What is Delirium? The ABCDE Bundle

According to my fiancé (yes we got engaged! And yes, he’s not a healthcare guy. In fact, he’s scared of needles), when he hears the word delirium, he thinks of someone being delirious or confused. Unfortunately, this state happens a lot in the ICU and causes a lot of problems.

You can go from being a crazy beast, pulling everything to being super quiet, not making eye contact to someone’s voice. What are the potential causes of delirium and what interventions can be done? Use THINK.

 

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The Gold Standard to determine’s someone state is called the RASS score, or the Richmond Agitation-Sedation Scale. It goes from +4 to -5, as listed below. In conjunction with this, utilizing the Confusion Assessment Method for the ICU (CAM-ICU) determines if delirium is present.

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A lot of times we are using medications for agitation and sedation but studies are showing that using multiple non pharmaceutical methods decreased delirium by 15%.

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In the article, the evidence shows the following will help prevent delirium:

  • Early mobilization.
  • Frequent reorientation.
  • Clinical status updates and schedules.
  • Discuss patient requiring memory recall.

To me, when I read that list, I think most of it is pretty easy. Except for early mobilization. From what I’ve heard, there are patients who are intubated sitting in a chair! In my current ICU, that does not happen. The biggest concern is the stability of the patient. So what can we do?

Implement the ABCDE Bundle,

which stands of Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility. It incorporates the best available evidence related to delirium, immobility, sedation/analgesia, and ventilator management in the ICU. For the ABC Bundle, the nurse and respiratory therapist will go through his or her checklist before the trial.

A stands for Awakening.

The first step is to see if the patient can undergo a Spontaneous Awakening Trial (SAT). The nurse assesses these qualities:

  1. Is patient receiving a sedative infusion for active seizures?
  2. Is patient receiving a sedative infusion for alcohol withdrawal?
  3. Is patient receiving a paralytic agent (neuromuscular blockade)?
  4. Is patient’s score on the Richmond Agitation Sedation Scale (RASS) >2?
  5. Is there documentation of myocardial ischemia in the past 24 hours?
  6. Is patient’s intracranial pressure (ICP) >20 mm Hg?
  7. Is patient receiving sedative medications in an attempt to control intracranial pressure?
  8. Is patient currently receiving extracorporeal membrane oxygenation (ECMO)?

If the answer is yes to any of the above, then there needs to be a discussion with the interdisciplinary team before performing a SAT. If the answer is no to all of the above, then proceed with performing the SAT. Stop the sedation. If the following occurs, you should put the patient back on sedation but try at 1/3 to 1/2 the rate the patient was on before.

  1. RASS score >2 for 5 minutes or longer
  2. Pulse oximetry reading <88% for 5 minutes or longer
  3. Respirations >35/min for 5 minutes or longer
  4. New acute cardiac arrhythmia
  5. ICP >20 mm Hgb
  6. 2 or more of the following symptoms of respiratory distress:
    • Heart rate increase 20 or more beats per minute
    • heart rate less than 55 beats per minute
    • use of accessory muscles, abdominal paradox, diaphoresis, dyspnea

If possible, changing the sedation from propofol to precedex will help patient be calm and it does not depress respiratory status (especially after 24 hours).

B stands for Breathing.

Spontaneous Breathing Trials (SBT) are up next. The respiratory therapist will assess for safety.

  1. Is patient a long-term/ventilator-dependent patient?
  2. Is patient’s pulse oximetry reading <88%?
  3. Is patient’s fraction of inspired oxygen (FIO2) >50%?
  4. Is patient’s set positive end-expiratory pressure (PEEP) >7 cm H2O?
  5. Is there documentation of myocardial ischemia in the past 24 hours?
  6. Is patient’s ICP >20 mm Hg?
  7. Is patient receiving mechanical ventilation in an attempt to control ICP?
  8. Is the patient currently taking vasopressor medications?
  9. Does the patient lack inspiratory effort?

If the answer is yes to any of the above, then it may not be safe to perform the SBT. If the answer is no to all of the above, then the SBT is performed. However, if any of the below occurs indicating signs of failure, then stop.

  1. Respiratory rate >35 breaths per minute for 5 minutes or longer
  2. Respiratory rate <8/min
  3. Pulse oximetry reading of <88% for 5 minutes or longer
  4. ICP >20 mm Hg
  5. 2 or more of the following symptoms of respiratory distress
    • Use of accessory muscles
    • Abdominal paradox
    • Diaphoresis
    • Dyspnea
    • Abrupt changes in mental status
    • Acute cardiac arrhythmia

And of course, who is watching for these symptoms? The registered nurses.

 

C stands for Coordination.

This refers to the coordination mostly between the respiratory therapist and the nurse, although the discussion during the interdisciplinary team will also play a part.

 

D stands for Delirium.

THINK about the causes, use the RASS score every 4 hours and the CAM-ICU score every shift.

 

E stands for Early Mobility.

What I’m interested in is the minimum criteria for early mobility protocol.

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However, if there’s any patient distress, then it’s time to stop. Below are the criteria for stopping early mobility.

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 It’s hard to start something new as an individual as it requires a cultural change and the healthcare team to be behind it. 

But maybe the next time you take care of a ventilated patient, you’ll think of the ABCDE bundle and implement it as a part of your care. 

 

CCRN: How to Pass The First Time

I passed the CCRN last week! Yay!!! The CCRN is a certification exam for critical care nurses. It basically verifies your knowledge about critical care concepts after working 1750 hours in the last two years. The benefit of getting the CCRN means getting a pay raise or a bonus. Or intellectually, it solidifies your basics. But if you’re reading this, you probably already know that. You have the more important question — how do I pass the CCRN?

Before I studied, I also searched the internet for the best way to study for this difficult exam. There were two things that stood out to me.

  1. Listen to Laura Gasparis’ videos.
  2. Do all of the questions from PASS CCRN®.

I got all of the material from a friend, from another friend.

I listened to all of the videos and wrote down notes the first time around so I wouldn’t have to listen to it again. It meant I had to pause the video sometimes to write notes. There were 6 videos about 2 hours long. So roughly 12 hours. I did 2 videos each week while working full time. It took 3 weeks to complete.

Then I did all of the questions from Pass CCRN. Don’t read the book. Doing the questions will inadvertently make you go through the important concepts and details. I gave myself the goal to complete either a complete section (for shorter, easier sections) or a certain number of questions each day. Cardiac (20%), pulmonary (18%), and ethical (20%) are the most heavily weighted sections. For the cardiac and pulmonary sections, it initially took me about 2-3 hours to complete 30 questions because I would read the rationale and write a flashcard for the material. There are over 300 questions on cardiac alone, and there’s a good reason for it.

I felt the most important things about cardiac are:

  • The different medications (pressors, vasodilators, diuretics, beta blockers, calcium channel blockers, ACE inhibitors, ARBs), how it works, side effects, and how it affects afterload, preload, and contractility (which comprises of stroke volume (SV)).
  • How does SV and heart rate (HR) affect cardiac output (CO)?
  • In different disease states, what is lacking, and what do you need to fix the problem?
  • How does the intra-aortic balloon pump (IABP) help? Complications?
  • What does the pulmonary artery measure, what do those values mean, and what do you do when you see a value out of wack? What are physical assessments would you find?
  • What are the different types of murmurs, where do you listen, what typically causes stenosis vs regurgitation?
  • Different types of chest pain, MI.
  • 12 lead EKG — this took some time for me since at work it’s only required to know how to read a lead II EKG. But since I started studying, I’d look at 12 lead EKGs at work and it’s kinda fun.

For pulmonary:

  • ABG interpretation (compensated vs uncompensated; what would breathing too fast or too slow cause? How would you treat different values?)
  • Ventilator settings – which ones affect respiratory rate? What does PEEP do? How does that relate to the V/Q ratio?

As I did the questions, I used a flashcard program called Anki. It’s a fantastic memorization tool using the concept of spaced repetition. And the best part is that it’s free to download on the computer or laptop and to use over the internet. It’s $25 to download on your iPhone or Android but it’s worth it.

Basically, I did the questions on one side of the screen, and had Anki opened on the other side. Anything I didn’t know or wanted to review, I either copy and pasted questions or answers, or paraphrased the concepts. It’s easy to put too many things to memorize on one card and that’s the last thing you want to do. When you’re reviewing the card, you don’t want to think, “oh I got half of the card correct… so do I choose that I got it right or wrong?” You want to be decisive and pick whether or not you got it correct.

I have the flashcards that I created for the CCRN that is easy for you to download, although you should probably create your own or edit mine to make it easier for you. Updated December 16, 2016: these flashcards can only be used with Anki on a computer or phone. If you are thinking about downloading the flashcards, please download Anki first and make an account. Also, please do not download these flashcards unless you will use them right away.

Updated August 3, 2015: I’ve given the CCRN Flashcards to many people who have used them and passed the CCRN. Since it is time consuming for me to email everyone who asks and I’ll have no income for the next two years while I’m in school, I’ve decided to sell them to help me pay for food during school. People have said that it’s worth $50 but I won’t charge that much for it, especially since I really want you, as my reader, to pass!

And good luck in your endeavor.

Just 89 out of 150 questions to pass. So you can do it! 25 are for research. Only 125 actually count. You have up to 3 hours to take the exam.

The exam is $225 if you’re a member of AACN. You’ll go to goamp.com to see the test sites and register for the exam. You’ll get 3 months to take the exam. Once you pick, you can change the test date once for free. Majority of the test sites are in the HR Block. How nice of them!

I took mine in Astoria, NY. I was the only one and it was quiet. Good experience.

Anyways, go for it.

Compassion Fatigue and what you can do about it

compassion fatigueToday I went to a journal club meeting on compassion fatigue. What does compassion fatigue even mean? Why is it important? And how can we combat it?

First let us define a few words.
Passion means an intense emotion.
Compassion means you’re intensely aware of others’ suffering and you have the desire to do something about it.
Sympathy is when you feel sorry for others.
Empathy is when experience others’ pain.

As a nurse, you probably will feel all of these emotions for your patients. You understand the patients’ suffering and you’re willing to do something about it. You feel sympathy for these patients. In fact, your entire unit probably feels sympathy. And your goal is to alleviate suffering.

However, empathy can be emotionally taxing and draining. You have to be careful not to be too empathetic for each patient  as doing so will drain your emotional capacity.

But what happens when there’s too much compassion? What is the opposite of compassion?

Indifference. You stop caring. It’s too much and you’re not satisfied.

What does this look like?

People may lash out at others. Others isolate themselves. People will often call out sick because they feel overloaded. They feel scared that they will make a mistake that could cost them their license or worse, a patient’s life. Nurses will feel burnout and eventually drop out of nursing. That is not good for the profession.

What can you do to combat compassion fatigue?

1. Set small and obtainable goals (SMART goals).

This applies to any setting, but especially in the critical care setting where there are chronic patients and dying patients who may make little difference everyday (either positively or negatively). The goal may not be curative but rather for comfort. If the patient is in pain, your goal could be to provide comfort.

Sometimes family members will have unreasonable goals for their loved ones because they are unfamiliar or are in denial of the serious condition. They may think that their loved one is going to go home being the same way they were before arriving at the hospital. In this case, your goal could be to alleviate the family’s fears and to be honest with the patients’ condition.

Setting your own small and measurable goals for the patient for those 12 hour shifts will allow you to feel good about the care you give.

2. Taking care of yourself.

The stability of your personal relationships at home will affect how you handle yourself at work. If you’re stable and confident with yourself, you will come away believing in yourself that you’re doing the best you can. Having enough time for yourself is crucial. Exercise, eat healthy, and building a positive network.

3. Work as a team.

Lastly, remember that you’re working as a team and not in isolation. Your coworkers also feel compassion for you and your patients. The more senior coworkers may have had experiences similar to the one you’re currently dealing with and can suggest goals for you.

Giving the same good, evidenced based nursing care for each patient is something my unit does consistently, no matter what condition the patients are in. In some cases, the patients get better. In other cases, patients get worse or stay chronically ill. By treating everyone in the same way, we feel that the patients’ destiny is not in our hands, but is determined by something higher up.

First float as a critical care nurse

fear vs courageI feel that anytime you float to another unit, there’s some anxiety because you’ll call different providers, things are in different places and there’s usually a different patient population. Since I came off of probation, I have to float now.

My first float was at the SICU. While there, I had 2 medical patients, so at least I was used to that. Here are a couple of things there made me feel comfortable.

  1. A list of numbers for the MLPs (the critical care PA, vascular PA, and surgical PA), respiratory therapist, med cart code, nurses lounge. If the float unit is nice, then they will already have these on a sheet prepared for you. If not, then ask the charge nurse or the secretary for this information.
  2. Bringing my own SBAR form. The float unit may not have the same form as your home unit.
  3. A quick orientation of the unit. Having an idea of where everything is will give you the tools you need to succeed!
  4. Remembering names. Introducing yourself to the nurses next to you and to the axillary staff and remembering their names will make it much easier to get help (or help them!) and get the job done.
  5. Ask questions. As always, feel comfortable asking questions! Anything from, ‘Where can I find a 3cc syringe?’ to a patient’s deteriorating condition to ‘can I have a boost?’

Although I had a pretty good first float, I’ve heard other stories from my coworkers stating that they had too many patients. You should be able to get the same ratio of patient population as you would normally. Good luck on your first float! 🙂

Finally off of my critical care probation!

sim manYesterday marked the last day of my critical care probation. So what did I do to pass? Instead of being at the hospital, I went to the simulation lab with Mr. Sim Man.

While I did sign a confidentiality agreement not to discuss the specifics of the lab, I can briefly state that it was similar to being at work in the hospital. When you receive a patient, you do a Head to Toe assessment, and determine the next step in care. Is he stable or unstable? If the patient doesn’t respond to your care, what is the next step?

It’s exciting to be off probation now, considering that I’ve been on the unit since December 2013! Now I will have to float to the SICU or CTICU, stepdown, PACU and ER. I’m a little scared to not know everything is (again), but it should be ok!

What mean, demanding patients want – poem

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He so in control, even when he’s ill
Demanding that the TV’s on
as he rolls into the new room
“Sir I need to make sure you’re breathing”
“No, the TV will keep my sanity”
Even when he can hardly breathe

Nothing’s my way
only his way
“But dad when you do it their way
you get better
and you do it your way
and you’re back in the hospital
So just listen to them”

No I don’t want that
then what do you want
I want what’s best for me
what is best for you?
I don’t know you tell me
let’s keep this on
Okay

He wants control, his decisions
because slowly but surely
he’ll lose one thing at a time
So he’s demanding
and mean

I get it
but what do I do?
How do I deal?
Just wait for 12 hours to be over?

It’s time to be a Strong Nurse

I was about to ‘boost’ a patient up in the bed with a colleague and I noticed how strong she was. I hardly did anything! Later that night, a patient coded and she started CPR. I noticed that she could do it for such a long time with so much force. She’d take a break just for a few minutes before she took over again.

When I took over, I realized how little endurance I had. I was wiped out after a minute.

After the code, another colleague mentioned how she heard pumping noises right before the code was called. She knew that it was that strong nurse doing CPR.

After I went home for the day, I felt my abs hurting.

This made me think about all the strong nurses there are. Especially in the ICU. Especially her. So she’s my strong nurse idol. I want to be a strong nurse.

I bought new running shoes and workout clothes yesterday from Adidas. I haven’t had a sports bra since high school (I’ve been swimming instead). I have to build my endurance. Do free weights. Etc.

It’s time to be a strong nurse.

And I’m bringing my boyfriend along for the ride.

Strong nurse!

Talking to intubated patients make a difference

I’ve taken care of my fair share of intubated patients. But over the last 2 nights, I encountered something different. They went from calm to wild in just a few minutes. If the sedation was down, then I increased that. Normally it works pretty fast.

But it wasn’t so in this case. Both patients were ‘bucking the vent.’ One didn’t have a PRN order ready so for one I had my coworker help me get an order and prepare ativan. But in the meantime, I remember reading critical care nursing journals about the experiences of previously intubated patients. They said to always assume that the patient can hear you. They said that when the nurse talked to them about where they were, what’s going on, and what to do, in a strong confident voice, that the patients felt comforted by that. So that’s exactly what I did.

This patient kept biting down on the tube (which is a big no no because we don’t want a punctured tube!!). “You’re in the hospital and you’re very sick. I’m Jessica, your nurse. Right now you’re having trouble breathing so you have a breathing tube. I know it’s uncomfortable but you need this. Try to calm down and take slow breaths. Open your mouth. Your face is very red but calming down will allow you to breathe better.”

Once I said this, the patient did calm down and opened her mouth.

“Good, your face is looking better and you’re oxygenating better. We are going to turn you to the side to clean you because you had a little accident, ok?”

She was able to cooperate much more at this point. And this happened before giving the ativan. My coworker then came in, administered it (“we’re going to give you something to help you relax now”), and she was at peace again.

Even though she couldn’t focus her eyes and couldn’t follow simple commands, it seems as though what I said did make a difference.

 

“I like your ring”

I had 3 patients last night.
One was bleeding from her ash splint cath.
One was in pain.
One said, “I like your ring!” As I told her to keep her arm straight so I could do a dressing change.

Haha, love my patients.