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The Cranial Nerve Assessment for Nurses

The Cranial Nerve Assessment for Nurses

The cranial nerve assessment is an important part of the neurologic exam, as cranial nerves can often correlate with serious neurologic pathology. This is important for nurses, nurse practitioners, and other medical professionals to know how to test cranial nerves and what cranial nerve assessment abnormalities may indicate. This becomes especially important when evaluating potential new strokes.

In school, cranial nerves tend to be something you memorize and then forget the day after the test. But they are important in testing a patient’s neurologic status, as an abnormality in a cranial nerve can indicate a central lesion (stroke, tumor, bleed, etc).

Every nurse should at the least know how to do a basic cranial nerve assessment, specifically the visual acuity and pupillary light reflex. When evaluating a stroke, The NIH scale is a method to evaluate the severity of a stroke. This scale walks you through evaluating many of the cranial nerves, but not all of them. If you want to feel confident when you chart “Cranial nerves II-XII grossly intact”, then keep reading!

1. The Olfactory Nerve (CNI)

The olfactory nerve is responsible for the sense of smell. Although rarely tested in practice, alterations in smell can be caused by serious intracranial pathology (brain tumors, strokes, TBI), neurodegenerative diseases like Alzheimer’s, Parkinson’s, or MS, or benign and transient causes such as the common cold.

If both branches of the olfactory nerve are damaged, this can lead to permanent anosmia (loss of smell) and can lead to food tasting bland and decreased appetite. In most individuals, the sense of smell decreases over time, with up to 75% of individuals older than 80 have some degree of anosmia.

 How to test the Olfactory Nerve

The olfactory nerve is almost never tested within an acute care setting such as in the hospital. However, this is sometimes tested in outpatient neurology offices. To test the olfactory nerve, blindfold the patient and have them smell and identify common scents such as vanilla, cinnamon, coffee, or peppermint while covering up one nostril at a time. Do not use ammonia or alcohol as these can trigger intranasal trigeminal nerve receptors and bypass the olfactory nerve.

2. The Optic Nerve (CNII)

The optic nerve is the second of the cranial nerves and is responsible for vision. This nerve transmits signals perceived in the retina and cones of the retina to the occipital lobe. This is commonly tested within the clinical setting and for a variety of presentations.

Partial or complete loss of vision can be caused by conditions such as:

  • Diabetes
  • Intracranial pathology (ischemia, stroke, tumors)
  • Inflammation or infection of the eye
  • Toxicity

How to test the Optic Nerve

When testing the optic nerve, you need to examine the visual fields, the visual acuity, and the pupillary light reflex. All three are an important part of the cranial nerve assessment, although the pupillary light reflex involves cranial nerve 3 as well.

Testing the Visual Fields (II)

If the patient loses part of their vision on one side, it is termed partial hemianopia, and if they lose complete vision on one side it is complete hemianopia. There are a few different ways to test visual fields, but here is an easy way. Stand one arm length away from the patient and ask them to cover up one eye or do it for them if they are unable. Close your own eye on the same side. Now hold up numbers with your fingers at each of the four corners of their vision. Once satisfied, test the other eye.

Testing the Visual Acuity (II)

Nurses often assess visual acuity, and most emergency departments will have a Snellen eye chart to use. The distance the patient stands depends on the visual acuity chart (it should say). If you do not have easy access to this, there is an app you can get on your phone which is super helpful!

Have the patient stand the appropriate distance away and have them cover up one eye. Do not have them forcibly close the eye as this can somewhat inhibit their ability to see out of their open eye. Ask the patient to read the 20/20 line on the chart. On a standard Snellen eye chart, this would be 20 feet away. If the patient gets more than half wrong, move onto the line above. Stop once the patient gets over 50% right. Mark this down and test the other eye. If they wear glasses – have them wear their glasses for this as well!

Pupillary Light Reflex (II, III)

The pupillary light reflex tests both cranial nerves II and III. First, inspect both pupils and make sure they are equal in size and shape. Then dim the lights if possible and shine a penlight directly into the right eye. Both pupils should constrict and maintain symmetry. Note if they are brisk or sluggish and if they are symmetric. Remove the light source and watch both eyes dilate equally as well. Do the same for the left eye.

3. The Oculomotor Nerve (CNIII)

The oculomotor nerve controls the majority of the extraocular muscles. It is primarily responsible for eye movement, eyelid movement, and pupillary constriction. If there is any oculomotor nerve impairment, there will be a pupillary dilation, ptosis (drooping eyelid), and outward deviation of the eye – termed abduction. When a patient has diplopia (double vision), it is often due to a unilateral lesion on this cranial nerve. In most cases, third nerve palsy resolves over weeks to months.

Causes of oculomotor nerve palsy include:

  • Intracranial aneurysm
  • Microvascular ischemia (in diabetics especially)
  • Trauma: Severe blows to head with skull fracture

Testing Extraocular Muscles (III, IV, VI)

To test the oculomotor nerve, you need to assess the EOMs. Testing the EOMs also tests cranial nerves IV and VI, as all three nerves are responsible for eye movement.

Hold your finger or a pen 2 feet in front of the patient’s eyes midline and have the patient focus on it with both eyes. Ask the patient to follow your finger or pen with only their eyes, moving the pen to the right, back to the midline, and then to the left and back again. Do this again for up and down. Lastly, do this again to the down-left diagonal angle, and then the down-right diagonal angle. You should have tested a total of 6 different directions – termed the “6 cardinal directions”.

Eye movement should be symmetric, smooth, and moving in all directions. At each extremity of vision, you should be observing excessive nystagmus. Nystagmus is repetitive uncontrolled eye movement.

Conjugate nerve palsy is when both eyes are unable to look in a specific direction during your testing. This most commonly occurs in the horizontal directions. This is usually due to a stroke within or near the brain stem.

The pupillary light reflex listed above is also used to assess the oculomotor nerve.

4. CN IV: The Trochlear Nerve

The fourth cranial nerve, the trochlear nerve, innervates the superior oblique muscle of the eyes. This means it controls the downward movement of the eyeball and prevents it from rolling upward. When there is a fourth nerve palsy, patients will often complain of vertical diplopia and/or tilting of objects. This may be most noticeable when in a downward gaze such as when going down the stairs. They may also have a head tilt, as the visual changes improve with tilting of the head. On exam, the eye will with deviated upward and rotated outward.

Testing the trochlear nerve involves evaluating the patient’s extra-ocular movements as described above.

5. CN V: The Trigeminal Nerve

The Trigeminal nerve is the 5th cranial nerve and responsible for facial sensation, as well as moving the muscles involved with biting and chewing. This has three branches including the ophthalmic V1, maxillary V2, and Mandibular V3. Compression of this nerve root can cause trigeminal neuralgia – a rare but painful condition.

How to test the Trigeminal Nerve

To test the trigeminal nerve, you are testing their facial sensation. Lightly touch both sides of the forehead and ask if they felt the same. Do this on the cheek, and then the chin. If the patient is uncooperative, you can test their corneal reflex. Do this by having the patient look right, then touch their left cornea with a whisp of cotton. They should blink. Do this on both sides.

6. CN VI: The Abducens Nerve

The sixth cranial nerve, the abducents nerve innervates the lateral rectus muscle of the eye. This means its responsible for outward movement of the eyes. Patients with dysfunction of this nerve will be unable to outwardly move their eyes. This causes horizontal diplopia, where the double images are side-by-side, which is worse at far distances.

This nerve is often the first nerve compressed when there is any increased intracranial pressure (ICP). However, more common causes include vascular disease (diabetes, hypertension, atherosclerosis) or trauma.

To test the abducents nerve, test the EOMs as described above.

7. CN VII: The Facial Nerve

Cranial nerve VII is the facial nerve, which controls the muscles of facial expression, as well as the sensation of taste of the front of the tongue. Facial nerve palsy can occur for various reasons, the most common being Bell’s palsy. Some other common causes include stroke, Lymes disease, trauma, or even diabetes.

How to test the Facial Nerve

To test the facial nerve, you must assess the patient’s facial expressions. Have the patient close their eyes tightly, then have them open their eyes. Ask them to frown, looking for symmetry in the forehead muscles. Have them smile and look for any drooping or asymmetry.

Clinical Tip: To differentiate Bell’s palsy from stroke, assess the patient’s use of their forehead muscles. Peripheral nerve lesions (such as with Bell’s palsy) cause paresis of the entire side of the face. Central lesions tend to only effect the lower portion of the face. This is not always the case though, so you must use clinical judgement. Bell’s palsy should have no other associated neuro deficits. Check out my Infographic for more information!

8. CN VIII: The Vestibulocochlear Nerve

The vestibulocochlear nerve, also called the auditory vestibular nerve, is responsible for hearing and balance. Vestibular neuritis is when the nerve becomes inflamed and can cause vertigo, dizziness, and balancing difficulties – most likely from a viral infection.

How to test the Vestibulocochlear Nerve

While not routinely tested within the hospital, the vestibulocochlear nerve involves testing both hearing and balance. Hearing is tested by holding your fingers a few inches away from their ears and rubbing them together. If they can hear, then that is a pass. Test their balance by assessing their gait while walking. The presence of nystagmus can also indicate vestibular dysfunction.

9. CN IX: The Glossopharyngeal Nerve

The glossopharyngeal nerve is partially responsible for the sensation of taste, pharyngeal sensation, as well as for the gag reflex. A damaged glossopharyngeal nerve can cause a loss of taste in part of the tongue and cause trouble swallowing.

How to test the Glossopharyngeal Nerve

Palatal Movement (IX, X)

Instead of doing the gag reflex which can be very uncomfortable for patients, you can instead assess palatal movement. Do this by having the patient yawn or say “ahh”, and observe their palate movement for symmetry. If this is abnormal, consider testing the gag reflex.

Gag Reflex (IX, X)

When performing the cranial nerve assessment, the easiest way to test the glossopharyngeal nerve is to test their gag reflex, however, this is usually not necessary in the clinical setting. Remember that approximately 20% of people will not have a gag reflex at baseline. Check both sides of the pharyngeal wall by gently poking the pharynx with a cotton swab.

Dysarthria (IX, X, XII)

There is no specific test for this but listen to the patient’s speech. Assess for any slurred speech or abnormality of the voice. Ask the patient or the family if it sounds different than normal.

10. CN X: The Vagus Nerve

The Vagus nerve innervates the hearts, lungs, and digestive tract, along with a few muscles. Most noticeably, it controls the heart rate, GI motility, sweating, and speech. It is also partially responsible for the gag reflex (along with cranial nerve IX).

Overstimulation of the vagal nerve can drop the heart rate and cause syncope, termed vasovagal syncope. Activities that stimulate the vagal nerve include bearing down, holding breath, carotid massage, or extreme fear or stress.

There are even implantable vagus nerve stimulators that can help slow down the firing of neurons within the brain and thus help manage seizures.

How to test the Vagus Nerve

The only real way to test the vagus nerve is via the gag reflex as described above.

11. CN XI: The Accessory Nerve

The accessory nerve innervates the sternocleidomastoid and trapezius muscles. This means it is responsible for tilting/rotating the head as well as shrugging the shoulders. This nerve can be damaged after neck surgery or blunt force trauma.

How to test the Accessory Nerve

To test the trapezius muscle, ask the patient to shrug both of their shoulders at the same time. Then apply some downward pressure with both hands and ask them to shrug both shoulders against the resistance.

To test the sternocleidomastoid, place a hand against their cheek and ask them to rotate their head against resistance in each direction. If you notice weakness, this indicates the opposite side is the weaker muscle.

12. CN XII: The Hypoglossal Nerve

The hypoglossal nerve controls most of the movement of the tongue. This means it is highly responsible for speech and swallowing. Damage to the hypoglossal nerve is rare, but if so are likely to be caused by tumors or gunshot wounds. Other causes include stroke or neurodegenerative disease.

How to test the Hypoglossal Nerve

To test the hypoglossal nerve, ask the patient to stick out their tongue. If the tongue deviates to one side, this indicates hypoglossal nerve dysfunction on the side of deviation. Then ask them to move their tongue from side to side rapidly. Additionally, listen for dysarthria when the patient is speaking as described above.

Cranial Nerve Assessment Cheat sheetCranial Nerve Assessment Cheat Sheet

How’s that for a refresher?  Although we may have forgotten some of the in’s and out’s of the cranial nerve assessment, this should serve as a reminder for how to examine cranial nerves. Hopefully, after reading this, you can feel more confident in your neurologic assessment!

If you need an easy cranial nerve assessment handout, you can download my handout here! This is the perfect cheat-sheet that you can refer to in practice when assessing cranial nerves!

References:

Gelb, D. (2019). The detailed neurologic examination in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/the-detailed-neurologic-examination-in-adults

Lee, A. G. (2019). Third cranial nerve (oculomotor nerve) palsy in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/third-cranial-nerve-oculomotor-nerve-palsy-in-adults

Lee, A. G. (2019). Fourth cranial nerve (trochlear nerve) palsy. In UpToDate. Retrieved from https://www.uptodate.com/contents/fourth-cranial-nerve-trochlear-nerve-palsy

Mullen, M. T. (2014). Differentiating Facial Weakness Caused by Bell’s Palsy vs. Acute Stroke. Journal of Emergency Medical Services39(5). Retrieved from https://www.jems.com/2014/05/07/differentiating-facial-weakness-caused-b

Oculomotor Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/neuroscience/oculomotor-nerve

Olfactory Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/neuroscience/olfactory-nerve

Rea, P. (2014). Clinical Anatomy of the Cranial Nerves. Cambridge, MA: Academic Press.

Trigeminal Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/trigeminal-nerve

9 Nursing Medication Errors that KILL

9 Nursing Medication Errors that KILL

Did you know that Medication errors are the 3rd leading cause of death in the United States – right behind heart disease and cancer? Med errors account for more than 250,000 US deaths every year. Medications save lives every day, but unfortunately, these same medications can also hurt our patients if given inappropriately. Now, most nursing medication errors don’t actually kill our patients, but they do increase morbidity, increase hospital admissions and length of stay, as well as decrease the quality of life of our patients. As nurses administer almost all of the medications within the hospital, this means that nurses are on the front lines and will be responsible for causing or preventing these nursing medication errors from occurring. While nurses are not the ordering physician, it takes a team of nurses, doctors, pharmacists, and patients to decrease these med errors from occurring.

1. Nitro Paste

There’s a reason that Nitropaste only seems to be good for one thing… causing headaches! I’ve found that Nitropaste doesn’t work well oftentimes due to medication errors in administration! If you’re anything like I was as a new grad – you may have been taught to squirt put a thin line of nitro-paste to the ½ inch or 1-inch mark (whichever was ordered by the physician). This usually leaves a good amount of paste leftover in the Nitrobid individual packet. What some nurses fail to realize is that this is incorrect dosing! Each individual packet of nitrobid 2% is usually preloaded (pun intended) with 1 gram or about 1 square inch of ointment. So if the provider orders ½ inch, squirt out half the packet on the application paper, or squirt the whole thing out if 1 inch is ordered.

 

Now you might be saying “OK, but underdosing of Nitropaste isn’t exactly killing my patient”. But you see – it can! Nitroglycerin is a SUPER important medication when treating acute coronary syndrome. If the patient has an acute coronary artery blockage (or similar pathology), nitroglycerin can quite literally dilate those arteries, improve blood flow around the obstruction, and can lead to saved cardiac tissue and potentially also saving a patient’s life! It is also very helpful for decreasing preload and afterload in your acute decompensated heart failure patients – so it is important to make sure the patient is receiving the correct dose!

2. Ceftriaxone and Lactated Ringer’s

Intravenous medication drips are very common within the hospital – especially IV fluids, antibiotics, and even critical drips within the ICU. Oftentimes our patients will have IV fluids running as primary, and they may also have secondary IV pushes or IV antibiotics. This really isn’t an issue with Normal Saline, as just about every drug is compatible with NSS. However, sometimes Lactated Ringer’s (LR) or another fluid is ordered instead. With LR, you want to avoid giving IV Ceftriaxone (Rocephin), as this may cause precipitates from forming which can harm the patient. This is because there is calcium within the LR, and Ceftriaxone + Calcium = bad! These precipitates can theoretically cause damage to your kidneys, lungs, or gallbladder.

 

This may not be a HUGE issue on the floors, since pharmacy often sends IV antibiotics to the floor and may caution the nurse not to run the ceftriaxone secondary to the LR. However, in the ED – they sometimes mix their own antibiotics and hang it secondary to whatever fluid is running. If this is LR – this can lead to issues as above. This is just another example of how ER nurses need to be hypervigilant about preventing medication errors like this from occurring – while simultaneously managing life-threatening emergencies of their patients.

3. Paralytic Before Sedation

Rapid Sequence Intubation (RSI) is the term used to define the methods taken to intubate a patient who is not unresponsive (yet!). Considering we’re about to stick a tube down their trachea and breathe for them – this requires sedation! To prevent the body from fighting against the intubation, this requires medication to paralyze them – a paralytic. During RSI, there is a specific sequence that must be followed.
In the ER or wherever the patient is being intubated, you must ALWAYS GIVE SEDATION BEFORE THE PARALYTIC. Why you ask? Well.. isn’t it obvious? If you paralyze someone before knocking them out – they are going to be TERRIFIED. They won’t be able to breathe or move, and will be cognizant of it… So no – this won’t kill the patient, but this nursing medication error will make the whole process much more traumatic, and the patient may remember the whole thing when they wake up.
Common IV sedatives (Induction agents) include: etomidate, midazolam, ketamine, fentanyl, propofol, thiopental
Common IV paralytics include: succinylcholine, rocuronium, vecuronium

4. IV Insulin

It doesn’t take long working as a nurse to realize how COMMON diabetes is in hospitalized patients. This is because uncontrolled diabetes eats away at basically every body system that you have. Your kidneys fail, your nerves are destroyed, your eyes go bad, and your arteries clog up! Diabetics often come in for Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycemic State (HHS), or a patient may just need IV insulin for hyperkalemia (to push the K+ back into the cells). IV insulin may be ordered for your patients with these conditions.
 
Insulin is usually given in a subcutaneous manner, so some nurses may not be used to giving it IV. Those SubQ insulin needles don’t hook up to a needleless IV system – so what do you do? Some facilities have special adapters, but honestly, the EASIEST way to do this is to draw the insulin up in your normal Subcutaneous syringe anyway. This will usually be 5-10 units. VERIFY this dose with other nurses – most facilities will require this. Then take a sterile NS flush, squirt half out, pull back on the syringe to make room, and squirt the insulin into the syringe. Essentially you’ve just diluted the insulin with ~5mL of saline. Now don’t set down the syringe – label it per facility protocol and give it to the patient the same way as any other IV push medication.
This may seem simple to some, but many nurses draw up the insulin in a regular 3mL syringe. I’ve seen nursing medication errors occur, and sometimes the patients are given up to 10x the ordered dose. This obviously leads to hypoglycemia and a need for close monitoring. Worst case – this med error can lead to death, and there have been accidental deaths due to insulin overdoses.
 
As a side note, when verifying ANY high-risk medication, make sure you look at the syringe AND the vial. I once had a nurse ask me to verify their 1mL (5,000u) subQ heparin dose. Turns out she had actually drawn up 1mL of INSULIN LISPRO! That’s 100 units! MUCH higher than most can tolerate. This med error was avoided by being diligent about verifying both the syringe amount and the vial.

5. Sound Alike – Look Alike

You may have heard about this in the news, but a nurse in Tennessee had accidentally killed a patient when she administered VECURONIUM instead of VERSED. This was apparently ordered to calm the patient down at MRI, so the nurse grabbed it out of the accu-dose, had overridden the medication, and administered the paralytic to the patient at CT. Now – there are MANY nursing errors in this scenario, so let’s talk about them.

Overriding the Accudose system

This is usually a major no-no on the floors, but I can tell you from firsthand experience, working in the ED, it is often done for many medications like Pain meds, Zofran, etc. In the ED, they don’t always have the luxury of waiting for the pharmacy to verify medications, and some systems won’t even have the pharmacist verify ED physician orders. If you absolutely HAVE to override, make sure you are hypervigilant about which medication you are pulling out, reconstituting, etc. If you are unsure of a medication – ASK for help! You shouldn’t be giving a medication that you don’t know about anyway. Always know the intended use, appropriate dosing, and potential side effects to monitor for! There are many sound-alike-look-alike drugs, and it can be common to make these nursing med errors if you aren’t careful!

Appropriate Monitoring

Monitoring the patient is an essential aspect of appropriate nursing management. As nurses, you are at the bedside and will be the first ones to notice a change in a patient’s status. Monitoring is especially important after the administration of ANY IV medication, but especially high-risk meds like IV narcotics or sedatives. The nurse, in this case, was going to give IV versed to a patient at MRI. This patient was NOT hooked up to the monitor, the nurse had injected the medication and reportedly left back to the ER. If you are giving IV versed, you should always have your patient on a monitor – at the least a pulse ox machine. Because she had given VECURONIUM instead of versed, her patient was paralyzed and couldn’t breathe – causing her suffocation in the MRI machine. Appropriate monitoring of the patient, even after administering the wrong medication, would have saved their life.

6. IV Haldol

Speaking of monitoring, it is also necessary to have cardiac monitor during and after administration of certain medications. This is because some medications can cause arrhythmias, and you want to be able to immediately identify them and recognize the need for rapid action.

 

Haldol is a medication that I often see being administered IV due to agitation or dementia. Unfortunately, this medication is high-risk for cardiac arrhythmias by increasing QT, predisposing the patient to PVCs, VTACH, Torsades, and even VFIB. It also is worth noting that Haldol is technically to be avoided in cases of dementia-related agitation due to an increased risk of sudden death. While our options are limited and Haldol may still need to be given, appropriate measures including cardiac monitoring should be used – at least when given IV.

7. IV Push Not IV Slam

Giving IV push medications is commonplace within the hospital. Usually, these are medications like Zofran, IV narcotics, Toradol, and Lasix (among many others). Nurses can be busy, so this can tempt us to quickly give the medication and move on to the next task. However, sometimes medications that are given too fast can cause unpleasant side effects for the patient, some even disastrous.

Dilaudid

Dilaudid (hydromorphone) is a common IV narcotic given for pain. This is the “heavy hitter” that providers can order for pain, and is approximately 7 times stronger than morphine. Ideally, Dilaudid should be given over 2-3 minutes, as administering Dilaudid more rapidly has been associated with increased side effects, specifically respiratory depression and hypotension. This is true for other IV narcotics as well (morphine and fentanyl). As a quick tip, many nurses will dilute the Dilaudid in a 50ml bag and run it over 15 minutes. Just be aware that a small amount of this medication will be wasted within the tubing itself.

Reglan

IV Reglan (metoclopramide) can be given IVP in doses ≤ 10mg undiluted over 1-2 minutes. If pushed too fast, this can cause an intense but short-lived feeling of anxiety and restlessness, followed by a period of drowsiness. A small dose of Benadryl is often ordered to treat the restlessness, but note this will increase the drowsiness experienced afterward. Be on the lookout for true dystonic reactions, characterized by involuntary contractions of the muscle of the body.

Cardiac Meds

Cardiac medications like Lopressor (metoprolol) and Cardizem (diltiazem) should be pushed slowly in order to prevent adverse events from occurring. Typically these include bradycardia and/or hypotension. Lopressor should be pushed over 2-5 minutes and Cardizem over 2 minutes.

Dexamethasone

Doses 4-10mg are often given undiluted over <1 minute. However, rapid administration is associated with perineal irritation. Patients will tell you “my crotch is on fire!”. This can even happen with slow administration, so warn the patient that this is a possible side effect, is short-lived, and will go away on its own. Its recommended to dilute it in a 50ml bag and run it over 5-15 minutes to minimize this occurrence.

8. Proper IM Location

OK – so not quite a medication error, but hear me out. When I was a nurse I was taught to inject most IM medications >1mL in the butt. However, where I was injecting in the butt wasn’t really specified. Many nurses just shoot for the middle of the buttock (dorsogluteal), but this can actually cause all sorts of injury to the patient. This can lead to skin and tissue trauma, muscle fibrosis and contracture, hematoma, nerve palsy, paralysis, and infection. Instead, these medications should be given in the ventrogluteal site (google it!).

The Deltoid muscle is an easy location for all injections 1-2mL in most adults. However, even 1 mL can be very painful in the deltoid depending on the patient. This is also not a recommended site if giving repeat injections, as the surface area of the muscle is not very high.

An important fact to know about intramuscular injections is that the vastus lateralis (the side of the thigh) actually offers the quickest absorption. This means that if you have a patient come in for a severe anaphylactic reaction – your best bet is to inject the epinephrine in the thigh as opposed to the arm.

9. Broad Before Narrow

Again – not really a medication error, but more of a nursing administration error. Antibiotics are given ALL the time within the hospital. Many times, patients are septic and need immediate treatment including multiple IV antibiotics. Some antibiotics have a very broad spectrum – meaning they kill all sorts of bacteria. Others have a narrow spectrum, meaning they kill fewer bugs. You always want to make sure to hang the broad-spectrum antibiotic first. This ensures that the antibiotic most-likely to help will be given first.

One common mistake is nurses think Vancomycin is broad-spectrum because it is a “heavy hitter”, but Vancomycin is actually narrow! Vancomycin only covers gram-positive organisms! This means unless the bacteria is actually MRSA or another Gram-positive infection, Vancomycin is less likely to help. PLUS it takes a while to infuse anyway. The best decision in sepsis is to hang the broad-spectrum antibiotic first. Common examples of broad-spectrum antibiotics include:

  • Ceftriaxone (Rocephin)
  • Cefepime
  • Pipericillin-Tazobactam (Zosyn)
  • Imipenem
  • Ampicillin

And there you have it! With great power comes great responsibility. Nurses are responsible for administering life-saving medications, but these medications can also hurt if given inappropriately. We must be vigilant in avoiding nursing medication errors and improve our patient-outcomes.

Do you have any other nursing medication errors to avoid? Let me know in the comments below!

5 Questions to Ask Before Calling the Doctor

5 Questions to Ask Before Calling the Doctor

Communication is an essential element in coordinating patient care in every clinical setting. Communication within the hospital is especially important due to the fact that there are often critical patients, and a patient’s status can change at any second. In order to convey this change of status accurately and provide the patient with the best care possible, it is imperative for the nurse and the provider to have great communication.

As a nurse, sometimes it can be difficult to know just what your patient needs. When you don’t know – it can be nerve-wracking trying to decide your next action. Do you call the doctor immediately, do you just ignore it and hope for the best, or do you have to call an RRT?

When you’re unsure – it’s common to call the doctor or provider because that is a frequent solution as they often know what to do. However, not every patient issue needs to be called to the provider. Decreasing these unnecessary calls can increase your efficiency and problem-solving skills, but additionally will allow the providers to be more efficient as well. To help you with the decision-making process – these are 5 questions to ask yourself before you call the doctor.

1. Is the Patient Stable?

Learning to be a great nurse involves learning how to prioritize. Whenever there is a change in patient status or a reason to call the provider, always ask yourself – “Is the patient stable?”. This will oftentimes seem obvious but calling a Rapid Response can be nerve-wracking. What if you call one and everyone thinks you’re dumb because it wasn’t necessary? This is a common worry as a new graduate RN. As you gain experience in nursing – you will be able to more easily be able to identify the need for an RRT when it presents itself. However, in order to assess your patient’s stability – you really must do two things first (in this order!):

Physical Assessment

You must lay eyes on your patient. Let me repeat that – YOU MUST LAY EYES ON YOUR PATIENT. You may not even need to touch the patient and already acknowledge the need for immediate emergent intervention. If they are unresponsive and not breathing and/or don’t have a pulse – you can immediately activate an emergency response (CODE BLUE). However, it won’t always be so black and white – so the next step is to assess their vital signs.

Vital Signs

Obtaining a new set of vital signs is imperative in order to assess the stability of a patient. “Is the patient stable” really just means “are their vital signs stable”. A patient who doesn’t have a pulse has a HR of 0 – so you don’t need to grab the Dynamap and grab a full set of vitals (spoiler – they won’t have any!). But it’s usually less clear. The patient may have increased lethargy, increased SOB (but not in acute respiratory failure), new chest pain, or any other changes of status. Getting these patient’s vital signs will determine whether or not they are stable. A patient who is SOB, in the tripod position, has an SPO2 of 80% on 4L NC, and RR of 48 – this patient needs an RRT or whatever emergency response team activated immediately. A patient with COPD who is moderately SOB, is 88% on 2L NC, and RR of 28 and mildly labored – this patient can likely be handled over the phone with changes in respiratory treatments and oxygen therapy.

If the patient has been deemed stable – you can move onto the next question.

Related content:

2. Is there more information I need to know first?

This will obviously depend on the situation and will require some investigation. If the patient is SOB – what is their history? Do they have any related diseases such as Asthma, COPD, or CHF? If they have back pain – have they had this before? What do they usually take for it? It’s possible the same complaint or situation may have happened earlier in their hospital stay – what was done about it and how did the patient respond?

Investigating trends in their labs or vital signs is also important. If a patient’s blood pressure is 180/90 – what has their BP been running? The same holds true for hypotension. A patient whose BP is 90/40 but who’s baseline is 90s/40s is important to know. If you get a call for an elevated troponin or lactic acid level – what were their previous levels? Note all of this information for when you have to call the provider – so you can anticipate what they will ask and assist them in making the appropriate clinical decision.

The next important step is to check the orders that already exist.

3. Are there any PRN orders?

Many times patient’s will have “PRNs” or medications “as needed” that are already ordered by the provider. This means they have a medication or order which can be used for pre-established reasons that the provider must list. Look at their MAR and see if they have any PRN medications.

Some frequent PRN medications are as follows:

  • Melatonin 3-9mg PRN for sleeping difficulty
  • Acetaminophen 650mg Q4H PRN for Fever > 101.4 F
  • Ondansetron 4mg IV PRN for nausea or vomiting
  • Morphine 2mg IV Q4H PRN for severe pain
  • Hydromorphone 0.5mg IV Q4H PRN for severe pain
  • Ketorolac 15mg IV Q6H PRN for moderate pain
  • Hydralazine 10mg IV Q6H PRN for SBP >160
  • Ipratropium-Albuterol Inhl Q4H PRN for SOB or wheezing

Other Frequent PRN orders include:

  • Oxygen via NC PRN – titrate SPO2 > 94%
  • Heating pad PRN for back pain
  • The patient may shower PRN

No matter the PRN order – it is your job as the nurse to look for which PRNs are available to you, and if you can utilize them accordingly. If your patient above who is mildly SOB and wheezing with a history of COPD – give them one of their Duonebs if it is appropriate. If they just received a treatment and still have not improved – then calling the provider is likely necessary.

Also check out my Nursing Medical Abbreviations graphic!

4. Can I phone a friend?

Sometimes we may not know what to do with our patients, but we may also be unsure if we need to call the doctor for it. Asking a fellow nurse’s opinion on what needs to be done for your patient can improve your problem-solving and clinical judgment. Your nursing colleagues, especially those with more experience or even just more skill in a particular area – may be the perfect person to ask of their nursing opinion. Do they feel like its necessary to call the doctor – or is there a nursing intervention that can be tried first instead? Are you unsure of what EKG rhythm you are reading and think you might see a run of VTACH but aren’t sure – ask a nurse who is good at rhythm interpretation.

Now I am NOT saying that asking a fellow nurse is a replacement for calling the provider. However, sometimes bouncing ideas off of our colleagues can save us from having to make an unnecessary call. Even calling the nursing supervisor may be a resource which you can utilize if appropriate. However – for a new significant change in patient status or vital signs – the provider will need to be called regardless.

5. Am I calling the right person?

OK – so you know that you’ve exhausted your other options, you have the background information you need… now you just need to actually call the provider. But make sure you are calling the right provider. First – check to see who the attending physician is on record. Is there an in-house medical team such as a hospitalist group, house coverage, or medical resident team that covers that attending? If not – you may need to reach out directly to the attending physician’s service to speak with whoever is on call. This will be facility-specific, so you may not always know if you are new. This is where asking your colleagues for assistance can benefit you.

Reaching out to the medical team (listed above) is common and usually, they can help! However, sometimes they are not the right person to be notified in certain instances. Are there any specialists on board? If Infectious Disease is seeing a patient and there is a positive blood culture – it would be better to put a call out to them instead. If a patient who is on dialysis has uncontrolled high BP, placing a call to nephrology would be a better choice as well. You can reach out to the general medical team – but don’t be surprised if they ask you to place another call to the specialists instead.

Now you are fully prepared to make the phone call and accurately communicate what is going on with your patient, you will have investigated the background information, you will have obtained vital signs and done a quick assessment, and you will have recommendations for medications or orders at the ready (thanks to the other nurses you’ve asked!). As you can see – this perfectly sets you up to provide a great phone report to the provider! To learn more about giving a great phone report to a provider and steps to calling the doctor – you can read all about it here!

Calling the doctor doesn’t have to be scary. If you critically think your way through these important steps, and utilize my IMSBAR communication style – you WILL succeed and you will be amazed at how far a little preparation can go.

You may also want to read:

Tips for New Nurse Practitioners

Tips for New Nurse Practitioners

*This post contains affiliate links. Please see my affiliate disclosure for more information*

While I’m no expert NP, I do know what its like to be a new one! After all – that was just a little over a year ago! Being so fresh in my mind – I have some valuable tips to share with new NPs or NPs to be. No matter what setting you start in, utilize the resources you have available to you, work your butt off, and constantly be open to learning – and you will succeed! But to help you on your journey – here are 6 of my best tips for clinical practice!

1. Use UpToDate Religiously

If you haven’t heard of UpToDate – I don’t know how you made it through NP school! This medical reference database is the GOLD STANDARD of medical information for Providers. While I’m working, I often use this to quickly reference drug dosing information and renal dosing considerations. On the spot, the algorithms are SUPER useful. You can just scroll down to the bottom, check out the algorithm section, and viola – suddenly you know just what to do for your patient with hyponatremia of unknown etiology. No but really – there is SO much useful information. If you have a bit more time on your hands – you can read through articles more in-depth related to literally whatever medical topic that is relevant to your clinical practice. Keep a list throughout the day of symptoms and diagnosis that you don’t feel 100% comfortable with, and make a habit of reading up on those topics on UpToDate at the end of the day.

Unfortunately, UpToDate is expensive, but most hospitals provide free access for it’s providers. If you create an account, you just have to login once every 3 months on the hospital’s network to maintain access – and you can download the easy-to-use app for your smartphone.

There are other reference apps out there – but UpToDate is by far my favorite and the gold standard. Check out my top 5 medical reference apps for more information!

2. Templates, Templates, Templates

When you’re a new NP – you are going to be overwhelmed – especially in a new hospital or office environment. You are going to forget to ask basic questions to the patients, and you are going to feel dumb plenty of times. You likely won’t have the most confidence when conducting you’re history and physical. That’s why templates are SUPER important in being your back-up. Find templates such as History/Physical or SOAP note templates, and use them with every patient. This will ensure that you don’t forget to ask about surgical history, family history, smoking status, even something as easy as allergies. If you can’t find a template that works for you – make one yourself! Get a system down, write down information in the same place when you’re doing your chart reviews, and this will help you know where to always find the information you need on your patient – especially in high-stress situations.

Since working as an inpatient hospitalist NP, I’ve been using the same H&P template since I started. I’ve made some small tweaks along the way, but this ensures I don’t forget to ask about anything important, and I always know where to look for the information on my patient. (You can get access to my templates here)

3. Master Verbal Report

As an NP – you will be communicating with physicians and other colleagues much more frequently, and mastering verbal report is essential. Sure – you might have been a nurse for years and know how to give a good NURSING report, but NP-to-Physician report is much different. Physicians are trained specifically to give and get report in a certain way, and unfortunately they can get a bit… testy if we take too long to get to the point or leave out crucial information. The idea it to be concise, but also include the relevant clinical information.

In general – start with their Age, Sex, relevant PMHx, Admission diagnosis, relevant findings, physical assessment, and any recommendations.

Since I work in the hospital, an example of this would be the following:

“86yo Female with a PMHx of HTN, HLD, T2DM, and COPD presenting with cellulitis of right lower extremity calcaneal wound. Initial XR does not indicate Osteomyelitis, MRI is pending, WBC  13, Lactic normal, Blood cultures pending. Patient was started on Zosyn and and vancomycin in the ED.”

After you present the initial basic information, you can specify exactly why you are calling and tailor it to their specific specialty – so obviously if you are calling a nephrologist you would focus on their renal function, blood pressure, electrolytes – etc.

I’m planning on doing a more detailed blog about presenting a patient to another provider whether or as NP or as an RN, so be on the lookout next week!

4. When in Doubt – Cheat!

When I began as a new NP in the hospital setting, I brainstormed the top 20 common diagnosis in my specific specialty. I sat down and made cheat sheets for each diagnosis including information on the etiology, pathophysiology, clinical manifestations, diagnostic findings, and clinical management. You can use textbooks and online resources to find uptodate information – as I said before I recommend UpToDate!

Making these cheat sheets can really help you narrow down specific need-to-know information for your exact clinical role. Making them yourself can help you retain the information. However, if you can’t find the time, the following books have some pretty solid cheat sheets:

These cheat sheets are going to help you look up relevant need-to-know information on the spot while you are at work. Personally, my sheets that I made on Acute kidney injury and hyponatremia have been especially handy in the inpatient setting.

5. Follow the Paper Trail

Whether you work inpatient or outpatient, there will be specialist consultation notes for you to read. You can learn a TON from these notes. These guys are literally specialists, and if you’re a generalist –  you’re kind of the jack of all trades and the master of none. Simply following the paper trail and reading up on your patient’s after you have seen them can help expand your knowledge tremendously.

But don’t only read specialist notes. Working inpatient, theres often medical students and medical resident notes which are very detailed and provide rationale – which Attending physician’s notes often do not have. Don’t write them off simply because they are not attendings. They learn so much in school that unfortunately, we as NPs do not. Reading these notes can be invaluable!

6. Have the Right Attitude

As a new NP, you are the new kid on the block. You need to be humble, ready to learn, confident in yourself but willingly admit when you don’t know. Trust your insticts, but check your ego at the door. We are dealing with patient’s lives here and nothing is more important than hard work, communication, and collaboration with our patients and our knowledgeable colleagues.

There are so many more tips to help new NPs, but I wanted to keep this list short and practical – things that will help you succeed in the clinical setting.

Something that I know will help you guys out as new NPs is signing up for my email list and getting access to my free NP resource library! You’ll be sent a folder with my templates for History and physicals (both inpatient and outpatient), Soap notes, and pronouncement notes. I plan on adding more useful information as time passes, so be sure to check back often!

10 Clinical Calculators for Inpatient Providers

10 Clinical Calculators for Inpatient Providers

Working in a hospital as a provider can be unexpected and stressful. There are so many factors to consider when managing a patient’s acute and chronic diseases. Luckily, there has been a great amount of research involving management of patients within the hospital. There are many different systems and calculations which can help with risk stratification, prevention, diagnosis, and management. These inpatient clinical calculators are sure to be useful to you during your shift in the hospital!

1

Padua Predictive Score for Risk of VTE

Inpatient medicine constantly involves predicting, preventing, diagnosing, and treating blood clots. Venous Thromboembolism (VTE) is the general term used to describe blood clots (thrombi) in the body which may have moved (embolized) to the lungs (pulmonary embolism).

VTE are an important cause of morbidity and mortality – especially with patient’s who have many comorbidities. Approximately 900,000 patients in the US are affected by VTE each year, and 60,000-100,00 American’s die. The first symptom of a PE is sudden cardiac death in 25% of people! You can see why it is SO important to prevent this from occurring within the hospital. Those admitted to the hospital are at higher risk for developing health-care associated VTE due to decreased mobility and recent surgery and/or procedures.

The Padua Predictive Score is a useful tool which separates patients into high and low risk groups for developing VTE. Those who score < 4 points are considered low-risk, and those >/= 4 are considered high risk. This calculator takes into account 11 factors which increase risk for VTE including age, mobility, history of cancer, heart disease, or respiratory disease, obesity, among others. If scores less than 4, consider non-pharmacologic measures such as SCDs or early ambulation. With scores greater than 4, pharmacologic measures are indicated including unfractionated heparin (UFH) or Lovenox (Enoxaparin).

Check out the Calculator!

2

Wells’ Criteria for DVT

The Wells’ criteria score system is a method to quantify the diagnostic probability for a patient presenting with a DVT/PE, however the calculators are different depending on which you are assessing for.

The Wells’ score for DVT involves specific risk factors for developing a DVT including the presence of symptoms such as calf/leg edema, recent immobility or surgery, leg tenderness, etc. The modified Wells’ score factors in a previous history of DVT.

Low Probability

Scores of 0 or less have a low-probability of needing further workout to rule out a DVT.

Moderate Probability

Scores of 1-2 points have a moderate probability and should get a high-sensitive D-dimer result. If <500 ng/ml, this effectively rules out a DVT. However, since the D-dimer test is nonspecific, a score >500 ng/ml warrants further investigation (i.e. a venous duplex).

High Probability

Scores of 3-8 have a high probability of a DVT and should get a venous duplex to rule out a clot regardless.

https://www.mdcalc.com/wells-criteria-dvt

3

Wells’ Criteria for PE

Just like the Wells’ score for DVT, there is a calculator for the pretest probability of a PE. The calculator assesses for PE risk factors including s/s of DVT, clinical suspicion of PE, HR >100, immobility/recent surgery, previous VTE, the presence of hemoptysis, and malignancy.

Low Probability

Scores <2 indicate a low probability of a PE. However, if s/s of PE are present (pleuritic chest pain, SOB, tachycardia, etc) then clinicians are encourages to use the PERC rule. The PERC rule is a list of 8 criteria which effectively rule out a PE in those with low-probability of having a PE. The patient must meet all of the following criteria:

  • Age < 50 years
  • Heart rate < 100 bpm
  • Oxyhemoglobin saturation ≥ 95% on RA
  • No hymoptysis
  • No estrogen use
  • No prior DVT/PE
  • No unilateral leg swelling
  • No surgery/trauma requiring hospitalization within the prior 4 weeks

If the patient meets any of the above, a D-dimer should be performed. In those already admitted to the hospital or critically ill patients, a D-dimer should be obtained regardless. As above, levels < 500 ng/ml do not require further workup, but levels > 500 ng/ml need further workup (i.e. CT Pulmonary Angiography).

Moderate Probability

Scores 2-6 indicate moderate probability for having a PE. This is handled with a high-sensitivity D-dimer score as above – the PERC rule is not used. If less than the cut-off, PE is ruled out. Otherwise, further testing must be performed.

High Probability

Scores >6 indicate high probability for having a PE. Those with high-risk should NOT have a D-dimer level checked. Instead, they should have diagnostic imaging to rule out PE regardless. The preferred test is a CTPA, but if this cannot be obtained than a V/Q scan should be ordered.

https://www.mdcalc.com/wells-criteria-pulmonary-embolism

4

CHA₂DS₂-VASc Score for AFIB Stroke Risk

Some medical conditions predispose patients to blood clot formation. One of those conditions is Atrial fibrillation, which increases the chance of clot formation within the atria of the heart. Clots formed in the right atria may embolize to the lungs, and clots formed in the left atria may embolize to the brain and cause a embolic stroke.

The CHA₂DS₂-VASc Score is a scoring system which helps clinicians to determine the need for oral anticoagulation to prevent clot formation and subsequent embolization. The score includes their age, sex, and their medical history including CHF, HTN, CVA, VTE, Vascular dz, or Diabetes.

Low Risk

Scores of 0 indicate a low-risk for stroke in those with Afib. No oral anticoagulation is recommended. Sometimes these patients are placed on low-dose aspirin.

Low-Moderate Risk

Scores of 1 indicate a low-moderate risk of stroke in those with Afib. In this category, clinical judgement must be used. If you are a generalist, remember that cardiology will often be the one to make this decision. Many choose not to anticoagulate those who’s only score is that they are a woman.

Moderate-High Risk

Scores ≥ 2 points indicate a moderate-high risk of stroke in those with Afib. Anticoagulation in this group is highly recommended. All studies have shown the benefit of anticoagulation significantly exceeds the risk for almost all patients with afib and a score ≥ 2. Typically the cardiologists specialists will be determining which anticoagulation that will be used.

https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism

5

HAS-BLED Score for Major Bleeding Risk

HAS-BLED is a system which scores the risk for major bleeding for those with Afib who are on oral anticoagulation. The system is scored by the following:

  • Hypertension – 1 point
  • Abnormal renal and/or hepatic function – 1 point each
  • Stroke – 1 point
  • Bleeding tendency/predisposition – 1 point
  • Labile INR on warfarin – 1 point
  • Elderly (age >65) – 1 point
  • Drugs (asa or NSAIDs) and/or alcohol – 1 point each

https://www.mdcalc.com/has-bled-score-major-bleeding-risk

Results are not separated into probability categories. Instead, clinical judgement must weight the benefits vs risks. However, the following risk can be estimated:

  • 0 points – 1.13 bleeds per 100 patient-years
  • 1 point – 1.02 bleeds per 100 patient-years
  • 2 points – 1.88 bleeds per 100 patient-years
  • 3 points – 3.74 bleeds per 100 patient-years
  • 4 points – 8.70 bleeds per 100 patient-years
  • 5-9 points – insufficient data (but high risk)

Remember this decision should be made with specialty consultation to cardiology.

6

Serum Osmolality

Other than blood clots and anticoagulation, inpatient providers often have to manage electrolyte abnormalities. One important electrolyte which often is low is sodium – called hyponatremia. The treatment of hyponatremia depends on the etiology. In order to determine the cause, an important calculation is the serum osmolality.

The calculator uses the serum sodium, BUN, Glucose, and ETOH to estimate the osmolality.

HypoOsmolar

Calculated osmolality <275 mOsm/kg is considered hypoosmolar (and usually hypotonic). This is the most common type of hyponatremia and fluid status must then be considered to determine etiology:

Euvolemic

Often caused by SIADH (from many causes) or thiazide diuretics.

Hypovolemic

Often caused by decreased PO intake, diuretics, GI losses, 3rd spacing, or adrenal insufficiency. This is treated with careful fluid resuscitation as replacing sodium too quickly can lead to deleterious effects such as osmotic demyelination syndrome (previously referred to as central pontine myelinosis).

Hypervolemic

Often caused by heart failure, liver cirrhosis, nephrotic syndrome, and severe AKI/CKD. Treatment in this case involves restricting water, loop diuretics (i.e. IV Lasix), and sometimes medications.

IsoOsmolar

Calculated osmolality 275-290 mOsm/kg is considered IsoOsmolar (and usually isotonic). This used to be caused by lab errors secondary to high lipid or protein levels.  However, Ion-specific electrodes are now used in the lab, so this error does not really happen anymore.

HyperOsmolar

Calculated osmolality >290 mOsm/kg is considered hyperOsmolary (and usually hypertonic). This is usually caused from solutes which cause osmotoic shifts of water out of cells into the extracellular fluid (i.e. glucose, mannitol, sorbitol, etc).

https://www.mdcalc.com/serum-osmolality-osmolarity

7

Sodium Correction for Hyperglycemia

Due to the osmotic shifts caused by hyperglycemia, hyponatremia should be corrected when glucose levels are elevated. The serum sodium concentration will fall by ~2. mEq/L for every 100 mg/dL of glucose elevation. For example, if the blood sugar is 400 and the sodium level is 124, the corrected sodium level is ~130 mEq/L. But you don’t have to do math, just use the calculator! It’s recommended to base your treatment plan on the calculated sodium level, as once the glucose is corrected the osmotic shifts will resolve.

https://www.mdcalc.com/sodium-correction-hyperglycemia

8

Fractional Excretion of Sodium (FENa)

The Fractional Excretion of Sodium (FENa) is calculated to determine the cause of acute kidney injury (AKI), and is a useful tool that many nephrologists utilize. This can help determine the difference between prerenal AKI from Acute tubular necrosis (ATN). This is calculated from the serum sodium creatinine, and the urine sodium and creatinine.

FENa levels < 1% generally indicate prerenal disease (i.e. decreased bloodflow to kidneys). Levels >2% usually indicates ATN. Levels between 1-2% can indicate both.

Remember that the FENa will not be accurate if the patient is on a diuretic. In general FENa is utilized by Nephrology, but can be useful to calculate if the etiology is unclear.

https://www.mdcalc.com/fractional-excretion-sodium-fena

9

Fractional Excretion of Urea (FEUrea)

The Fractional Excretion of Urea (FEUrea) can be used to differentiate between prerenal AKI and ATN in patients who are on diuretics as FENa will not be accurate. Levels 50-65% generally indicate ATN , and levels <35% indicate prerenal disease.

Again, many factors can determine these tests and they should be interpreted with the consultation of specialists (nephrologists).

https://www.mdcalc.com/fractional-excretion-urea-feurea

10

    Calcium Correction for Hypoalbuminemia

Unrelated to sodium and fluid status, calcium levels can be falsely altered in the presence of hypoalbuminemia. Calcium ions have two forms – ionized and protein-bound. About 40% of calcium in the blood is bound to protein (i.e. albumin), and about 50% circulates as free ionized calcium. The ionized calcium is what is truly clinically significant because this is what is physiologically active. If a patient is symptomatic from hypocalcemia – their ionized calcium will be low.

Since almost half of the calcium in the bloodstream attached to albumin, abnormal albumin levels will affect serum calcium levels. To correct this, you need to know the patients serum calcium and their albumin level. The calculator will give you a good idea of what their corrected calcium level actually is. So if you see a malnourished patient with an Albumin of 2.0 and a serum calcium of 7.0, the corrected calcium is 8.6 mg/dl.

This is not an exact science and many factors (i.e. acid-base disturbance) will alter calcium binding to protein and may cause ionized calcium levels to fluctuate. This is why most clinicians will order an ionized calcium level when serum calcium levels are significantly low (even in the presence of low albumin).

https://www.mdcalc.com/calcium-correction-hypoalbuminemia

1

Padua Predictive Score for Risk of VTE

Inpatient medicine constantly involves predicting, preventing, diagnosing, and treating blood clots. Venous Thromboembolism (VTE) is the general term used to describe blood clots (thrombi) in the body which may have moved (embolized) to the lungs (pulmonary embolism).

VTE are an important cause of morbidity and mortality – especially with patient’s who have many comorbidities. Approximately 900,000 patients in the US are affected by VTE each year, and of those 60,000-100,00 die. The first symptom of a PE is sudden cardiac death in 25% of people! You can see why it is SO important to prevent this from occurring within the hospital. Those admitted to the hospital are at higher risk for developing health-care associated VTE due to decreased mobility and recent surgery and/or procedures.

The Padua Predictive Score is a useful tool which separates patients into high and low risk groups for developing VTE. Those who score < 4 points are considered low-risk, and those ≥ 4 are considered high risk. This calculator takes into account 11 factors which increase risk for VTE including age, mobility, history of cancer, heart disease, or respiratory disease, obesity, among others. If scores less than 4, consider non-pharmacologic measures such as SCDs or early ambulation. With scores 4 or greater, pharmacologic measures are indicated including unfractionated heparin (UFH) or Lovenox (Enoxaparin).

2

Wells’ Criteria for DVT

The Wells’ criteria score system is a method to quantify the diagnostic probability for a patient presenting with a DVT/PE, however the calculators are different depending on which you are assessing for.

The Wells’ score for DVT involves specific risk factors for developing a DVT including the presence of symptoms such as calf/leg edema, recent immobility or surgery, leg tenderness, etc. The modified Wells’ score factors in a previous history of DVT, as these patients are more likely to develop another one.

Low Probability

Scores of 0 or less have a low-probability of DVT, and thus usually do not warrant further workup to rule out a DVT.

Moderate Probability

Scores of 1-2 points have a moderate probability and should get a high-sensitive D-dimer. If <500 ng/ml, this effectively rules out a DVT. However, since the D-dimer test is nonspecific, a score >500 ng/ml warrants further investigation (i.e. a venous duplex).

High Probability

Scores of 3-8 have a high probability of a DVT and should get a venous duplex to rule out a clot regardless. This means that a D-dimer test is not indicated since a Venous Duplex will be obtained regardless.

3

Wells’ Criteria for PE

Just like the Wells’ score for DVT, there is a calculator for the pretest probability of a PE. This calculator assesses for PE risk factors including s/s of DVT, clinical suspicion of PE, HR >100, immobility/recent surgery, previous VTE, the presence of hemoptysis, or malignancy.

Low Probability

Scores <2 indicate a low probability of a PE. However, if s/s of PE are present (pleuritic chest pain, SOB, tachycardia, etc) then clinicians are encourages to use the PERC rule. The PERC rule is a list of 8 criteria which effectively rules out a PE in those with low-probability of having a PE. The patient must meet all of the following criteria:

  • Age < 50 years
  • Heart rate < 100 bpm
  • Oxyhemoglobin saturation ≥ 95% on RA
  • No hymoptysis
  • No estrogen use
  • No prior DVT/PE
  • No unilateral leg swelling
  • No surgery/trauma requiring hospitalization within the prior 4 weeks

If the patient meets any of the above, a D-dimer should be performed. In those already admitted to the hospital or critically ill patients, a D-dimer should be obtained regardless. As above, levels < 500 ng/ml do not require further workup, but levels > 500 ng/ml do (i.e. CT Pulmonary Angiography).

Moderate Probability

Scores 2-6 indicate moderate probability for having a PE. This is handled with a high-sensitivity D-dimer score as above – the PERC rule is not used. If less than the cut-off, PE is ruled out. Otherwise, further testing must be performed.

High Probability

Scores >6 indicate high probability for having a PE. Those with high-risk should NOT have a D-dimer level checked. Instead, they should have diagnostic imaging to rule out PE regardless. The preferred test is a CT Pulmonary Angiography (CTPA) – but if this cannot be obtained, a V/Q scan should be ordered.

4

CHA₂DS₂-VASc Score for AFIB Stroke Risk

Some medical conditions predispose patients to blood clot formation. One of those conditions is Atrial fibrillation, which increases the chance of clot formation within the atria of the heart. Clots formed in the right atria may embolize to the lungs and cause a pulmonary embolism, and clots formed in the left atria may embolize to the brain and cause an embolic stroke.

The CHA₂DS₂-VASc Score is a scoring system which helps clinicians to determine the need for oral anticoagulation to prevent clot formation and subsequent embolization. The score includes their age, sex, and their medical history including CHF, HTN, CVA, VTE, Vascular dz, or Diabetes.

Low Risk

Scores of 0 indicate a low-risk for stroke in those with Afib. No oral anticoagulation is recommended. Sometimes these patients are placed on low-dose aspirin.

Low-Moderate Risk

Scores of 1 indicate a low-moderate risk of stroke in those with Afib. In this category, clinical judgement must be used. If you are a generalist, remember that cardiology will often be the one to make this decision. Many choose not to anticoagulate those who’s only score is that they are a woman.

Moderate-High Risk

Scores ≥ 2 points indicate a moderate-high risk of stroke in those with Afib. Anticoagulation in this group is highly recommended. All studies have shown the benefit of anticoagulation significantly exceeds the risk for almost all patients with afib and a score ≥ 2. Typically the cardiologists specialists will be determining which anticoagulation that will be used.

Remember to always take into account the patient’s risk of major bleeding (see below!)

 

5

HAS-BLED Score for Major Bleeding Risk

HAS-BLED is a system which quantifies the risk for major bleeding for those with Afib who are on oral anticoagulation. The system is scored by the following:

  • Hypertension – 1 point
  • Abnormal renal and/or hepatic function – 1 point each
  • Stroke – 1 point
  • Bleeding tendency/predisposition – 1 point
  • Labile INR on warfarin – 1 point
  • Elderly (age >65) – 1 point
  • Drugs (asa or NSAIDs) and/or alcohol – 1 point each

Results are not separated into probability categories. Instead, clinical judgement must weight the benefits vs risks. However, the following risk can be estimated:

  • 0 points – 1.13 bleeds per 100 patient-years
  • 1 point – 1.02 bleeds per 100 patient-years
  • 2 points – 1.88 bleeds per 100 patient-years
  • 3 points – 3.74 bleeds per 100 patient-years
  • 4 points – 8.70 bleeds per 100 patient-years
  • 5-9 points – insufficient data (but high risk)

Remember the decision for a patient with Afib to not be on oral anticoagulation should be made with specialty consultation.

6

Serum Osmolality

Other than blood clots and anticoagulation, inpatient providers often have to manage electrolyte abnormalities. One important electrolyte which often is low is sodium – called hyponatremia. The management of hyponatremia depends on the etiology. In order to determine the cause, an important calculation is the serum osmolality.

The calculator uses the serum sodium, BUN, Glucose, and ETOH to estimate the osmolality.

HypoOsmolar

Calculated osmolality <275 mOsm/kg is considered hypoosmolar (and usually hypotonic). This is the most common type of hyponatremia and fluid status must then be considered to determine etiology:

Euvolemic

Often caused by SIADH (from many causes) or thiazide diuretics.

Hypovolemic

Often caused by decreased PO intake, diuretics, GI losses, 3rd spacing, or adrenal insufficiency. This is treated with careful fluid resuscitation as replacing sodium too quickly can lead to deleterious effects such as osmotic demyelination syndrome (previously referred to as central pontine myelinosis).

Hypervolemic

Often caused by heart failure, liver cirrhosis, nephrotic syndrome, or severe AKI/CKD. Treatment in this case involves restricting water, administering loop diuretics (i.e. IV Lasix), and sometimes other medications.

IsoOsmolar

Calculated osmolality 275-290 mOsm/kg is considered IsoOsmolar (and usually isotonic). This used to be caused by lab errors secondary to high lipid or protein levels.  However, ion-specific electrodes are now used in the lab, so this error does not really happen anymore.

HyperOsmolar

Calculated osmolality >290 mOsm/kg is considered hyperOsmolary (and usually hypertonic). This is usually caused from solutes which cause osmotoic shifts of water out of cells into the extracellular fluid (i.e. glucose, mannitol, sorbitol, etc).

 

7

Sodium Correction for Hyperglycemia

Due to the osmotic shifts caused by hyperglycemia, hyponatremia should be corrected when glucose levels are elevated. The serum sodium concentration will fall by ~2. mEq/L for every 100 mg/dL of glucose elevation. For example, if the blood sugar is 400 and the sodium level is 124, the corrected sodium level is ~130 mEq/L. But you don’t have to do math, just use the calculator! It’s recommended to base your treatment plan on the corrected sodium level, as once the glucose is corrected the osmotic shifts will resolve.

8

Maintenance Fluid Rate

As inpatient providers, we have to order IV fluids on many patients. Maintenance fluids may need ordered if the patient is NPO, or if they have fluid losses/dehydration. In order to determine the best rate at which to run the IV fluids, there is a simple calculation. Take their weight in Kg, subtract 20 Kg and add 60mL. Then for every over Kg left, add 1mL. So a 60Kg patient gets 100ml/hr. If this is confusing – you can just use the calculator below!

Keep in mind this rate is a general estimation, and the patient’s own medical history should be taken into account. If they are fluid overloaded (i.e. CHF, Liver cirrhosis, etc), then a slower rate may be more appropriate. Always use your physical examination to guide your management. If the patient is elderly, consider slowing the rate as well. If the patient is having continuous fluid losses (i.e. diarrhea), then consider increasing the rate to 1.5x the maintenance rate – or using your best judgement.

(The calculator also lists the 20ml/kg bolus amount for sepsis patients)

9

Calcium Correction for Hypoalbuminemia

Unrelated to sodium and fluid status, calcium levels can be falsely altered in the presence of hypoalbuminemia. Calcium ions have two forms – ionized and protein-bound. About 40% of calcium in the blood is bound to protein (i.e. albumin), and about 50% circulates as free ionized calcium. The ionized calcium is what is truly clinically significant because this is what is physiologically active. If a patient is symptomatic from hypocalcemia – their ionized calcium will be low.

Since almost half of the calcium in the bloodstream attached to albumin, abnormal albumin levels will affect serum calcium levels. To correct this, you need to know the patients serum calcium and their albumin level. The calculator will give you a good idea of what their corrected calcium level actually is. So if you see a malnourished patient with an Albumin of 2.0 and a serum calcium of 7.0, the corrected calcium is 8.6 mg/dl.

This is not an exact science and many factors (i.e. acid-base disturbance) will alter calcium binding to protein and may cause ionized calcium levels to fluctuate. This is why most clinicians will order an ionized calcium level when serum calcium levels are significantly low (even in the presence of low albumin).

10

   Arterial Blood Gas (ABG) Analyzer

Arterial Blood Gases (ABGs) are commonly ordered in patients with respiratory failure in the hospital. This helps clinicians determine etiology and guides management of many respiratory conditions. If you struggle with analyzing ABGs, this calculator can help. Simply input the pH, PaCO2, Bicarb, Sodium, Chloride, and Albumin. This will help you determine whether the ABG abnormality is respiratory, metabolic, and which type with compensation (if any).

It is important for clinicians to be able to analyze blood gases on their own as well. You can read more about ABG interpretation in my ABG guide!

 

If you’re a practicing NP or NP student and need access to my free NP Resource library – sign up here! It has both inpatient and outpatient SOAP note templates, History and physical sheets, death pronouncement notes, and more to come!

References:

Barbar, S., Noventa, F., Rossetto, V., Ferrari, A., Brandolin, B., Perlati, M., … Prandoni, P. (2010). A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. Journal of Thrombosis and Haemostasis, 8(11), 2450-2457. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20738765

Bauer, K. A., & Lip, G. Y. (2019). Overview of the causes of venous thrombosis. In UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-causes-of-venous-thrombosis

Data and Statistics on Venous Thromboembolism. (2019, August 9). Retrieved August 11, 2019, from https://www.cdc.gov/ncbddd/dvt/data.html

Garcia, D. A., & Crowther, M. (2019). Risks and prevention of bleeding with oral anticoagulants. In UpToDate. Retrieved from https://www.uptodate.com/contents/risks-and-prevention-of-bleeding-with-oral-anticoagulants

Goltzman, D. (2019). Diagnostic approach to hypocalcemia. In UpToDate. Retrieved from https://www.uptodate.com/contents/diagnostic-approach-to-hypocalcemia

Higgins, C. (2007, July). Ionized calcium. Retrieved from https://acutecaretesting.org/en/articles/ionized-calcium

Hoorn, E. J., & Sterns, R. H. (2019). Causes of hyponatremia without hypotonicity (including pseudohyponatremia). In UpToDate. Retrieved from https://www.uptodate.com/contents/causes-of-hyponatremia-without-hypotonicity-including-pseudohyponatremia

Kearon, C., & Bauer, K. A. (2019). Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity. In UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-deep-vein-thrombosis-of-the-lower-extremity

Lip, G. Y. (2011). Implications of the CHA2DS2-VASc and HAS-BLED Scores for Thromboprophylaxis in Atrial Fibrillation. The American Journal of Medicine, 124(2), 111-114. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20887966

Manning, W. J., Singer, D. E., & Lip, G. Y. (2019). Atrial fibrillation: Anticoagulant therapy to prevent thromboembolism. In UpToDate. Retrieved from https://www.uptodate.com/contents/atrial-fibrillation-anticoagulant-therapy-to-prevent-thromboembolism

Sterns, R. H. (2019). Causes of hypotonic hyponatremia in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/causes-of-hypotonic-hyponatremia-in-adults

Sterns, R. H. (2019). Overview of the treatment of hyponatremia in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-treatment-of-hyponatremia-in-adults

Sterns, R. H. (2019). General principles of disorders of water balance (hyponatremia and hypernatremia) and sodium balance (hypovolemia and edema). In UpToDate. Retrieved from https://www.uptodate.com/contents/general-principles-of-disorders-of-water-balance-hyponatremia-and-hypernatremia-and-sodium-balance-hypovolemia-and-edema

Sterns, R. H. (n.d.). Diagnostic evaluation of adults with hyponatremia. In UpToDate. Retrieved from https://www.uptodate.com/contents/diagnostic-evaluation-of-adults-with-hyponatremia

Thompson, B. T., Kabrhel, C., & Pena, C. (2019). Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism. In UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism

Wells, P. S., Anderson, D. R., Bormanis, J., Guy, F., Mitchell, M., Gray, L., … Lewandowski, B. (1997). Value of assessment of pretest probability of deep-vein thrombosis in clinical management. The Lancet, 350(9094), 1795-1798. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed?term=9428249

Yu, A. S., & Stubbs, J. R. (2019). Relation between total and ionized serum calcium concentrations. In UpToDate. Retrieved from https://www.uptodate.com/contents/relation-between-total-and-ionized-serum-calcium-concentrations

Six Steps for Sepsis Management

Six Steps for Sepsis Management

Sepsis is not a specific disease but rather a clinical syndromewhich represents the body’s response to severe bacterial infection. Sepsis is very common. In fact, within the hospital, you will take care of patients with sepsis in any department. Sepsis is a very serious condition with a poor prognosis. As the medical team suspecting and treating sepsis – there are important management steps that need to be taken in order to maximize patient outcomes and save lives!

Early sepsis– while not clearly defined – is the presence of infection and bacteremia – which can and likely will progress to sepsis without intervention. Sepsis used to be identified using SIRS criteriaSystemic Inflammatory Response syndrome. This syndrome is defined as the presence of at least 2 of the following 4 clinical indicators: Fever >38C or <36C, HR >90bpm, RR > 22/min or PaCO2 <32 mmHg, or WBC >12,000/mm3, <4,000/mm3, OR 10% BANDS. Once SIRS is identified with suspected source of infection – sepsis diagnosis was met. However, the definition of sepsis has changed with 2016. Sepsis is now is defined as life-threatening organ dysfunction in response to infection. Organ dysfunction, usually from hypoperfusion, can be evidenced by hypotension, altered mental status, tachypnea, or increased sofa score by 2 points (see below).  Septic shockis defined as those patients who have received fluid resuscitation and still have a MAP <65 mmHg and a lactic >2.0 mmol/L. These patients require vasopressors and should be monitored in the ICU.

Sepsis can be very serious and even fatal. Because of this – it is important to kn ow the steps to take in sepsis management. Performing these correct steps can literally mean the difference between life and death.

1. Recognition and Early Intervention

The most important aspect of sepsis management is recognizing it’s presence and acting quickly. Common symptoms of sepsis include fever, chills, sweats, and confusion. Common signs include altered mental status, elevated temperature, tachypnea, tachycardia, and hypotension.

Initial management should include investigating the extensiveness of their infection, and applying initial measures to help them. After vital signs are taken an IV should be established and lab work drawn. If the patient’s blood pressure is low – consider starting 2 large-bore IVs. Be sure to draw at least 1 set of blood cultures per IV site (up to 2) as this will need ordered in all sepsis patients. Make sure the blood cultures get drawn before antibiotics are started.

Diagnostics should investigate the source of the infection – sometimes it is not obvious. If unsure – it is a good idea to obtain a urinalysis with culture to r/o UTI and a Chest x-ray to r/o pneumonia should be ordered. A wound culture, sputum culture, or abdominal imaging may be ordered if clinically indicated. Blood work will usually include blood cultures x 2, CBC with differential, CMP, and a lactic acid level. Sometimes in severe cases, an ABG can be ordered to evaluate acid-base status.

Lactic acid levels are very important in sepsis. Lactate is released from cells when they are forced to utilize glycolysis instead of the Kreb’s cycle (throwback to Cell Biology!). This means that there is decreased tissue perfusion due to decreased volume, increased oxygen demand, and decreased oxygen delivery. Lactic levels correlate with severity of sepsis.

Apply oxygen at 2 L/min unless contraindicated – titrate if SPO2 <92%. During sepsis, oxygen demand increases and delivery diminishes. Supplemental oxygen will help put less stress on the body and may help diminish lactic acidosis.

The qSOFA (Quick Sequential Organ Failure Assessment) score is now starting to be used as a clinical tool for sepsis. This is usually used within the hospital to stratify the mortality of patients with sepsis (see infographic for more details).

2. Fluid Resuscitation!

Fluid resuscitation during sepsis is the staple of sepsis management. Evidence shows early fluid intervention decreases mortality. There is such a massive need for fluid because during sepsis there is poor tissue perfusion and often hypovolemia. To correct this – large amounts of fluids are needed.

Typically, 0.9% normal saline is used 9 times out of 10. The recommended standard volume is a 30 ml/kg bolus. So if a patient was 70 Kg, they would receive 2100 ml total. This should be given as quickly as possible – as tolerated. This amount is typically given to anybody recognized as possibly having sepsis, but is especially indicated in those with sever sepsis, fast heart rate, or low blood pressure. Traditionally even larger amounts of fluids were given (5-6 Liters), but several randomized control trials showed no difference in mortality compared with the now-recommended 2-3 Liters.

Exceptions to receiving this bolus includes those with active pulmonary edema. Those with a history of Heart Failure, end-stage renal disease, or severe liver disease should still receive fluids. However – it is recommended to give fluids in 500mL bolus increments and to reassess lung sounds and breathing status after each bolus. If pulmonary edema ensues – the bolus should be stopped and the patient may need diuretics.

3. Timely Antibiotic Administration

Another very important aspect of sepsis management is early antibiotics. The term empiric simply means antibiotics based on the best “clinical guess”.

The choice of empiric antibiotics will be selected based off of the patient’s signs or symptoms and where the likely source – since certain organisms are more likely from one source as opposed to another. This means the antibiotic regimen should be geared towards covering all likely gram-positive and gram-negative organisms. For sepsis – usually a broad spectrum antibiotic like Zosyn or a Carbapenem is combined with another antibiotic of a different lass – such as Vancomycin. Vanco is often added when the patient has risk factors for MRSA.

Correct regimen of antibiotics are important – however timely administration of those antibiotics are just as important. Antibiotics should be initiated within the first hour after suspecting sepsis – especially during severe sepsis or septic shock. This is because several observational studies have shown poorer outcomes with delayed antibiotic initiation. Once again, try to be sure you obtain both sets of blood cultures before you start the antibiotics!

As nurses, it is often up to you to choose which antibiotic to start first as both are often ordered concurrently. If you have both Zosyn and Vancomycin ordered – start with the broad-spectrum antibiotic first. But what exactly is broad-spectrum? This means heavy-hitter antibiotics that cover most pathogens – both gram positive and negative. Contrary to popular belief – vancomycin is NOT broad-spectrum. In fact, it has a very narrow spectrum specific for gram positive organisms such as Staph or Strep. Most cases of sepsis are from gram negative sources. This means starting the Zosyn first should be your priority. Additionally – Zosyn runs much quicker as a loading dose (4.5 grams over 30 minutes) – whereas vancomycin usually runs over 1.5 hours.

4. Hemodynamic Management

Sometimes when sepsis becomes severe – distributive shock can occur. This is termed septic shock. When this occurs – hemodynamic compromise is present.  If blood pressure remains low, the patient’s tissue perfusion continues to suffer and steps need to be taken to improve outcomes.

The patient may require more fluid if they are still hypovolemic after the initial bolus and can tolerate more fluids. However, the mainstay of treatment of septic shock is intravenous Vasopressors. For the most part – Norepinephrine (Levophed) is the go-to pressor for sepsis. However, other choices can be chosen based on clinician discretion (i.e. If very tachycardic consider Vasopressin which has no beta stimulation). Sometimes, multiple vasopressors may need to run concurrently to manage septic shock.

When a patient is in septic shock with hemodynamic compromise – they should have a central venous catheter inserted and/or an arterial line. Vasopressors can be started in a peripheral line, but a central line should be ordered as vasopressors can be caustic and damaging to the peripheral vasculature. Additionally, these catheters can monitor CVP and continuous blood pressures. If a patient is in cardiogenic shock and has inadequate cardiac output – cardiac inotropes can be added such as dobutamine or epinephrine.

Sometimes during severe septic shock, IV glucocorticoids may or may not help. Usually this is ordered if fluid resuscitation and vasopressors have failed.

5. Monitoring

Monitoring is the essential last step to sepsis management. Patient’s with sepsis can respond well to the regimen – or they can decompensate unexpectedly. Sepsis has a high mortality and the patient’s should be monitored very closely.

If the patient has any hemodynamic compromise and are on pressors – they should be monitored in the ICU for a few days until they become stable. Patient’s with mild to moderate sepsis should be closely monitored on a med-surg or telemetry floor. Continuous cardiac monitoring is essential during sepsis. The increased tissue demand for oxygen places the heart at a greater risk for having cardiac events secondary to the sepsis. It is not uncommon for someone with sepsis and cardiac comorbidities to have secondary myocardial ischemia and/or infarctions.

Blood pressure should be monitored closely – especially initially. Normotensive blood pressure should be maintained (SBP >100). However – maybe even more importantly the MAP (mean arterial pressure) should be monitored closely. The goal of MAP should be >65mmHg – this ensures adequate tissue perfusion (i.e. brain). Heart rate is also an important metric to monitor. Tachycardia is usually present – often in the 120s-130s during fever and sepsis – sometimes higher. While giving fluids – heart rate should improve. This can be somewhat helpful in monitoring the response of fluid therapy. Fever should be monitored as well – as sometimes it can become very high and increases insensible water losses and further propitiates hypovolemia. Remember a rectal temperature is preferred in those with suspected sepsis – especially the elderly. Urine output is also often monitored during severe sepsis – as secondary hypoperfusion of the kidneys can cause acute kidney injury and decreased urine output.

Nursing assessments should include skin color and perfusion, mucous membranes (i.e. dry vs moist), mental status, and heart/lung sounds. Nurses should be vigilant in recognizing flash pulmonary edema or cariogenic shock which may develop after rapid administration of fluids with underlying comorbidities (i.e heart failure, ESRD, etc). 

If the initial lactic acid level is elevated > 2 mmol/L, then a repeat level should be drawn in 4 – 6 hours. The lactic acid level should respond quickly to changes in tissue perfusion. CBC should be trended each day to monitor for resolution of the leukocytosis, bandemia, and/or thrombocytopenia. Electrolytes and kidney/liver function should also be monitored closely dpeneding on which abnormalities are present.

6. Patient Disposition and Follow-Up

Last but certainly not least – the patient needs to be sent to the correct unit, needs the correct consults, and needs adequate follow-up. Almost all patients admitted to the hospital with sepsis will warrant an Infectious Disease consultation. Additionally, if they have any pre-existing comorbidities these consults should be made as well (i.e. cardiology for heart failure, nephrology for kidney disease).

Patients should have frequent nursing assessments and daily physician assessments, with close follow-up of labs. Blood cultures can start showing growth at about 24 hours. The pathologist will gram-stain the growth and give a report of “gram positive cocci” a similar description. This tells the clinician if they are on the right track and can guess at the offending organism. At about 48 hours, most clinically significant bacteria will be identified and a sensitivity is done to detect the bacteria’s sensitivity vs resistance to various antibiotics. Urine, wound, and sputum cultures have similar timelines. Antibiotics may be changed depending on the results. Remember, Infectious Disease should likely be involved in this decision.

And those are the six steps to sepsis management. Knowing the general steps to sepsis can help you as the nurse provide high quality care to your septic patients and help improve outcomes. As always, it is a collaborative team effort in offering you patients the best possible care.

Do you have any other sepsis tips? leave them in the comments below!

 

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