugs each year right now, but that could grow to 10 million - more than the number of people who die from cancer - if action isn't taken.

The study started in July and was lead by Jim O'Neill, a former Goldman Sachs chief economist. O'Neill was selected by United Kingdom Prime Minister David Cameron.

The review looked at three bacteria already showing concerning levels of resistance - Klebsiella pneumonia, E. coli and Staphylococcus aureus - and three public health issues in HIV, tuberculosis and malaria for which resistance is already a concern.

"Something like this which is going to affect everybody, it could have a devastating impact on international trade and travel and globalization,"Jim O'Neill said via the BBC.

After the findings were released, British Prime Minister David Cameron made a call to action saying, "If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine."

And much of the blame for these bugs gaining resistance seems to be getting put on an overprescription of drugs.

"People who are waiting for joint replacement, transplant surgery, cesarean section, those are high risk operations for infection afterwards. If we don't have antibiotics that work anymore, that's serious stuff. It means we can't do those operations," Dr Hilary Jones told ITV.

The review focuses on the world's two most populated countries, India and China, as some of the most egregious offenders of overprescription.

O'Neill says a global effort is needed to fight these resistant bugs and is calling for new drugs to be developed.
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HINTS:
Hint 1: When your gloves get wet this winter, blog them with a towel, then let them air dry -- this will keep both leather and fabric gloves from warping. And to help maintain their shape even more, store them in cloth or paper bags, which will allow the material to breathe.

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Hint 2: Dry winter air can leave you with 'static-cling hair'!


To tame those flyaways, warm a tiny dab of anti-frizz cream
between your palms. then gently glide your hands over the
flyaways. The extra hint of moisture breaks the static cling,
bringing your hair back to beautiful. (Tresemme sells a
product: Anti-Frizz Secret Smoothing Cream)

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Hint 3: Don't fight the snow or ice in the morning, try this tip:


Before you go to bed, dampen a sponge in a solution of 1 tbs. salt and 1 2/2 cups water, then wipe your car's windshield. The salty coating will lower the freezing point of water, so snow and condensation won't stick to the glass
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English is a complicated language drawing from many different sources. It is easy to sound foolish or ignorant, especially if you are trying to sound smart by using (and misusing) some of these common phrases.


RANDOM FACT:
What is the difference between "e.g." and "i.e."?

The abbreviation e.g. stands for the Latin exempli gratia, or "for the sake of example." It means exactly that; a series of examples. The abbreviation i.e. stands for id est, or "that is," and explains the subject you have mentioned.
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Bonus Fact:
What is the difference between et al and et cetera?

The Latin phrase et al, short for et alia (and other things) and et alii (and other people), is more specific than et cetera (and the rest). Only et al can refer to people.
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Statistics
Women and chronic obstructive pulmonary disease (COPD)
7 million:
Number of women with COPD.
4:
The number of deaths among women from COPD has more than quadrupled since 1980.
2000:
Since 2000 COPD has claimed the lives of more women than men in the U.S. each year.
1.5:
Women with COPD are 1.5 times more likely to have never smoked than men.
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Current Topics in Safe Patient Handling and Mobility

To avoid injuring their patients and themselves, healthcare providers must get in the habit of using safe patient handling and mobility (SPHM) technology. In this supplement, national experts share their perspectives and best practices on topics ranging from dealing with bariatric patients, managing slings, and assessing a patient’s mobility to transforming the culture, building the business case for an SPHM, and developing a successful SPHM program.

Safe patient handling and mobility: A call to action

By Melissa A. Fitzpatrick“The way we’ve always done it” is no longer an acceptable rationale for manual patient handling and mobilization. We must change our mindset and embrace appropriate technology to keep ourselves and our patients safe from harm.

Elements of a successful safe patient handling and mobility program

By John CelonaTo build a successful program, identify your facility’s specific needs, design the program, obtain leaders’ and nurses’ commitment, and provide effective education and training.

Transforming the culture: The key to hardwiring early mobility and safe patient handling

By Kathleen M. Vollman and Rick BassettAccomplishing early patient mobility and safe handling requires a culture change, deliberate focus, staff education, and full engagement.

Standards to protect nurses from handling and mobility injuries

By Amy GarciaLearn about ANA’s interprofessional national standards on safe patient handling and mobility, developed by a panel of interdisciplinary experts

Implementing a mobility assessment tool for nurses

By Teresa Boynton, Lesly Kelly, and Amber PerezThe authors describe a nurse-driven tool you can use at the bedside to evaluate your patient’s mobility level and guide decisions about patient lifts, slings, and other technology.

The sliding patient: How to respond to and prevent migration in bed

By Neal WiggermannPulling patients up in bed carries a high risk of caregiver injury. Find out how to prevent patient migration and manage it safely when it occurs.

Prepare to care for patients of size

By Dee KumparNearly a third of patient-handling injuries involve bariatric patients. Handling and mobilizing these patients safely requires skill and specialized technology.

Developing a sling management system

By Jan DuBoseDisposable or launderable slings? In-house or outsourced laundering? These and other key decisions require input from all departments involved.

Making the business case for a safe patient handling and mobility program

By John CelonaThe author explains three approaches to justifying a safe patient handling and mobility program and presents a decision-analysis case study.
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Patient Satisfaction, Outcomes Could Improve with Use of Nursing Quality Analytics Data
Posted: 26 Nov 2014 07:33 AM PST
Having access to a quality analytics database that measures clinical data specific to the role of nurses as well as data about the nursing environment, could help improve patient satisfaction and outcomes nationwide, according to Christina Dempsey, chief nursing officer at Press Ganey.

Press Ganey, an organization that works to help hospitals and other medical facilities improve patient experiences, recently acquired the National Database of Nursing Quality Indicators (NDNQI) from the American Nursing Association (ANA). NDNQI includes clinical quality measures and corresponding information on nurse engagement and the nursing environment. Press Ganey is distilling the data into four areas that affect the patient experience. They believe this approach will ultimately help their clients decide where to invest in improvements.

“Nurse-sensitive indicators reflect the structure, the process and the outcomes of nursing care,” Dempsey told HealthITAnalytics. “The structure of nursing care is indicated by the supply of the nursing staff, the skill level of the nursing staff, and the education of the nursing staff. Process indicators measure things like assessments, intervention, and job satisfaction. And then outcomes are those things that improve if there’s a greater quantity or quality of nursing care, such as pressure ulcers and falls.”

“… Being able to bring some of that data together will allow managers, clinicians, and nurses at the bedside better understand what they need to do for which population of patients to get the highest and best return,” Dempsey said.
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Essential Services October 11, 2013 -- Today the Huffington Post reported that the partial federal government shutdown was threatening to stop forensic nurse examiners from helping sexual assault victims in the District of Columbia. The blog post explained that the relevant programs rely on federal funding, and it focused on the worrisome funding outlook. But it also explained that the nurses do rape kits that are critical to the criminal justice system. And it suggested that they act as advocates for victims, helping them through the various aspects of the process. The piece might have done more to educate the public about what the forensic nurses do, particularly their skilled physical and psychosocial care and their forensic testimony in court. But the post did at least signal the importance of having the nurses on call 24-7 to come to hospitals and care for victims. We thank the Huffington Post and political bloggers Amanda Terkel and Jason Cherkis. ...
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Appreciating nurses 365 days a year, not just during Nurses’ Week
The Joint Commission strongly believes that nurses play a pivotal role in the delivery of high-quality, high-reliability health care. On the front lines every day, nurses are leaders in multi-disciplinary health care teams across many settings: ambulatory, acute care, home care, behavioral health, public health, and long-term care/nursing care centers.
Nursing’s commitment to improve quality, promote safety and reduce patient harm is at the heart of the profession. Whether situated in clinical practice, administration, research or education, the leadership provided by professional nurses can result in better patient care. From inner city hospitals to rural ambulatory clinics, nurses demonstrate value through their relentless focus on the patients’ needs. Advanced practice nurses play a critical role in providing access and treatment for many patients, particularly in rural and underserved areas, throughout the country. This commitment to patients’ needs is just one of the many reasons nursing is consistently voted by consumers to be one of the most respected professions in the United States.
The Joint Commission’s commitment to nurses extends from our recognition of nursing care requirements in our standards to the Nursing Advisory Council, a strategic group that advises our Board of Commissioners on issues of importance to nursing practice and patient care. We renamed our Long Term Care program to “Nursing Care Center” last year to recognize nursing as the pivotal profession managing and delivering patient care in nursing homes and assisted living facilities.
The Joint Commission wants to add its voice to those who recognize, support and appreciate “Nurses Leading the Way – Every Day”. We know that there are many exceptional nurses doing exceptional work. Please join our conversation by sharing examples of how nurses in your organization have improved quality and safety for patients and the public and how The Joint Commission can support nurses’ efforts in moving toward ‘zero patient harm’.
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Study: Newer pneumonia vaccine shows greater efficacy
A study in the CDC's Morbidity and Mortality Weekly Report revealed the pneumococcal vaccine PCV13 showed a nearly 30% greater efficacy in preventing pneumonia-related hospitalization in pediatric patients compared with an earlier seven-strain
version. ... HealthDay News(11/6)
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Quiz Time
Your patient, who has a central catheter in place, states she has jaw and ear discomfort during infusions of antibiotics. Her symptoms may indicate:
a. thrombotic occlusion.
b. mechanical phlebitis.
c. catheter-tip migration.
d. catheter rupture.
See answer at end of Newsletter
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Hospital nurses are dissatisfied with electronic health records (EHRs), according to a survey by Black Book Rankings.
92%:
Percent of nurses who are dissatisfied with EHRs
90%:
Percent who say EHR use has negatively affected communications between nurses and their patients
26%:
Percent who agree with the statement, “As a nurse, I believe the current EHR at my organization improves the quality of patient information.”
79%:
Percent of job-seeking RNs who say that the reputation of the hospital’s EHR system is a top three consideration in their choice of where they will work
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the reason this is blank is because AOL insists that it is to be BOLD....so it stays blank. Sorry .:-\
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Hint 1: For an easy, free mini massage that stretches and soothes your arches, slip off your shoes and roll each foot over a tennis ball, golf ball, or soup can for a minute or two. To cool throbbing feet, roll them over a bottle of frozen water.

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Hint 2:

Can't tell what that stain is? Still want to remove it? Try this sure-fire remover: Mix a teaspoon of 3% hydrogen peroxide with a little cream of tartar or a dab of non-gel toothpaste. Rub the paste on the stain with a soft cloth. Rinse. The stain, whatever it was, should be gone. OR according to a friend of mine:
"The stain one makes me think of what being a grandma has taught me. Those baby wipes have taken more stains off of clothes and upholstery than anything else I've tried."


Hint 3:
Every good do-it-yourselfer knows how important it is to take care of the tools in your toolbox. One way to condition them and keep rust from invading is to rub them down with hair conditioner..
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Father Describes The Surprising Death Of 4-Year-Old Son From Enterovirus D68
Enterovirus D68 is a rare viral infection whose symptoms are similar to a common cold: a cough, runny nose, a low-grade fever. But while a cold is innocuous, since September, five children have died after being infected with enterovirus D68. Andrew Waller, the father of one of those children, joined HuffPost Live on Thursday to talk about his tragic experience with the virus.
Four-year-old Eli Waller died overnight after contracting the virus. It was a total shock for the family, since Eli had not displayed any symptoms of the virus beforehand.
"The day before, that Wednesday, he appeared to be fine," Waller told host Ricky Camilleri. "He didn't really have any fever, he didn't show any overt signs of being sick. He'd been outside during the day [so] he was pretty tired, as a kid would probably normally be after running around outside all day." ...
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Long ago, while a newbie student nurse, I saw a RT suctioning a alcoholic patient for an entirely too long a time...be very careful of doing that cruelty. I wanted to say something...but was too timid. Now, it would have been an entirely different outcome !
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.
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Presidential Shades
Formerly known as the Presidential Palace, the White House was what color before being painted white after it was burned by the British two hundred years ago in 1814?
Answer? Grey
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HINTS:  When doing the cleaning, it isn't easy getting into those hard-to-reach spots like the corners of window and door tracks. Even a damp cloth or sponge may not suffice. Pop into your bargain store and buy yourself a pack of cheap artist brushes, the flat kind with stiff bristles. Then use the appropriate size to brush out the dry dirt before wiping or vacuuming up.

_________________________________________________

Hint 1:

Next time you shop for clothes, try the scrunch test. Take a
handful of the material, squeeze tightly, then release. If
this produces a mass of creases when it's dry, imagine what
it will be like when it comes out of the wash. If you don't
like ironing, look for another label in a different fabric
that will pass the scrunch test.

_________________________________________________

Hint 2:

Whether working in the garden, general cleaning around the
house or doing stuff on the car and in the garage, dirt and
grease can get under the fingernails and be the devil's own
job to remove. Before tackling any of this dirty work, rake
your fingernails over a bar of soap to fill the gaps. After
the job, clean hands in the usual way, then scrub out the soap with a brush.
 
RANDOM TIDBITS

In the United States, pepperoni is the overwhelming favorite addition to a cheese pizza. In Japan, seafood (eel and squid) is a popular choice, while green peas are added to the mix in Brazil. In Costa Rica, pizza pies are often topped with coconut.

The Pizza Hut restaurant chain got its name when the first location opened in Wichita in 1957. The sign only had space for three more letters besides "Pizza," and because the restaurant building resembled a hut, the choice was a natural one.

Modern pizza (also known as pizza margherita) is made with tomatoes, mozzarella cheese, and basil - though to represent the three colors (red, white, and green) of the flag of Italy.

Benjamin Salisbury, who found success as son Brighton Sheffield on the sitcom The Nanny, played a Domino's delivery person on a series of TV commercials in 2006, promoting the chain's short-lived Fudgem brownies.

It's not delivery; it's DiGiornio (introduced nationally in 1996) that stormed onto the scene to become the top-selling frozen pizza in the United States. Its "rising crust" has helped the brand rise to claim nearly 20 percent of the market. Perennial favorites Red Baron and Tombstone are the next biggest brand names.

Carmela Bitale became an unknown hero to millions in 1983 when she patented her "package saver for pizza and cakes." It's the tiny plastic stand used by pizza take-out and delivery services that helps keep the top of the cardboard box from sticking to the pizza.
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Cool way to separate an egg yolk!

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HUMOR SECTION
While visiting Annapolis, a lady tourist noticed several students on their hands and knees assessing the courtyard with pencils and clipboards in hand.

"What are they doing?" she asked the tour guide.
"Each year," he replied with a grin, "the upperclassmen ask the freshmen how many bricks it took to finish paving this courtyard."

When they were out of earshot of the freshmen, the curious lady asked the guide: "So, what's the answer?"

The guide replied, with a grin: "One."

--------------------------------------------------
( I can only say with this one..........."Oh Boy !!! )

As a jet was flying over Arizona on a clear day, the copilot was providing his passengers with a running commentary about landmarks over the PA system.

"Coming up on the right, you can see the Meteor Crater, which is a major tourist attraction in northern Arizona. It was formed when a lump of nickel and iron, roughly 150 feet in diameter and weighing 300,000 tons, struck the earth 50,000 years ago at about 40,000 miles an hour, scattering white-hot debris for miles in every direction. The hole measures nearly a mile across and is 570 feet deep."

The lady sitting next to me exclaimed: "Wow, look! It just missed the highway!"
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Contrary to popular belief, most blondes do indeed know the value of a dollar. The other day a blonde from Atlanta had her car break down. The tow truck driver charged her $65.00 to take the car to the garage less
than 10 miles away.

When she told her husband that evening, he said that the driver had taken advantage of her.

She said, "I thought so. But I made him earn it. I kept the brakes on all the way."
~**~**~~**~~**~~**~~**~~
CEU SITES---(CME and CNE)
Those that are-----Free and Otherwise..........
Go to www.sharedgovernance.org for access to a 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. info@sharedgovernance.orgwww.sharedgovernance.org
Pay Only $34.99 for a full year of CONTACT HOURS
www.nurse.com for CNE offerings.
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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/

Decubqueen's website: www.accuruler.com.
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

 Metric conversion calculators and tables for metric conversions
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*
MEDICAL RECALLS
*
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Baxter Healthcare Corporation, INTRAVIA Empty Containers with PVC Ports – Particles Found in Patient Solution
Baxter Healthcare Corporation
One Baxter Parkway
Deerfield, Illinois 60015
Reason for Recall:Baxter Healthcare found visible particles in INTRAVIA Empty Containers. These particles might be found in the solution in the tube that leads from a container to a patient’s vein.
These particles may irritate the patient’s veins, cause pain, worsen a previous infection, cause allergic reactions, block blood vessels, and cause death.
No injuries have been reported. Contact Baxter Healthcare Center for Service to arrange for return of the recalled devices.
  • Call 1-888-229-0001, Monday through Friday, 7:00 am – 6:00 pm, Central Time.
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Siemens Healthcare Diagnostics, Rapid Gram Negative Combo Panels - May Produce Incorrect Results

Siemens Healthcare Diagnostics, Incorporated.
2040 Enterprise Boulevard
West Sacramento, California 95691
Reason for Recall: Incorrect test results may occur for the following antibiotics: Aztreonam, Cefotaxime, Ceftazidime, and Ceftriaxone. The test may report certain bacteria as sensitive to one of these antibiotics when the bacteria are actually resistant. Using these recalled devices may cause ineffective patient treatment, and in rare instances may contribute to death. See article for the listing of all the lot numbers of the: Rapid Neg BP Combo Panel Type 3 and Rapid Neg Urine Combo Panel Type 1 and Type 3....
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Aurobinda-Pharma USA, Inc. Issues Voluntary Nationwide Recall of Northstar Label Gabapentin Capsules, USP 300 mg Due to Complaints of Empty Capsules
Empty capsules could result in missed dose(s) of gabapentin resulting in adverse health consequences that could range from no effect, short term reduction in efficacy, short term withdrawal effect, or status epilepticus (long period seizures) that could be life-threatening. Aurobindo Pharma USA, Inc. has not received any reports of adverse events related to this recall to date, but has received four complaints for empty capsules.
Gabapentin is used as in the treatment of epilepsy and for the management of postherpetic neuralgia (pain after shingles). The affected Gabapentin lot is GESB14011-A, Expiration 12/2015 and is packaged in 100-count bottles, NDC 16714-662-01. The product can be identified by the imprint D on yellow cap and 03 on yellow body with black edible ink. Product was distributed through Northstar label to retail outlets nationwide.
*******************
Baxter Initiate Voluntary Recall of One Lot of Highly COncentrated Potassium Chloride Injection In The U.S. Due to Mislabeled Overpouch
November 20, 2014, DEERFIELD, Ill. — Baxter International Inc. is voluntarily recalling one lot of Highly Concentrated Potassium Chloride Injection, 10 mEq per 100 mL to the user level due to a complaint of mislabeling of the overpouch. The inability to detect this overpouch mislabeling at the point of care may result in the administration of a dose lower than intended. In the high-risk patient population – patients prone to severe electrolyte imbalance – this hazardous situation may lead to serious, life-threatening adverse health consequences. There have been no reported adverse events associated with this issue to date.
Potassium Chloride is indicated for treatment of potassium deficiency and administered intravenously. Some containers of Product Code 2B0826, Highly Concentrated Potassium Chloride Injection, 10 mEq per 100 mL, Lot Number P319160, Exp. 06/30/2015, NDC 0338-0709-48 were incorrectly labeled on the overpouch as Highly Concentrated Potassium Chloride Injection, 20 mEq per 100 mL. Products were distributed to customers in the U.S. between June 23, 2014 and October 2, 2014. Unaffected lot numbers can continue to be used according to the instructions for use. http://www.fda.gov/Safety/Recalls/ucm424248.htm
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ADVERTISEMENTS
from the members
This ad is from Decubqueen (Gerry)..........Accuruler Created for accurate wound measurements. Designed by nurses, for nurses. Now carrying wound care and first-aid supplies at prices you can afford.
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NEW MEMBERS
Please send the prospective members' screen names and first names to me: RNFrankie@AOL.com
No new members this month.
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NOTICE:
I attempt to send newsletters to your email addresses on file and if the newsletters are rejected THREE consecutive times, I must then delete the email address until you contact me with an updated email address. So, be certain to let me know when you change your address. RNFrankie@AOL.com
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EDITORIAL STAFF:
GingerMyst @AOL.com (Anne), GALLO RN @AOL.com (Sue), HSears9868 @AOL.com (Bonnie), Laregis @AOL.com (Laura), Mrwrn @AOL.com (Miriam), and Schulthe @AOL.com (Susan)

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PARADIGM 97 CO-FOUNDERS:
MarGerlach @AOL.com (Marlene) and RNFrankie @AOL.com (Frankie)

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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
" Optimism is the faith that leads to achivemnet.
Nothing can be done alone without hope and confidence"
Helen Keller
Hope to hear from you..... Frankie


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