Wednesday, March 26, 2014
Sunday, January 19, 2014
What terms do you use to describe your patient's decreased level of consciousness? Obtunded, somnolent or drowsy are common words I hear. But what exactly is the difference between them? What exactly does the patient look like? How do I communicate this safely in handover to the next nurse after I leave?
The RASS is an objective highly reliable level of consciousness scale. It is a way to screen for increasing or decreasing levels of consciousness. When a nurse assesses and communicates with the scale, the numbers increase as the patient’s consciousness is heightened and decreases as the patient decreases. The differentiating between levels uses very objective criteria. This makes the scale reliable nurse to nurse. The assessment between the levels use very objective criteria. This makes the scale very logical and helpful to understand. As the numbers increase the nurse can assess, document and communicate increasing level of anxiety or agitation. In ICU environments, where nurses use sedation drugs to purposefully sedate patients on a ventilator, the RASS is a great tool for targeted sedation. When the RASS is used in non-ICU environments, nurses use it to screen for and catch over sedation and respiratory depression before it happens. Since sedation always precedes respiratory depression, screening is an effective way to head off over sedation. It is important for the nurse to assess and document a patients level of wakefulness anytime the patient is receiving any medications that can cause sedation. Including anxiolytics, and even promethazine, prochlorperazine, and diphenhydramine as well as opiods. It is also very important to document level of wakefulness when a nurse is taking care of a patient with neurological conditions or conditions that can affect wakefulness such as liver failure with its rising levels of ammonia and respiratory failure and its rising levels of carbon dioxide. Risk factors for over sedation include Obstructive Sleep Apnea, elderly, narcotic naïve, and post op. Also do not take it for granted that your patients know not to take their own medications while in the hospital. Be sure you tell your patients not to take anything without you being aware. Troubleshooting is allowed with RASS in a case where your patient awakens quite briskly and fully after you have touched them, remaining awake for greater than 10 seconds…it would be necessary to take into account that they may have interfering variables such as HOH or neuro issue. Be sure this is passed on to nurses in hand-off. Few patients may have something like this going on. Report fluctuating level of consciousness to physicians. This is often an early tell tale sign of delirium.
Sessler, C. N., Gosnell, M. S., Grap, M. J., Brophy, G. M., O'Neal, P. V., Keane, K. A., ... & Elswick, R. K. (2002). The Richmond Agitation–Sedation Scale: validity and reliability in adult intensive care unit patients. American journal of respiratory and critical care medicine, 166(10), 1338-1344.
Benítez-Rosario, M. A., Castillo-Padrós, M., Garrido-Bernet, B., González-Guillermo, T., Martínez-Castillo, L. P., & González, A. (2013). Appropriateness and Reliability Testing of the Modified Richmond Agitation-Sedation Scale in Spanish Patients With Advanced Cancer. Journal of pain and symptom management, 45(6), 1112-1119.
Calver, L. A., Stokes, B., & Isbister, G. K. (2011). Sedation assessment tool to score acute behavioural disturbance in the emergency department. Emergency Medicine Australasia, 23(6), 732-740.
Monday, December 30, 2013
I just read this great article Michael Solomon: miracle-cure-driving-patient-satisfaction-for-hospital-and-healthcare-customers/ . And I agree with everything Michael says, I also recognize the real barriers to changing culture. As of now hospitals are trying to change and change rapidly from a clinician-centric delivery model to a patient-centered model. Hospitals are trying to standardize and decrease costs, while at the same time, deliver individualized patient centered care. So much of this change in how we relate to patients is really occurring in the interactions between clinician and patient and the culture of the organization. The challenge that leaders face today is that training clinicians to communicate better is not done with a power point or a sign. It isn't taught with online modules or posters. Changing is going to take real investment. One just needs to look at the evidence and research on the matter. Communication skills are learned through a process of role modeling and coaching with feedback. Other especially effective methods include the use of video feedback with coaching. The coach/educator has to have very good skills at observation, questioning and guiding people to their own realizations. It is a delicate dance between understanding each person's unique relational style and language and professional communication. Another innovative method that I have found to be very effective is the use of patients as teachers. Asking patients to volunteer as "patients" for teaching communication skills. (It takes a special person to volunteer for this "patient" role in that they should have some experience in teaching and learning.) This fun way to teach communication skills involves asking clinicians to engage in a communication activity and receive feedback from the patient's perspective. When clinicians have this opportunity to see themselves through the patient's eyes, it can be very impact-full. Making it real this way is relevant, in that these patient actors are likely to pick up on medical terminology and assumptions about health literacy. The next level of improving communications with clinicians and patients is going to take a commitment to evaluating systems and infrastructure, and determining what forces in hospital culture and systems deter clinicians from taking adequate time and energy to sit down with patients. Identify organizational forces that deter clinicians from sitting down with patients and drive rushing through discharge and education. I love the idea of introducing nursing's caring theory to an organizations nursing model of care. This helps to reinforce the patient centered models inside the education and culture of nursing within an organization. Evaluate what needs to change and push for new incentives for patient-centered care. Once clinicians see the outcomes of their energies through feedback about readmission and population health, culture change will take off. According to Kotter, the change process involves dedicating meaningful time and education resources to effective training and marketing the new ideas. I believe hospitals are on the edge of a real paradigm shift. I cant wait to see what happens!