Professional Identity Booster

Defining one’s professional identity in nursing establishes what it means to think, act, and feel like a nurse.1 Whether we are new nurses or have practiced for decades, we could all use a refresher (like a booster vaccine) to our professional identity, reminding ourselves who we are as nurses. I have found a good place to start is to ask yourself when you felt at your best at work over the last few weeks. Was it treating a patient with a complicated condition, sitting with a grieving family member, or mentoring a new nurse? Consider how you felt when you were working at your peak, and recognize the unique contribution you bring to your practice. To make this exercise an even more potent booster, invite your whole unit to participate and take turns sharing your “me at my best” nursing moments at a shift huddle or staff meeting.Another effective booster is to take intentional steps to move forward in your professional identity. What is one thing you will do this year to keep moving forward as a nurse? You could attend a conference, get involved in a local chapter of American Association of Critical-Care Nurses, volunteer for a professional committee, or set a date for a certification examination. Continually developing, leading, and learning boosts our professionalism and strengthens and defines our nursing identity. Consolidation on chest radiographs can represent atelectasis, a frequent complication after open-heart surgical procedures. Incentive spirometry promotes lung expansion, thereby improving oxygenation and ventilation and decreasing postoperative pulmonary complications. Nasotracheal suctioning (A) can be effective at clearing deep secretions, which can reduce the risk for mucous plugs but is less likely to directly impact atelectasis. Although prone positioning (B) can also improve lung expansion, it may be contraindicated following a sternotomy and should not be performed without discussion with the clinician team. Opiate pain medications (D) can improve pain control and therefore improve the patient’s ability to breathe deeply, which may allow for increased lung expansion. However, if pain control is not necessary for deep breathing, opiates would increase the risk of sedation, which could lead to poor inspiratory effort and actually increase atelectasis. Prolonged intubation has been associated with increased rates of dysphagia and therefore aspiration in critically ill patients. Appropriate positioning, including keeping the head of the bed elevated to 30° or higher, can help prevent aspiration. This patient is at risk for aspiration of oral secretions because of their inability to protect their airway on the bedside swallow evaluation. Because of that risk, nothing should be given by mouth until safety can be established, and applesauce should be avoided (B). Laying the patient flat decreases their ability to protect their airway and could increase aspiration risk (C). Given the risk of prolonged intubation and the fact that the patient is coughing after each sip of water, it is less likely that the patient’s cough is a primary respiratory issue, so a nebulizer is unlikely to be effective (D). Women with myocardial infarction are more likely than men to present with atypical symptoms such as pain in locations other than the chest, including the neck. Women are also more likely to present with nausea, emesis, dyspnea, and a fear of death. Cholecystitis may cause nausea, vomiting, and abdominal pain, but typically the right shoulder, not the neck, is the site of referred pain (A). Given the mother’s orientation and lack of deficits, acute stroke is less likely (B). Pulmonary embolism may cause dyspnea and chest pain but typically not nausea and vomiting (C). Her symptoms are concerning for a time-critical diagnosis of acute myocardial infarction and should be assessed as soon as possible. Venous thromboembolism is a common complication of critical illness and an intensive care unit (ICU) stay. It is present in up to 30% of patients in the ICU and an even higher percentage of patients with specific types of cancer, like gastric adenocarcinoma. Insufficient mobility is a leading risk factor for venous thromboembolism development. A catheter-associated infection is unlikely in the absence of a central venous catheter (A). Delirium is a well-demonstrated complication in patients in the ICU but is more likely in patients treated with mechanical ventilation (C). Muscle atrophy can also result from immobility but is not an independent, serious risk as compared with venous thromboembolism (D). Gabapentin is renally cleared, and renal failure in the absence of dialysis can lead to gabapentin accumulation, resulting in somnolence. Mild hypotension is not likely to lead to lethargy but may be an adverse effect of gabapentin accumulation. This patient is not demonstrating fluid overload, so large-volume dialysis would not be indicated (A). Vasopressors are not indicated for mild hypotension (B). A patient who remains lethargic could become unable to protect their own airway and require mechanical ventilation; at this time, however, vital signs and laboratory values indicate adequate ventilation (D). The laboratory results indicate hyperkalemia. One precipitating factor is endogenous release of potassium from tissue breakdown, as can occur in patients with necrotizing enterocolitis. Presentation on the electrocardiogram includes peaked T waves, a widened QRS complex, and ventricular tachycardia. Ventricular fibrillation and cardiac arrest can result. Jitteriness (A) and a prolonged QT interval (D) can occur in patients with hypocalcemia. Hypotonia (B) occurs in patients with hypercalcemia and those with hypokalemia. A boot-shaped heart on a radiograph is a classic finding in tetralogy of Fallot. Cyanosis, diminished pulmonary vascular markings, and a systolic ejection murmur along the left sternal border are also consistent with the defect. The 4 lesions in tetralogy of Fallot are obstruction of the right ventricular outflow tract (eg, pulmonary stenosis), right ventricular hypertrophy, ventricular septal defect, and overriding aorta. The degree of right ventricular outflow tract obstruction can vary and determines the presence and degree of cyanosis. Symptomatic infants are initially treated with an intravenous prostaglandin E1 infusion to maintain patency of the ductus arteriosus and blood flow to the lungs. Oxygen (A) and indomethacin (D) promote ductal closure and can worsen hypoxia. Surfactant (B) is used to prevent respiratory distress syndrome. The history of respiratory distress along with the assessment and radiologic findings are consistent with congenital diaphragmatic hernia, a condition in which abdominal contents herniate into the chest cavity during fetal life. The herniated contents compress the lung on the ipsilateral side and displace the heart to the contralateral side. The priority initial stabilization interventions are endotracheal intubation to manage respiratory distress and eliminate the risk of air entering the stomach from bag-valve-mask ventilation; insertion of a large-bore orogastric tube to decompress the stomach; and gentle mechanical ventilation to minimize barotrauma. A chest tube (B) is used to decompress a tension pneumothorax. Although oxygen saturation monitoring is important in patients with congenital diaphragmatic hernia (C), it does not take priority over insertion of an orogastric tube to prevent further lung compression. Additionally, preductal and postductal monitoring is typically performed, and a probe placed on the right lower extremity provides only postductal oxygen saturation. Intra-arterial access for blood pressure monitoring is a core management strategy (D) but does not take priority over insertion of an orogastric tube. The inability to pass an orogastric tube is pathognomonic for esophageal atresia with or without tracheoesophageal fistula. In esophageal atresia the esophagus ends in a blind pouch and the infant is unable to swallow secretions, resulting in drooling or copious amounts of oral secretions. Aspiration of oral secretions can lead to respiratory distress. Most infants with esophageal atresia/tracheoesophageal fistula have other abnormalities; the most recognized relationship is with the VACTERL association. Trisomy 13 (A) is associated with craniofacial, musculoskeletal, genital, and central nervous system anomalies. Chromosomal anomalies associated with esophageal atresia/tracheoesophageal fistula include trisomy 18 and trisomy 21. Infants with Beckwith-Wiedemann syndrome (C) may have a maternal history of polyhydramnios, but the associated gastrointestinal defects are abdominal wall defects such as omphalocele and umbilical hernia. 22q11.2 Deletion syndrome (also known as DiGeorge syndrome) (D) is characterized by craniofacial and musculoskeletal anomalies and has associated findings that include congenital heart disease and aplasia or hypoplasia of the thymus and parathyroid glands. Extremely low-birth-weight infants (birth weight of 1000 g or less) are at significant risk for hypothermia and fluid and electrolyte imbalances. The use of a double-walled incubator and humidification from the time of neonatal ICU admission to at least the first week of life can reduce these risks. To minimize the risk of intraventricular hemorrhage, extremely low-birth-weight infants should be positioned with the head midline (A). The use of adhesive removers should be avoided in extremely low-birth-weight infants (B). Mineral oil, petrolatum, or emollients should be used instead. Because infants are obligate nose breathers, gastric decompression for an infant receiving continuous positive airway pressure ventilation should be managed with an orogastric tube (C). AACN Certification Corporation publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN certification examination handbook. The contributor of each question written for this column has listed the source used in developing each item. Clinical practice should be based on primary sources of evidence when possible; this column will also include secondary sources to help nurses become aware of available resources for certification review.