Vagal Maneuvers: How to Stop your Patient’s SVT

Mar 15, 2021 | 0 comments

Vagal Maneuvers: How to Stop your Patient’s SVT

Vagal maneuvers are used in the clinical setting to slow down fast heart rates – primarily for supraventricular tachycardia (SVT) and sometimes rapid atrial fibrillation (AF RVR).

There are numerous physical maneuvers that can slow down the heart rate – and there is an important modified technique which can almost triple your chances of success!

Svt and Vagal Maneuvers

Supraventricular Tachycardia (SVT) is a very rapid regularly arrhythmia caused by a reentrant loop within the heart.

Essentially – the signal goes around and around in a circuit, producing very fast heart rates.

While SVT is an umbrella term for any tachycardia originating above the ventricles of the heart, it usually is used in reference to AV Nodal Reentrant Tachycardia (AVNRT). This arrhythmia is due to a reentrant loop within/near the AV node itself.

Some patients have abnormal conduction tissue in this area, and if a premature beat comes at the wrong time – it can throw them into this very fast heart rhythm.

This condition occurs more often in younger patients, females, and can be secondary to certain triggers like exercise, stimulants, or even alcohol.

Patients will usually be symptomatic and feel palpitations, fatigue, or dizziness. They can also have chest pain, SOB, or syncope.

Remember when the heart is beating this fast, the cardiac chamber’s ability to fill is decreased, and cardiac output can suffer – leading to symptoms.

When a patient comes in with SVT, their heart rate is usually very fast, with rates often between 150-200 bpm.

We want to stop or “break” this rhythm as soon as possible, so the patient does not decompensate.

If we look at the Adult tachycardia ACLS algorithm, we can see that the first thing we do to attempt to stop the SVT in a stable patient is vagal maneuvers.

The Vagus nerve and the Heart

In order to understand vagal maneuvers, you first need to understand how the vagus nerve works.

The vagus nerve is the primary method that the parasympathetic nervous system affects the body.

This is the 10th cranial nerve which travels from your brain throughout the body. This is how the brain controls certain automatic functions.

When the vagus nerve is activated, the following effects on the body occur:

Bronchial constriction
Pupillary constriction
Increased blood flow to the stomach’
Increased digestion

Remember – “rest and digest”

Regarding the heart, the vagus nerve also has important physiological effects on the cardiac system. These include:

Slowing of the heart rate
Slowing of the conduction velocity of the AV node
Decreases the strength of contractions

As you can see, stimulation of the vagal nerve can be utilized to slow the conduction and increase the refractory period of the AV node which hopefully breaks the SVT reentrant loop, leading to conversion back to normal sinus rhythm (NSR).

There are various physical maneuvers that can stimulate the vagus nerve – and many you may do without trying. These include:

Coughing
Vomiting
Cold water immersion

Then there are certain physical maneuvers termed “vagal maneuvers” that we can perform in the hospital to intentionally cause vagal response and hopefully slow down a tachyarrhythmia such as with SVT.

These maneuvers include the Valsalva maneuver and the carotid sinus massage.

But did you know that by modifying the Valsalva maneuver – you can almost triple your chances of success?

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The Modified Valsalva Maneuver

The Valsalva maneuver is the classic vagal maneuver used to stimulate the vagus nerve and stop SVT.

This is used on patients who are stable (stable vital signs) and can follow commands.

To perform the Valsalva maneuver, the patient intentionally “bears down” or strains for 10-15 seconds.

This has a 17% success rate in converting SVT. However, by modifying the Valsalva maneuver we can almost triple this success rate!

The Modified valsalva or the positional valsalva maneuver has a significantly higher success rate of 43%!

That’s almost half of your patients with SVT who this can convert back to NSR without any additional medications or interventions.

To perform the modified Valsalva maneuver:

Have a Physician or APP at the bedside
Place the patient in a semi-recumbent position (45° Semi-fowlers)
Have the patient take a normal breath in
Have them forcefully exhale with a closed glottis (bearing down) for 15 seconds
Immediately place them supine and raise their legs to 45 degrees for 15 seconds
Return to semi-fowlers position and watch for up to 1 minute for resolution of the SVT

Clinical Tip: If the patient has trouble bearing down, you can place an empty 10-mL syringe in their mouth and have them blow hard enough to see the plunger move.

As you can see, this technique requires a few assistants, but it is clearly the better option when attempting to convert SVT with vagal maneuvers.

The Carotid Sinus Massage

The carotid sinus massage is a vagal maneuver that you can perform on someone who cannot follow commands.

The carotid sinus is an area located just below the internal carotid artery at the level of the thyroid cartilage, near the pulse.

This area is very sensitive to mechanical pressure, and mechanical pressure to this area can stimulate the vagus nerve.

To perform the carotid sinus massage:

Place the patient supine with their neck extended toward the opposite side
Ensure there is no carotid bruit with your stethoscope
Locate the carotid sinus. This is inferior to the angle of the mandible at the level of the thyroid cartilage near the pulse
Apply firm pressure for 5-10 seconds
You can repeat on the other side if needed

The carotid sinus should never be performed in the following circumstances:

Without a physician / APP at the bedside
On both sides simultaneously
In someone with TIA or stroke within the last 3 months
In someone with known carotid stenosis or active carotid bruit

Complications of Vagal Maneuvers

Any side effects from vagal maneuvers are usually short-lived and an “over-exaggeration” of expected effects.

These include sinus pauses, brief asystole, bradycardia, AV blocks and hypotension.

These will usually fix themselves within seconds to minutes.

Strokes are a major concern with the carotid sinus massage and can happen in <1% of patients.

This is why those with potential carotid stenosis or recent history of strokes should not have the carotid sinus massage.

References:

Aehlert, B. J. (2017). ECGs made easy (6th ed.). Elsevier Health Sciences.

Burns, E. (2019). Supraventricular tachycardia. In ECG Library. Retrieved from https://litfl.com/supraventricular-tachycardia-svt-ecg-library/

Frisch, D. R., Zimetbaum, P. J. (2020). Vagal maneuvers. In UpToDate. Retrieved from https://www.uptodate.com/contents/vagal-maneuvers

Grauer, K., MD. (2014). ECG Pocket Brain: Expanded Version (6th ed., pp. 65-68). Gainesville, FL: KG/EKG Press.

Knight, B. P. (2020). Atrioventricular nodal reentrant tachycardia. In UpToDate. Retrieved from https://www.uptodate.com/contents/atrioventricular-nodal-reentrant-tachycardia

Tintinalli, J. E., Brady, W. J., Laughrey, T. S., & Ghaemmaghami, C. A. (2016). Cardiac Rhythm Disturbances. In Tintinalli’s emergency medicine: A comprehensive study guide (8th ed., pp. 126). McGraw-Hill Education.

Want to Learn More?

If you want to learn more about vagal maneuvers, SVT, and every other cardiac arrhythmia – check out my ECG Rhythm online video course out now!

It’s specifically designed for nurses, and not only teaches you how to identify each arrhythmia, but also why and how they occur, and what to do about it!

If you’re not ready to take that leap yet but still want to learn more about ECG rhythms – be sure to download my free ECG Cheat Sheet below!

You may also like:

William Kelly, MSN, FNP-C( Author )

I am an ER Nurse Practitioner who creates content for bedside nurses and clinicians, making practical application of nursing education. Read more!

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5 Appendicitis Signs you Don’t Want to Miss!

Feb 10, 2021 | 0 comments

5 Appendicitis Signs you Don’t Want to Miss!

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Knowing Appendicitis signs is super important for nurses and medical professionals.

Appendicitis is the number one cause for abdominal pain needing emergent surgery. Missing appendicitis can lead to worsened outcomes including sepsis, perforation, longer hospital stays, and an increased chance of death.

The Appendix and Appendicitis Signs

The appendix is a small appendage at the beginning of the large intestine which stems off of the cecum.

The actual function of the appendix is unknown, although there are some theories that it assists with maintaining healthy gut bacteria as well as with the immune system.

The appendix can become blocked and inflamed which leads to appendicitis, which is inflammation of the appendix.This is usually blocked by a small piece of feces that occludes the appendix, termed a fecalith.

The appendix can also be blocked by stones, lymphoid tissue, infections, and even cancer.

This blocked appendix eventually develops bacterial overgrowth, ischemia, and possibly can even perforate the bowel. It can cause sepsis and severe infection.

Many cases of appendicitis happen between the ages of 10-30. While common in children, it also occurs in young adults and sometimes even older individuals.

Abdominal pain is very common, and sometimes it can be difficult to tell what is causing it because there are so many potential causes of abdominal pain.

Pain in the abdominal doesn’t always present where you would expect as well. There are specific physical exam appendicitis signs which can be used to raise the suspicion of appendicitis.

Appendicitis Symptoms

A patient who presents with appendicitis will often complain of the following appendicitis symptoms:

General malaise, indigestion, or change in bowel habits
Vague abdominal pain, usually near the umbilicus, which eventually migrates toward right lower quadrant (RLQ)
Nausea and/or vomiting
Fever

There are other symptoms as well, but these are the most common. As you can see – these are not super specific aside from the location of the pain which can be a late sign.

Up to 33% of patients can have retrocecal or pelvic appendix which can cause right flank pain or pelvic pain instead of the typical RLQ pain. This is why it is so important to know not only appendicitis symptoms but also appendicitis signs.

The physical exam is super important when evaluating abdominal pain. There are multiple physical exam maneuvers that you can do as the nurse or APP to detect appendicitis signs and further guide the need for imaging.

Related Article: 5 Advanced Physical Exam Maneuvers

1. Mcburney’s Sign

The first appendicitis sign to know is Mcburney’s sign. This is the bread and butter of recognizing appendicitis.

Mcburney’s sign, also known as Mcburney’s point tenderness is when the patient’s most tender area is 1.5-2 inches from the anterior superior iliac spine in the direction of the umbilicus. Ok… so where exactly is that?

Draw an imaginary line from the anterior superior iliac spine to the naval, and approximately 1/3 down the line closer to the iliac spine is Mcburney’s point.

If you press generally in the RLQ and they are tender, appendicitis should be high up in your differential.

If a patient has abdominal pain with this being their most tender area, they should undergo further testing to rule out acute appendicitis.

Mcburney’s sign is 50-94% sensitive, and 75-86% specific for appendicitis. This means if the pain is specific to this location, it very well could be appendicits.

Other causes of RLQ tenderness include kidney stones, ovarian cysts or torsion, ectopic pregnancy, testicular torsion, abdominal wall strain, or some other type of abdominal condition.

2. Guarding and Rebound Tenderness

Guarding is when a patient involuntarily tenses their abdominal muscles when you palpate.

Rebound tenderness is when the pain temporarily worsens when you suddenly release pressure.

While these aren’t specific appendicitis signs, they indicate potential peritonitis which is inflammation of the inside of the abdominal wall cavity.

Causes of peritonitis include ruptured appendicitis, perforated bowel in another area like with perforated diverticulitis, or direct infection through trauma or with peritoneal dialysis.

Any guarding or rebound with abdominal pain should raise suspicion for serious pathology, and CT imaging should be highly considered.

Bottom line – if the patient is tender in the RLQ and they are guarding and have rebound tenderness – this is highly suspicious for acute ruptured appendicitis.

Related Article: 6 Steps for Sepsis Management

3. Rovsing’s Sign

Rovsing’s sign is when you palpate the left lower quadrant and the patient is tender in the right lower quadrant (RLQ) area.

This indicates local peritoneal irritation. This is also called indirect tenderness.

This appendicitis sign is only 22-68% sensitive, and 58-96% specific. This means it’s not always going to be present with appendicitis, but if it is there – you should be ruling appendicitis out.

4. Psoas Sign

Psoas sign is when the patient lies supine and attempts to flex their hip against resistance. Place your hand on their thigh and ask them to lift their leg. If they have pain in the RLQ – this is a positive Psoas sign.

Alternatively, you can lie them on their left side and passively extend their right hip behind them. If this causes pain in the RLQ – this is also a positive Psoas sign.

This appendicitis sign checks for irritation of the iliopsoas muscle. This because the iliopsoas muscle lies in close proximity to the appendix.

The Psoas sign tends to correlate more with retrocecal appendicitis. This is when the appendage is in the direction of the colon behind the cecum, which can present in up to 33% of cases.

5. Obturator Sign

The Obturator Sign is when the patient is lying supine, and you passively flex their hip and knee, and then internally rotate. If this causes pain in the RLQ – this is a positive obturator sign.

Sometimes the appendix lies in close proximity to the right obturator internus muscle. This specific sign is associated with a pelvic appendix when the appendix tip migrates in the direction of the pelvis.

Appendicitis Management

After using these appendicitis signs into your physical exam, you should have a pretty good idea of how suspicious you are of appendicitis.

The next steps usually involve abdominal imaging.

In children and sometimes pregnant women, this can be a RLQ ultrasound. However, in most adults, this involves a CT abdomen/pelvis with contrast.

The CT abdomen/pelvis is the preferred test for appendicitis and has the highest sensitivity. This is recommended to be done with IV contrast, with or without PO contrast. If the patient has a BMI <25, it is a good idea to use PO contrast to enhance visualization of the appendix. The use of PO contrast is often facility dependent.

CT abdomen/pelvis is also great because it can give you possible alternative causes of abdominal pain. The downside is the obvious radiation exposure.

Once appendicitis is diagnosed, antibiotics should be started and surgery should be consulted emergently.

Antibiotics for acute appendicitis include:

Zosyn
Flagyl + Ceftriaxone or Cefepime
Ertapenem

For a full list, please look out the EMRA app. or read about the management here on UpToDate

Ultimately, the patient will likely need emergent surgery to remove the appendix, although rarely it can be just managed medically with antibiotics.

Don’t forget about these essential appendicitis signs to incorporate into your physical exam of your patient!

Also check out:

REFERENCES

Textbooks:

Bates Guide to Physical Examination

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide

UpToDate:

Acute appendicitis in adults: Clinical manifestations and differential diagnosis

Evaluation of the adult with abdominal pain

Management of acute appendicitis in adults

Other Sources / Apps:

Appendicitis (Wikem)

EMRA Antibiotic Guid‪e

Patient Care Organization Sheets

Great for bedside RNs!

Use these FREE patient care organization sheets to keep your patient information nice and organized. What do you have to lose - it's absolutely FREE!

William Kelly, MSN, FNP-C( Author )

I am an ER Nurse Practitioner who creates content for bedside nurses and clinicians, making practical application of nursing education. Read more!

HealthAndWillness.org

21+ mRNA Vaccine Questions Answered for Nurses

Jan 27, 2021 | 2 comments

21+ mRNA Vaccine Questions Answered for Nurses

Last updated: January 27, 2021

The new mRNA vaccines for COVID are being distributed, and as a nurse, it is important to know these vaccines, how they work, and their safety data!

Our patients respect our medical opinion, and we need to give accurate information so they can make an informed decision.

This article mainly focuses on the mRNA vaccines (Pfizer and Moderna), as they are currently the vaccines being distributed as they have obtained FDA emergency use authorization.

With these vaccines being so new – it leaves many wondering, “is it’s safe?”

I’m going to go over what the data tells us and hopefully give you enough insight into making an informed decision, and help your patients do the same!

Quick Note: I want to preface this article by first stating that I am a nurse practitioner and I see many COVID patients on the frontlines in the ED. I am not, however, an epidemiologist or scientist who works directly with COVID in a lab, so I am simply basing my own opinions on what the data says, as well as my understanding of the virus by seeing it firsthand.

1. How do mRNA Vaccines Work?

Vaccines generally work by introducing a dead or weakened virus, or part of a virus into your bloodstream via an Intramuscular or subcutaneous injection.

This creates an immune response that helps your body be able to attack the real virus whenever it comes into contact with it in the future. Typical vaccines include those with:

A live but weakened or “attenuated” virus, which leads to a better immune response, but can actually cause the disease in very few people – mainly those who are immunocompromised.
A dead or “inactivated” virus, in which the virus has been inactivated and is unable to replicate and cause disease. This doesn’t create as good of an immune response so it may need multiple doses or boosters. An example of this is the flu shot or hepatitis A.
Those that contain a piece of the virus, like part of its specific protein. This also cannot replicate or cause disease. Examples include hep B, meningitis, and HPV.
There’s also some vaccines that contain a toxoid that the virus creates, such as tetanus or diphtheria, like the Tdap vaccine.

The mRNA Vaccines (Pfizer and Moderna) actually do not inject the virus or any of it’s parts into you.

Instead, it contains mRNA which codes for the COVID spike protein – a protein specifically found on the COVID virus.

RNA is a single-stranded molecule that normally takes information from your DNA in the nucleus of the cell, and brings it to the ribosome of the cell to create proteins which basically keep the cell running and functioning appropriately.

So what scientists at Pfizer and Moderna have done is isolated the genome sequence of the mRNA which codes for the spike protein in the coronavirus, as this protein is not naturally found within your body. So what does the body do with this mRNA?

The mRNA is absorbed into your cells and carried to your ribosome where it is used as instructions to create the spike protein of COVID.

This protein cannot lead to disease, but it should lead to an immune response. Your body sees this foreign entity and creates antibodies to kill it and any future proteins it detects.

If the actual COVID virus now enters your body, your body should be able to detect it, and your immune system will target the cell and destroy it before it has a chance to replicate enough to cause disease and hopefully prevent you from spreading it.

2. Are mRNA Vaccines Safe?

This isn’t an easy question since it is so new, but so far it seems to be very safe and effective.

While mRNA vaccines have not actually been used in the US, researchers have been studying them for decades and have tested them on humans before for viruses like rabies, flu, CMV, and Zika.

In order to test the safety and efficacy of these new vaccines, clinical trials were conducted.

Pfizer and Moderna injected this vaccine into willing people and followed them for any adverse side effects, as well as those who ended up getting symptomatic COVID or severe disease.

Over 30,000 people were enrolled in the Moderna trial and over 40,000 people in the Pfizer trial.

Those who got the Pfizer vaccine get 2 injections, 21 days apart. Those who got the Moderna vaccine get 2 injections, 28 days apart.

Pfizer was tested on people 16 years and older, and Moderna was tested on adults 18 years and older.

Long story short – what they found was that most symptomatic covid cases were occurring in the placebo groups, which means those who did not receive the vaccine. Severe cases of COVID almost exclusively occurred in the placebo group!

The Pfizer vaccine boasts 95% efficacy beginning 1 week after the second dose, and Moderna boasts 94.1% efficacy 2 weeks after the second dose.

Both mRNA vaccines essentially use the same mRNA, basically the same ingredients, and both had very similar findings in their trials. This in and of itself is reassuring and offers an element of reproducibility.

The data from these trials are overall VERY reassuring. You can read more about the Pfizer or Moderna trials to get more information!

3. What Side Effects Can be Expected?

Common side effects include local injection site pain, headache, and fatigue. These vaccines should not cause COVID symptoms such as cough or SOB. It is impossible for these vaccines to cause actual COVID disease.

These vague side effects are common and expected when getting a vaccination, and are often an indication of the body’s immune response. They are short-lived and not severe.

Symptoms after the first injection tend to be less severe, and symptoms after the second injection were more significant – although both were very short lived (1-2 days).

Anecdotal Note: I have received both injections from the Moderna Vaccine. After the first shot, I had arm soreness which was worse than a typical vaccine, but resolved over 1-2 days. The day after my second injection, I had body aches and fatigue which resolved by the next day.

These symptoms seem common based on my colleagues experiences as well. Those who had symptomatic COVID anecdotally reported worsened symptoms after the first dose, although still short-lived.

Are all side effects mild and short-lived? We’ll dive more into that in future questions!

4. Can the mRNA Vaccines cause Anaphylaxis?

Just like any medication or vaccine, allergic reactions can occur.

Anaphylactic reactions have occurred after COVID vaccine administration, although not common, and seem to mainly occur in those with a history of severe allergies.

Overall it seems to be very rare – 11 people per million. Regardless, we know how to treat anaphylaxis and allergic reactions very well – Benadryl, Solumedrol, and Pepcid!

The CDC recommends those without a history of anaphylaxis to wait 15 minutes after their injection for monitoring, and those with a history of anaphylaxis to wait 30 minutes – just to be on the safe side.

5. Can the mRNA Vaccines cause Facial Paralysis?

Bell’s palsy is unilateral facial paralysis that can occur, which is usually temporary.

In the COVID vaccine trials, there were 7 reported cases of Bell’s palsy, in the over 70,000 participants in Pfizer/Moderna’s clinical trials.

While there were slightly more cases in the vaccine groups than the placebo groups, this rate is consistent with bell’s palsy rates in the general public, so likely not statistically significant.

However, some viruses and vaccines have been associated with bell’s palsy in the past, although rare.

Even if there is a small rare chance of the COVID vaccine causing Bell’s Palsy – it is usually temporary and treatable, and the benefits outweigh the risks.

6. Can the mRNA Vaccines cause COVID?

No – it is physiologically impossible for it to cause COVID disease.

Vaccines that contain live “weakened” viruses do have the capacity to cause disease in those who are immunocompromised – an example being the MMR vaccine.

However, those with only pieces of the virus or mRNA that code for pieces of the virus cannot cause COVID. So mRNA Vaccines cannot cause COVID illness.

7. Will these Vaccines cause False Positive Results on Testing?

No, the vaccine should not alter PCR or antigen testing. Test swabs collect viral particles and test for their genetic code. These swabs are collected from areas where you are expressing the virus, like the nasopharynx.

While the mRNA causes your cells to produce the COVID spike protein, they are not expressed or spread outside of your body.

The PCR and antigen tests check for active infection and do not check for antibodies. The vaccine should not alter these test results.

8. Do the Vaccines Change your DNA?

No. Only specific viruses can alter your DNA. These viruses are called retroviruses and require a specific protein called reverse transcriptase.

The mRNA in the COVID vaccines do not alter your DNA in any way.

9. Do the Vaccines Contain a Microchip?

No – this is nonsense and I’m not really sure what else to say about it.

10. Do the mRNA Vaccines cause Infertility Issues?

There is no convincing evidence to suggest that the mRNA vaccines cause infertility.

This idea was picked up and used by anti-vax propaganda. This myth started when a German Epidemiologist and a former Pfizer employee asked the FDA to not grant authorization to use the vaccine.

They said that the COVID vaccine’s mRNA is similar to the syncytin-1 protein which is used in mammals to help create placenta during pregnancy.

While the proteins do share a minimal amount of similar code, the scientist and medical community at large reject the notion that it could cause infertility.

While it is still so new – it cannot be said with certainty because we don’t have the data. However, 23 women did conceive during these trials, and they are still being followed.

11. Can Pregnant Patients Get an mRNA Vaccine?

This is a decision that should be discussed with the patient’s OBGYN, and they can come to a decision together.

The clinical trials did not study vaccination in pregnant mothers, so we don’t have specific data regarding pregnant individuals. There were some animal studies that looked promising.

The American College of Obstetricians and Gynecologists (ACOG) recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet the criteria for vaccination based on priority groups.

This means it is likely a good idea for pregnant mothers who are at an increased risk of getting COVID to get the mRNA vaccine.

What we do know is that pregnant mothers are at increased risk from side effects and complications if they get COVID.

They are more likely to be hospitalized, placed in the ICU, ventilated, and die than if they weren’t pregnant.

12. Can Breastfeeding Mothers get the Vaccine?

Again – this decision should be made with the patient’s OBGYN and Pediatrician.

There is just not enough data studying this to make a sweeping recommendation.

It is unlikely that the vaccines would be unsafe for the baby, and there is a possibility of passing on some passive immunity obtained from the vaccine to a breastfeeding infant.

13. Can those with Autoimmune Diseases get the Vaccine?

While there doesn’t appear to be any specific contraindications, this is something that should be discussed with the patient’s physician / Rheumatologist.

The risks of getting symptomatic COVID may be worse than the risks of getting the COVID vaccine.

14. Should Patients who had Symptomatic COVID get the Vaccine?

The idea is that if you had symptomatic COVID – you should have natural antibodies already for the virus – so why get the vaccine?

This is a decision you have to decide on with your Provider. It likely won’t hurt and could help, so the CDC is in favor or those who had COVID to also get vaccinated.

While it may be recommended to wait 90 days after symptomatic covid for the infection, this is not a rule and there is no specific timeline established.

This is more to allow those who have not built any immunity to receive the vaccine first.

You should get the vaccine after you recover from symptomatic COVID and when you feel it is appropriate.

15. What if you or your Patient doesn’t get the Vaccine?

As of today COVID has killed over 400,000 people in the US and 2.15 million people worldwide. This number is rising very quickly.

Even if COVID doesn’t kill you or your patients, it can cause many long-lasting side effects.

During an active COVID infection, it can cause multifocal pneumonia and respiratory failure leading to hospitalization, ventilation, and possibly death.

Severe COVID can also cause blood clots leading to pulmonary embolisms and embolic strokes.

It can cause inflammation of your brain and heart as well, leading to irreversible damage in some cases.

There have been observational studies done which show that up to one-third of patients who had symptomatic COVID had persistent symptoms after resolution of the virus. These include:

Fatigue
Dyspnea (Shortness of breath)
Chest Pain
Cough
Anosmia (loss of smell)
Ageusia (loss of taste)
More (joint pains, headaches, myalgias, etc)

There may still be other long-term side effects that we still don’t know about.

So what’s riskier? Getting a vaccine that seems to be very safe and doesn’t seem to have any serious long-lasting side effects, or take your chances with getting COVID?

I can’t make that decision for you or your patients.

But if you do decide to get the vaccine, what can you expect?

16. If you get the Vaccine, What can you Expect?

You can expect to get 2 injections, 21 days apart with Pfizer or 28 days apart with Moderna.

The full efficacy seems to be established about 1-2 weeks after the second injection, depending on the vaccine (1 week after Pfizer, 2 weeks after Moderna).

These were the timelines studied in the clinical trials.

17. Can I Stop Wearing Masks and Social Distancing once I’m Vaccinated?

Well – no, not immediately.

Remember that even a 94-95% efficacy still leaves that 5-6% of people who will still get symptomatic COVID.

These people will likely be contagious, and they still could get severe COVID and have to be hospitalized or worse.

Secondly, both Pfizer and Moderna require 2 shots before full efficacy is expected. The body takes time to build up an antibody response. It can take 1-2 weeks after the second dose for full efficacy.

Additionally, it has not been proven by evidence that these vaccines prevent you from spreading COVID. The trials only prove that they are 94-95% effective at reducing symptomatic COVID.

That’s right. Even if you don’t get symptomatic COVID – you could possibly spread it.

18. Could you get the COVID vaccine and be an Asymptomatic Spreader?

Theoretically, it is unlikely that you will be spreading the virus after vaccination.

Hopefully, your body has created an immune response and antibodies which will attack COVID before it can replicate and cause disease or be contagious.

HOWEVER – we don’t have the data to back this up, and there another important consideration – Mucosal Immunity.

We don’t know how well the antibodies penetrate the nasal mucosa. There is a possibility that the virus can still replicate in the mucosa of your nasopharynx.

While it may not cause symptomatic disease since you should have circulating antibodies – you might still spread it to others when coughing, sneezing, or even breathing.

This is something that we should have more data on soon.

This is why it is imperative to continue to wash our hands, wear our masks, and practice social distancing.

19. When will Herd Immunity be Established?

It is going to take some time for the majority of the US to become vaccinated.

This means we need about 70%+ of the population to be vaccinated or infected before some type of herd immunity can be expected and established.

Herd immunity occurs at different percentages of vaccinated/infected individuals based on each specific virus.

This number is unknown for COVID, but experts say at least 70% need to be vaccinated and/or infected for some type of herd immunity to protect us.

It is unlikely that mask mandates and social distancing will become a “thing of the past” until we get to this point.

20. Will the mRNA Vaccines Cover the New Strains?

Unfortunately, there are multiple mutated strains or variants popping up in the UK, Africa, and other places.

These strains are spreading fast as they are more contagious (30-70% more transmissible).

However, these don’t necessarily seem to be more deadly. However, with surges in COVID cases and hospitalizations, increased deaths could occur due to the burden put on the healthcare system.

As far as we know, these vaccines should be effective against these mutated variants.

However, preliminary data does suggest that the vaccines may not work as well against the South African variant! Just in case, Moderna has already begun production on a “booster shot” which would specifically target these variants.

21. How Long will Immunity Last from these mRNA Vaccines?

As mentioned above – complete immunity is not guaranteed.

However, if antibodies are created, it is unknown how long they will last.

What we do know is that immunity wanes over time. Those who get symptomatic illness tend to build a better immune response than those who get vaccinations.

Many patients who had symptomatic COVID in early 2020 still have antibodies – this is good news!

We don’t know how long immunity will last, and we don’t know how much further mutations will alter the effectiveness of the immunity.

22. Are there other Vaccines Available?

Pfizer and Moderna are mRNA vaccines which have already obtained emergency use authorization (EUA) from the FDA.

There are two other vaccines that may obtain approval as well. These are not mRNA vaccines. They include:

Johnson & Johnson, which uses adenovirus to carry genetic material for COVID
AstraZeneca, which uses a chimpanzee adenovirus to do this

These do not appear to be as effective as the mRNA vaccines, but may still prove helpful, and we must continue to follow the data.

Production and distribution of the mRNA vaccines will prove tough, and additional effective vaccines will be helpful!

So Should you or your Patient get the Vaccine?

That’s for you to decide, based on the data and taking into account what your physician or healthcare provider recommends.

Additionally, it is for your patients to decide based on informed consent.

It is not your job to judge them or tell them what to do. All you can do is offer evidence-based recommendations and up to date information, and allow them to make that decision for themselves.

You can also lead by example and get the vaccine for yourself, trusting the science and once again being that hero that we were once called in the beginning of this pandemic.

I think frontline workers and those with a high risk should seriously consider getting vaccinated.

As far as everyone else – that’ a decision you (or they) have to make, but the data looks promising and this could be our chance at returning to a state of semi-normalcy.

Note: If you want more information – you should follow Dr. Kat the Epidemiologist on TikTok! She creates great content backed in science on all things COVID and mRNA Vaccines!

I got my vaccine! Did you? Why or why not? Let us know in the comments below!

You might like: “These 8 COVID nursing tips could save your life”

References:

Pfizer / Moderna Studies:

Moderna Announces Primary Efficacy Analysis in Phase 3 COVE Study for Its COVID-19 Vaccine Candidate and Filing Today with U.S. FDA for Emergency Use Authorization

PFIZER AND BIONTECH CONCLUDE PHASE 3 STUDY OF COVID-19 VACCINE CANDIDATE, MEETING ALL PRIMARY EFFICACY ENDPOINTS

Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine (Pfizer)

Safety and Immunogenicity of SARS-CoV-2 mRNA-1273 Vaccine in Older Adults (Moderna)

Vaccine Info:

Coronavirus disease 2019 (COVID-19): Vaccines to prevent SARS-CoV-2 infection (UTD)

Facts about COVID-19 Vaccines (CDC)

Understanding mRNA COVID-19 Vaccines (CDC)

Vaccine Types

Anaphylaxis:

Allergic Reactions Including Anaphylaxis After Receipt of the First Dose of Pfizer-BioNTech COVID-19 Vaccine

Interim Considerations: Preparing for the Potential Management of Anaphylaxis After COVID-19 Vaccination

Bell’s Palsy:

FDA: Track Vaccine Recipients for Facial Paralysis

Pregnancy & Breastfeeding:

COVID-19 Vaccines and Pregnancy: Conversation Guide for Clinicians (ACOG)

Vaccination Considerations for People who are Pregnant or Breastfeeding (CDC)

Why COVID Vaccines are Falsely Linked to Infertility

Persistent COVID:

Coronavirus disease 2019 (COVID-19): Evaluation and management of adults following acute viral illness (UTD)

COVID Cheat Sheet

Everything you need to know about treating COVID pneumonia in the ER and Inpatient setting!

William Kelly, MSN, FNP-C( Author )

I am an ER Nurse Practitioner who creates content for bedside nurses and clinicians, making practical application of nursing education. Read more!

HealthAndWillness.org

Adverse Drug Reactions Nurses NEED to know

Dec 28, 2020 | 2 comments

Adverse Drug Reactions Nurses NEED to know

Medications are a huge part of modern medicine and how we treat disease, but there are many adverse drug reactions that can occur.

As nurses, it is important to educate our patients about these adverse drug reactions, what to expect, and what to do if they are experienced by our patients.

Some of these medication reactions are ingrained in us, but others are less commonly taught.

Make sure you remember to educate your patients who are being prescribed these medications!

Antibiotics and Adverse Drug Reactions

Antibiotics are essential in treating bacterial disease, but they don’t come without their own side effects!

There are many different classes of antibiotics. Because of this, some adverse drug reactions apply to only certain antibiotics, and some apply to antibiotics as a whole.

1. Diarrhea and Antibiotics

All antibiotics can cause diarrhea. This is due to normal “good” bacteria in your intestines being killed by the antibiotic, leading to imbalances digestion.

While all antibiotics can cause diarrhea, there are certain antibiotics that are more likely to cause diarrhea.

These include amoxicillin, cephalosporins, clindamycin. When mixed with clavulanic acid, diarrhea tends to be more pronounced (i.e. Augmentin).

Clostridium Difficicile (CDIFF) is an opportunistic diarrheal infection that can lead to profuse diarrhea and can be difficult to treat.

Antibiotics increase the risk of CDIFF – especially broad-spectrum antibiotics like cephalosporins, fluoroquinolones, and clindamycin.

Patient Education Example: “Some watery diarrhea and mild cramping can be expected while on antibiotics. Make sure to stay hydrated if this occurs. If you have excessive diarrhea, severe abdominal pain, abdominal swelling, fever, or blood or pus in your diarrhea – you should contact your doctor or return to the emergency department”.

2. Allergic Reactions

All medications and antibiotics can cause allergic reactions.

True allergic reactions cause itchy hives and potentially swelling of the face, eyes, lips, or mouth. It can even cause swelling of the airways and lead to wheezing and stridor.

When giving any prescribed medications, the patient should always be educated on the potential signs of an allergic reaction.

Patient Education Example: “All new medications can cause allergic reactions, and mild-moderate allergic reactions are common with antibiotics. If you develop a red, raised, itchy rash, immediately stop taking the antibiotic and call your doctor. If you develop swelling of the face, eyes, lips, tongue, or shortness of breath – this is potentially a life-threatening severe allergic reaction called anaphylaxis, and you should seek immediate medical care or call 911.”

3. Rifampin and Birth Control

Antibiotics were frequently thought to interact with birth control… but this is somewhat of a myth.

There is no convincing evidence that any antibiotic other than Rifampin interacts with birth control.

Rifampin is not a commonly prescribed antibiotic but is the recommended treatment for tuberculosis.

There is a concern that antibiotics as a whole can affect the gut microbiome which may alter estrogen levels, but this has not been proven and is likely untrue.

If patients are prescribed rifampin, they should be educated to use backup protection for up to 1 month after they finish the rifampin.

Patient Education Example: “While commonly believed to interact with birth control, there’s no evidence that most antibiotics do. If you want to be safe, you can use a backup method like condoms while taking the antibiotic, and up to a few days to a month after you finish.”

4. Doxycycline and GI Upset

Doxycycline is commonly given for infections including cellulitis, URIs, tick-borne illnesses, pneumonia, STDS, and more.

Doxycycline works great, but it does have some significant adverse drug reactions that we need to educate our patients about.

Doxycycline can cause some significant GI upset, including nausea, vomiting, and diarrhea.

Educating the patient to take this pill with food or milk can help, although it may inhibit some absorption of the drug.

Doxycycline (and clindamycin) can cause drug-induced esophagitis which can lead to significant inflammation and pain within the esophagus.

To prevent this, educate the patient to take Doxycycline with a full glass of water, milk, or eat food afterward, and stay upright for 30 minutes after taking it.

Patient Education Example: “Doxycycline can cause significant nausea and vomiting, and drinking milk or eating food directly after taking it can help minimize this. If not, drink with a full glass of water and remain upright for 30 minutes afterwards to prevent any damage to your esophagus.”

5. Flagyl and ETOH

Metronidazole, or Flagyl, or is commonly given for intestinal infections like colitis or diverticulitis, and for vaginal infections like trichomoniasis.

Flagyl is traditionally taught to NEVER be taken with alcohol as this can cause a “disulfiram-like reaction”.

Disulfiram causes excessive nausea, vomiting, and other unpleasant symptoms when mixed with alcohol.

Evidence of this severe reaction occurring with Flagyl is somewhat lacking, but it can sometimes occur. Educate the patient on this potential reaction, but if they do drink they may be fine.

It is never a bad idea to recommend against taking medications with alcohol.

Patient Education Example: “Flagyl can potentially cause nausea and vomiting if taken with alcohol. Avoid any alcohol consumption while taking it”.

6. Fluoroquinolones and Tendon Rupture

Fluoroquinolones are a powerful class of antibiotic which kill a broad-spectrum of bacteria.

These are commonly utilized to treat UTIs, Abdominal infections, and Pneumonia.

Fluoroquinolones have fallen out of favor recently due to their large number of potential side effects, even if rare.

These side effects include:

Hyper/hypoglycemia
Peripheral neuropathy
CNS effects (seizures, increased ICP, tremors)
Psych reactions (psychosis, hallucinations, deririum, etc)
Aortic aneurysm and dissection
Tendonitis and tendon rupture.

Sometimes these antibiotics are still needed, so be sure to educate the patient on these possible side effects.

The tendinopathy can occur hours or days after starting the antibiotic or sometimes delayed for months.

This is more likely to occur in those >60 years old, those on steroids, with diabetes or kidney failure, or with extended therapy.

Patient Education Example: “Cipro can rarely cause significant side effects like inflammation and even rupture of your tendons, most commonly the Achilles tendon above your heel. If you feel any swelling or pain in this area or near another joint, immediately stop taking and contact your doctor”.

Non-Antibiotics and Adverse Drug Reactions

Antibiotics are not the only cause for adverse drug reactions, and every medication has expected side effects.

While there are many potential adverse effects for every single medication, there are a few common or interesting side effects you should know to educate your patients on!

7. Dexamethasone and the Burning Crusade

Dexamethasone is a steroid given for various reasons, including sore throats, cerebral edema, migraines, and various other conditions in and out of the hospital.

Dexamethasone is commonly ordered IV in the ED and hospital. One interesting side effect that you need to warn your patients about perineal discomfort when given IV.

When given rapidly, perineal discomfort (burning or tingling) can occur.

I’ve personally heard “MY CROTCH IS ON FIRE!”.

This is usually short-lived but can cause significant discomfort and be shocking for the patient if not warned.

Dilute the dexamethasone in NS and infuse over 15-30 minutes to help minimize this side effect.

Patient Education Example: “I’m going to give you some IV Dexamethasone to help with your condition. Sometimes it can cause brief burning or discomfort in your groin, but we are giving it slowly to try and prevent that. It can still happen though, so if it does I just want you to be aware.”

Related Content:

8. Adverse Drug Reactions with Opioids

Opioids like Oxycodone or Hydrocodone are commonly given for pain and can be a great tool we can use to offer relief to our patients.

Unfortunately, opioids do have significant side effects that need to be taught to our patients.

Opioids cause respiratory depression and this is how opioid overdoses kill people.

But appropriate doses, it shouldn’t cause significant respiratory depression unless mixed with other medications or alcohol.

Opioids also cause drowsiness and even stupor, so anything that requires a high level of mental alertness needs to be avoided.

This includes driving or operating heavy machinery.

Patient Education Example: “Oxycodone helps your pain but can cause drowsiness, so you shouldn’t drive or operate any heavy machinery. It can increase your risk of falls, so be careful on the stairs. You should never take this medication with alcohol, other opiates, or benzodiazepines like Xanax or Ativan.”

Related Content: Opioid Alternative Analgesics in the ER

9. Anticoagulants and Bleeding

Anticoagulants are often necessary to prevent blood clots in those with a history of DVT, PE, or Atrial Fibrillation.

Unfortunately, they also hinder the body’s natural ability to clot when injured.

This can lead to ineffective clotting and an increased risk of bleeding. Patients on blood thinners should take extra precautions to prevent trauma like falls.

If there is a head injury, these patients should be evaluated by a medical professional, preferably within the ED where a CT scan can be obtained to rule out an intracranial bleed.

Patient Education Example: “Eliquis helps prevent blood clots, but it also increases your chance of bleeding. If you fall or sustain any injury, you should be evaluated by a doctor. If you hit your head, you should call your doctor or come to the ER.”

Every medication has adverse drug reactions, but we should be knowledgeable about these common or potentially serious reactions, and educate our patients!

Is there any other drug reaction that you are sure to educate your patients about? Let us know in the comments!

Patient Care Organization Sheets

Great for bedside RNs!

Use these FREE patient care organization sheets to keep your patient information nice and organized. What do you have to lose - it's absolutely FREE!

References:

Diarrhea and Antibiotics:

Diarrhoea associated with antibiotic use (2007).

Managing antibiotic associated diarrhoea (2002).

Which antibiotics increase the risk of developing Clostridium difficile (C diff) colitis? (Medscape).

Rifampin and Birth Control:

Antibiotic and oral contraceptive drug interactions: Is there a need for concern? (1999)

Can antibiotics affect my birth control? (Planned Parenthood)

Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use (UTD)

Patient education: Hormonal methods of birth control (UTD)

Doxycycline and GI Upset / Pill Esophagitis:

Doxycycline: Drug information (UTD)

Drug Induced Esophagitis (2020)

Flagyl and ETOH:

Fact versus Fiction: a Review of the Evidence behind Alcohol and Antibiotic Interactions (2020)

Metronidazole (systemic): Drug information (UTD)

Fluoroquinolones and Tendon Rupture:

Ciprofloxacin (systemic): Drug information (UTD)

Fluoroquinolones (UTD)

Dexamethasone and Perineal Pain:

Dexamethasone (systemic): Drug information (UTD)

Opioids and Decreased CNS activity:

Oxycodone: Drug information (UTD)

William Kelly, MSN, FNP-C( Author )

I am an ER Nurse Practitioner who creates content for bedside nurses and clinicians, making practical application of nursing education. Read more!

HealthAndWillness.org

These 8 COVID Nursing Tips could save your life

Dec 14, 2020 | 3 comments

These 8 COVID Nursing Tips could save your life

This post may contain affiliate links, which means I get a commission if you decide to purchase through my links, at no cost to you. Please read affiliate disclosure for more information

Whether we want to admit it or not, the COVID19 pandemic is not ending anytime soon. Even with the vaccines coming soon, there is still be months of hard work ahead of us. Using these COVID nursing tips might be able to help!

As nurses, COVID can be exhausting and even somewhat demoralizing. I have felt plenty of burn-out since this all began, and nurses across the nation can relate.

In this article, I will list some COVID nursing tips for ER and inpatient nurses – to help you get through your shift safely!

1. Minimize Contact

This is easier said than done – but minimize your contact with patients who have symptoms consistent with COVID. If you need a refresher, common symptoms of COVID include:

Fevers
Cough
SOB
Body aches and Headache
Nausea and Vomiting
Loss of taste/smell

As an NP, this is actually fairly doable. I can conduct my history at 3-6 feet away, and perform a very limited physical assessment, often without even touching the patient. Sounds terrible, but the safety of healthcare workers is essential.

Bedside nurses are much more hands-on. What I’m going to say might be controversial, but you do not need to listen to every patient with lung sounds. We are going to get a chest X-ray anyway. Minimize contact, minimize exposure, and minimize your risk as best possible.

Patients with COVID often have normal or somewhat diminished lung sounds. Knowing this does not change management. When I do listen to lung sounds, they are patients with asthma, COPD, or CHF, because I’m specifically looking for wheezes or rales.

Make sure you get everything you need before garbing up and entering the room. Bring with your IV equipment and blood tubes, vital sign hookups if not already in the room, any medications already ordered, a COVID nasopharyngeal swab, etc.

If the patient may be discharged and an ambulatory pulse ox might be ordered – might as well get them up and walk them around the room while recording their SPO2. This is using your nursing judgment to anticipate orders. Let’s face it – not all Providers are great about putting in every order at the same time (guilty!).

2. Reduce, Reuse, Recycle (Your N95)

Don’t take your N95 for granted, because they’re running out! At least, that was the worry when this pandemic started and is definitely a possibility if infections and hospitalizations continue as they have been in the US.

However, we can’t afford to be wasteful. Before COVID, we would use an N95 like a surgical mask – apply it when taking airborne precautions, and removing it upon leaving the room. This life of luxury is no more.

Many hospitals have decontamination protocols for N95s – where they decontaminate them in some capacity. However, not every hospital will do this. If needed, there are multiple ways that you can decontaminate your N95 yourself using the following COVID nursing tips.

Bake It

No, really – throw that N95 in the oven! Baking with dry heat at 75° C (167° F) for 30 minutes effectively kills Sars-COV-2. Researchers at Stanford found that this can be done for 20 cycles without significantly reducing the filtration efficiency. Other studies indicated that only 2 cycles proved safe.

Hang the N95 from the oven rack with a wooden paperclip, or place an oven-safe fabric on a metal sheet. Do not place the N95 directly on the metal as this can overheat the mask.

Rotation Schedule

COVID has been found to survive on hard surfaces for 48 hours, plastic for 72 hours, and cardboard for 24 hours. While scientists aren’t 100% sure on the specifics of covid spread via surfaces, they do know that COVID doesn’t spread much through touch.

An alternative method to decontaminating your N95 is to leave it in a safe, warm, dry area and allow it to “air-dry” for 3-4 days. Placing it in a paper bag may be useful for this. This will kill the coronavirus without degrading the filter.

If you have three or four N95s, you can start a rotation cycle and effectively never run out of N95s.

Please note this does not appear to be a well-studied decontamination procedure and is solely based on theory.

Other methods

There are other methods to decontaminate your N95, including moist heat, UV radiation exposure, boiling, and even steaming. These all kill COVID but degrade the N95 at varying rates, and are likely more difficult to perform while at home.

If the idea of having to decontaminate and then reuse your N95 does not fit your desires – you can always skip this COVID nursing tip and buy a reusable N95 Device.

3. Buy a Reusable N95 device

They do make reusable N95 devices which are somewhat affordable and probably worth it.

Using a reusable N95 is more comfortable, less of a hassle, and can leave you feeling more protected.

Envo Mask is all the rage in my ER, and for good reason. This reusable N95 is comfortable and won’t fog your goggles. There are replaceable filters that you use, making this usable forever (but hopefully COVID won’t last forever too).

You can also buy a respirator, which can be cheaper depending on which one you get. If you do, you need to make sure you buy the appropriate filter though, as many of these respirators were intended to be used for occupational exposure. The 2091 filter is recommended by the CDC.

Please be aware it can be somewhat difficult to speak to people with a respirator on, as they can have a hard time hearing. This can be especially difficult over the phone.

4. Protego Skin!

We’ve all seen those horrid photos of nurses who worked 12+ hours in an n95 mask, with deep facial markings to prove it. Many of us have experienced this firsthand.

You shouldn’t only worry about your patient’s skin breakdown. Wearing an N95 for 12 hours straight can cause your own skin-breakdown, and it can be very irritating, painful, and eventually lead to open wounds. There are a few different COVID nursing tips regarding your skin protection that can help!

Take Breaks

To minimize skin breakdown, frequent removal of the N95 is recommended. However, with the COVID pandemic among us – that is not always feasible.

If able to safely remove your N95, the recommendation is to take a 15-minute break every 2 hours. For the vast majority of us, this just won’t work.

Skin Protectant

Probably one of the safest options, you can apply a liquid skin protectant onto your skin. Once applied and allowed to dry, this creates a protective barrier that minimizes moisture and friction.

Any skin protectant should work, and skin repair creams with dimethicone can also be effective. Apply it over the areas where the N95 will cause the most skin breakdown (nasal bridge, cheeks, behind ears). Avoid getting the product in your eyes or mouth.

Good skin protectants to use:

Make sure to always allow the product to fully dry before applying your N95.

Protective Dressing

If skin protectant doesn’t do the trick – you can try a protective dressing.

The issue with protective dressings is they can alter the fit of the N95. Unfortunately, that could mean catching COVID. This is why skin protectant is a safer option. Still – if your skin really needs it – you can likely put a protective dressing in a safe manner.

Cut a thin dressing into small pieces, and apply a thin layer to the nasal bridge, the cheekbones, and behind the ears.

You should use a foam dressing that has a non-permeable outer layer, so any hydrocolloid dressing should work well. A good example is the Duoderm Hydrocolloid Dressing.

You should attempt to confirm the N95 fit by blowing out and seeing if there are any leaks. Definitive fit testing can also be done and is more accurate, although may not be feasible on the unit.

5. Surgical Mask Woes

Even with using our N95s, we are still recommended to be using a surgical mask on top of that. This prevents soiling of the N95 mask and adds that extra layer of protection for splashes.

Unfortunately, surgical masks wrap around your ears and they can lead to skin breakdown of your ears and just hurt.

There are scrub caps and headbands with buttons sowed on which you can loop the surgical mask onto, which takes the pressure off of your ears entirely.

They also make plastic devices that connect both sides and loop around the back of your neck. You can even MacGyver your own version with some rubber hands and/or paper clips.

6. Bad Breath

No – wearing a mask won’t give you hypercarbia… But it can give you hyper-halitosis. If you have bad breath – you’ll definitely notice it now. Sure, bad breath won’t kill you, but it’s just not fun to be breathing in for 12 hours.

Working 12-hour shifts without time for water breaks will cause dry mouth and will increase the odor of your breath as well!

One easy fix is to buy some gum. This leaves your breath smelling minty and fresh. If you’re someone who needs more help for your halitosis, you can try special toothpaste or special mouthwash.

Make sure you are able to stay hydrated. Drink plenty of water before your shift (not that you’ll have much time to pee). Try to take a few breaks throughout the shift just to drink some water and stay hydrated.

7. Wrap it Before you Tap It

No – I’m not talking sex-ed. I’m talking about your smartphone!

Let’s be real, we all bring our phones to work. No, we probably don’t have time to scroll Instagram (follow me!), but we occasionally check the time and maybe our messages.

I personally use multiple apps on my phone throughout my shift to help with antibiotic selection or to reference something related to patient care.

The problem is, we don’t want to contaminate our phones with COVID or who knows what else.

One simple COVID nursing tip is to bring a Ziplock baggie to work that your phone easily fits in. Ziplock it shut. Your touch screen actually works through the ziplock bag!

You could also just leave your phone at home – but if that doesn’t give you anxiety thinking about it, then something is wrong with you.

If you risk it and just use your phone while at risk, you should know how to decontaminate your phone. Pro Tip: Don’t put your phone in the oven like the N95!

8. Decontamination Station

After a long shift working with COVID patients ALL day (or night), there is nothing you probably want more than to get home and crawl in bed. But you are also aware of all the NASTINESS on your body, scrubs, and everything else you’ve touched.

You need to have a procedure for how you clean yourself and your items. The last thing you want to do is infect members of your household!

Leave anything items you can at work, like your stethoscope, scissors, pens, penlights, etc. If you have a locker – use that!

Make sure you carry hand sanitizer in your car. Use it immediately once you get in before touching the steering wheel. Do not touch your face now that you are maskless.

Once you get home, find a way to strip quickly without touching anybody or anything. I put anything in my pockets (like my phone) on the island counter. I put my clothes directly in the washing machine. Take an immediate shower with hot water and plenty of soap.

After this, I personally go through and wipe down everything I touched including the doorknob, the bathroom door, etc with a disinfectant. I then wipe down all the items I had placed on the island counter. You can use clorox wipes, lysol wipes, but I personally use Original Pine-sol which kills COVID within 10 minutes (THAT’S the power of Pine-sol baby).

Other related content:

COVID Nursing Tip: Always Follow Hospital Policy

As always you should ALWAYS be following hospital policy and procedures whenever implementing any of these COVID nursing tips. This is an unconventional time, so there may not be much oversight regarding infection control practices, but make sure anything you do is safe for you and your patients.

Comment down below your COVID Nursing tips!

References:

COVID risk and statistics

Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

Sustainability of Coronavirus on Different Surfaces

Covid Skin Breakdown:

NPIAP position statement on preventing injury with N95 mask

OSHA: COVID-19

COVID Decontamination:

Assessment of N95 respirator decontamination and re-use for SARS-CoV-2

Reuse of N95 Masks

Respirator:

CDC: Certified Equipment List

COVID Cheat Sheet

Everything you need to know about treating COVID pneumonia in the ER and Inpatient setting!

William Kelly, MSN, FNP-C( Author )

I am an ER Nurse Practitioner who creates content for bedside nurses and clinicians, making practical application of nursing education. Read more!

HealthAndWillness.org

Intravenous Fluids: Types of IV fluids

Nov 25, 2020 | 11 comments

Get the IV Fluid Cheat Sheet (FREE)

Everything you need to know about IV fluid!

Intravenous Fluids: Types of IV fluids

Intravenous fluids are commonly used in hospitals and emergency departments. There are many different types of IV fluids, which are used both as IV boluses as well as maintenance fluids. Understanding the difference between the types of IV fluids can be challenging, but as a nurse, it is important to understand.

Indications for Intravenous Fluids

Intravenous fluids are very commonly used in healthcare settings. Most frequently, IV fluids are used to hydrate those with dehydration. Additionally, they can be used to support blood pressure in those with hypotension or sepsis.

IV fluids can also be used as maintenance fluids for those who are not able to intake enough hydration throughout the day.

In the ER, I commonly order Intravenous fluid to those with nausea and vomiting, diarrhea, dehydration, acute kidney injury, abdominal pain, headaches, bleeding, or infections.

Maintenance Fluids vs IV Bolus

Maintenance fluids are intravenous fluids that are run at a slower rate, usually to account for decreased PO intake or expected fluid losses. Patients who are NPO (nothing by mouth) are commonly ordered maintenance fluids, as well as those with ongoing fluid losses.

Maintenance Fluids

Ongoing fluid losses commonly occur with various medical conditions. Fevers commonly require increased maintenance fluid, as they cause “insensible water losses” from sweating and overall increased metabolism.

Those experiencing frequent vomiting or diarrhea require increased fluid to account for their ongoing water losses in their vomit or stool. The same goes for those with drains experiencing significant drainage.

Those with burns or pancreatitis often require a large volume of fluids.

Those admitted with dehydration, mild hyponatremia, or acute renal failure will usually require maintenance fluids in order to slowly correct their hydration, sodium levels, and renal function.

When a patient is NPO, maintenance fluids keep the patient hydrated. To calculate maintenance fluids when a patient is NPO, you can take the patient’s body weight in Kilograms, and use the following equation: (Kg – 20) + 60 = mL/hr. (Ref).

Please note that this is not a hard rule. Those with ongoing fluid losses and various medical conditions may require a faster rate, and those who are older or with CHF may require slower rates.

Clinical Note: Just because a patient is NPO after midnight does not mean that they need maintenance fluids ordered. Do you usually drink water in the middle of the night while you sleep?

IV Bolus

IV boluses are intravenous fluids given rapidly over a short amount of time. This is most frequently used within acute care settings such as the ER or the ICU in those who are unstable with low blood pressure. Giving an IV bolus helps support blood pressure and correct hypotension.

It is common for a 1 liter IV bolus to be ordered on patients initially presenting to the ER, as fluids can help many different conditions. You will commonly see between 1-3 Liters of IV boluses, for conditions such as dehydration, sepsis, shock, migraines, abdominal pain, and n/v/d.

In sepsis, 30ml/kg boluses are commonly ordered. If a bolus is ordered, hang the bolus (usually 1L bags) by gravity and open the clamp wide open. Make sure the patient keeps their arm straight if the IV is in the AC, otherwise the bolus won’t flow.

Clinical Note: If using a pump, run the fluid at 999ml/hr. Please note that in true emergencies this may not be fast enough, and using gravity and/or a pressure bag will infuse the fluid more quickly.

Important Fluid Concepts to Understand

Before diving into the different types of IV fluids, there are a few important underlying concepts we need to understand.

Tonicity, Osmolarity, and Osmosis

Tonicity refers to a fluid’s ability to move fluid into or out of cells and is related to osmolarity – which is the total concentration of solutes within a solution. The more solutes, the higher the osmolarity.

In the body, water shifts into or out of our cell through a semi-permeable membrane – the cell wall. This means water freely flows through it, but larger solutes do not such as our electrolytes (sodium, chloride, potassium, etc).

Osmosis occurs, which is when water flows from a higher osmolarity to a lower osmolarity to “balance” out the concentrations of each side, in this case inside and outside of the cell.

Isotonic, Hypotonic, and Hypertonic Fluids

Isotonic fluids are IV fluids that have nearly the same osmolarity as intracellular fluid. This means that this IV fluid should not cause any significant net fluid shifts into or out of cells.

Hypotonic fluids are IV fluids that have a lower osmolarity than inside the cells, which causes net fluid shifts into the cells. This leads to cellular swelling, which can be deadly in certain conditions like severe head injuries and increased Intracranial Pressure (ICP).

Hypertonic fluids are IV fluids that have a higher osmolarity than inside the cells, which causes net fluid to shift out of the cells. This leads to cellular dehydration and shrinking.

Types of IV Fluids

There are many different types of IV fluids that can be ordered, and knowing the difference between them is important. Certain intravenous fluids are useful for certain situations, and others can be harmful.

As a nurse, it is important to know the basics. As a nurse practitioner, you will be responsible for ordering these fluids so this becomes even more necessary to understand.

Normal Saline (0.9% NS)

Normal Saline, NS, or NSS is the standard fluid given in both boluses and as maintenance fluids. Normal saline contains sodium chloride (NaCl) and is isotonic. This means when given through the IV, there should be no net movement of fluid or electrolyte into or out of the cells.

This ensures that there is no unnecessary swelling or shrinking of the cells when infused. Normal saline is the cornerstone intravenous fluid because it can be given for most situations, including:

Hydration
Maintenance Fluids
Hyponatremia
Hypotension or Shock
Sepsis
with Blood transfusions

Normal saline is cheap and does not result in allergic reactions, and almost all medications are compatible.

Use caution with heart failure or end-stage renal disease, and those on dialysis or in acute fluid overload should probably not receive IV fluids.

A large amount of Normal Saline (3-5+ liters) can cause significant hyperchloremic non-anion gap metabolic acidosis, especially if the patient has renal failure. This can worsen their outcomes within the hospital.

As with any IV fluid, continually monitor fluid status by making sure the patient is not having worsened lower extremity edema or new rales/crackles in the lungs.

If the patient develops sudden shortness of breath during IV fluid administration, consider fluid overload and flash pulmonary edema as a potential cause, especially with a history of heart failure.

You should always be assessing for IV infiltration as well. If there is significant swelling, blanching, and coolness near the IV site – you probably need to remove it and start a new IV.

Related articles:

Lactated Ringers (LR)

Lactated Ringers (LR) is another isotonic fluid that is commonly given. LR is the fluid of choice by surgeons, and some consider LR to be slightly better than NS, but the general consensus is that ‘One is not better than the other’.

Lactated Ringers differ from NS in that it not only has sodium chloride, but also has sodium lactate, potassium chloride, and calcium chloride.

So why choose LR over NS? LR is buffered and won’t cause the hyperchloremic metabolic acidosis that large volumes of NS can. Some studies showed improvement in renal function in critically ill patients who were on LR as opposed to NS, but the evidence is mixed.

LR can be given for all of the indications that NS can be given, including:

Dehydration
Maintenance Fluids when NPO
Ongoing fluid losses
Sepsis
Allergic Reactions

LR is preferred over NS in certain situations, including:

Pancreatitis
Burns
Surgical patients (surgeon preference)
Sepsis

LR should be avoided in:

Severe liver or renal failure
Metabolic alkalosis > 7.5
Hyperkalemia or Hypercalcemia
Blood transfusions (If run in the same line can cause precipitation)

As with any fluid administration, be on the lookout for fluid overload as well as local site reactions including infiltration or phlebitis.

Side Note: LR contains sodium lactate, not lactic acid. However, giving LR during sepsis can mildly influence the lactic acid level (about .9 mmol/dL), but this does not actually worsen the sepsis, and has actually giving LR has been shown to indicate lower mortality overall. Interestingly enough, NS also seems to elevate Lactic levels within in the blood.

Intravenous Fluids IVF - Isotonic fluids

Half Normal Saline (0.45% NS)

Half normal saline (.45% NS) has half the tonicity of Normal saline. This means Half-NS is hypotonic, so the IV fluid has a lower osmolarity than the fluid inside the cells.

This means that half normal saline will cause fluid to shift inside the cells, causing the cells to swell. This can be good in certain situations, and very bad in others.

Half-Normal Saline is rarely given alone, but usually in combination with Potassium or dextrose. However, you may see slower rates given in conditions which cause significant cellular dehydration, such as with:

Hypernatremia
Severe DKA

Half-Normal saline, when run alone, is typically the wrong choice for most other scenarios as it can deplete intravascular volume and cause cellular edema. Hypotonic fluids are especially bad when it comes to:

Head injuries or increased ICP
Trauma
Burns
Liver disease

When given, make sure the patient’s sodium levels are monitored daily, as this can cause hyponatremia.

Intravenous Fluids IVF - Hypotonic fluids

Hypertonic Saline (3% NS)

Hypertonic saline is given with severe hyponatremia or with increased intracranial pressures.

Hypertonic saline is carefully and selectively given, as correcting sodium too quickly can lead to osmotic demyelination syndrome, causing irreversible neural damage.

If a patient has severe hyponatremia and symptoms consistent with cerebral edema, then hypertonic saline should be administered. These symptoms include:

Seizures
Severe headaches
Decreased LOC
Tremors

The dose is usually a 100mL bolus given over 10 minutes (a rate of 600ml/hr), which can be repeated twice if needed.

Additionally, hypertonic saline can be given in the setting of severe head injury to reduce intracranial pressure.

If your patient is ordered hypertonic saline, this needs to be on a pump, and the patient needs to be hooked up to the monitor and have frequent neuro checks. Seizure precautions should also be taken if severe hyponatremia is present.

Intravenous Fluids IVF - Hypertonic fluids

Dextrose-Containing Solutions

Dextrose can be added to any of the fluids mentioned above, as well as to water. Dextrose solution is usually ordered for:

Hypoglycemia
Maintenance fluids

Dextrose is osmotically active, meaning it does cause the fluid to increase its tonicity, and will lead to net fluid shifts out of the cells. However, dextrose is rapidly metabolized, so the effective osmolarity tends to be higher than the base fluid, but lower than the calculated osmolarity.

Common dextrose solutions include:

D5W: Dextrose 5% in Water
D10W: Dextrose 10% in Water
D5NS: Dextrose 5% in NS
D5 1/2 NS: Dextrose 5% in 1/2 NS
D5LR: Dextrose 5% in LR

Overall, there is little evidence that dextrose with NS has any benefit or harm when compared to saline alone. However, dextrose should probably be added in:

Hypoglycemia
Alcohol intoxication
Starvation ketosis

Dextrose should not be used in:

Hyperglycemia
Hypokalemia

An amp (25gm) of 50% Dextrose (D50) is often given as an IV push medication to treat profound hypoglycemia or in conjunction with IV insulin to lower potassium levels.

D5W and D10W are often used for slow correction of chronic hypernatremia, or when hyponatremia has been too-rapidly corrected. It is often commonly found mixed with certain medications.

A patient on dextrose-solution should have their blood sugar monitored, as well as their electrolytes as with any IV fluid. Dextrose-containing solutions should not be given in boluses unless as described above with D50.

Potassium-containing Solutions

Sometimes potassium may be added to each liter bag of fluids. Potassium may be added to maintenance fluid in:

Hypokalemia
Ongoing potassium losses
DKA or severe hyperglycemia

Potassium is as osmotically active as sodium, so this will increase the osmolarity and cause the fluid to be more hypertonic.

This means that adding potassium to an isotonic fluid will make it hypertonic, so may not be a good choice in those with cellular dehydration like in DKA.

In these instances, adding potassium to a hypotonic base fluid such as D5NS with potassium is a great alternative option.

Remember that potassium should NEVER be used as a bolus. IV administration should not exceed 10mEq/hour in most situations, or 20mEq/hour in critical situations with cardiac monitoring and preferably a central line.

Related Article: “9 Nursing Medication Errors that KILL”

Bicarbonate-containing Solutions

Sometimes Bicarb can be added to IV fluids, in order to assist with significant metabolic acidosis. This is not super common outside of the ICU.

And that sums up IV fluids! Hopefully you found this article helpful. If you have any unanswered questions, please comment down below!

References:

Rochwerg, B. et al (2014). Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Annals of internal medicine, 161(5), 347–355. https://pubmed.ncbi.nlm.nih.gov/25047428/

Sterns, R. H. (2020). Maintenance and replacement fluid therapy in adults. In T. W. Post (Ed.), UpToDate. https://www.uptodate.com/contents/maintenance-and-replacement-fluid-therapy-in-adults

Wilkins, L. W. (2005). Fluids and electrolytes made incredibly easy. Lippincott Williams & Wilkins.

Zitek, T., Skaggs, Z. D., Rahbar, A., Patel, J., & Khan, M. (2018). Does Intravenous Lactated Ringer’s Solution Raise Serum Lactate?. The Journal of emergency medicine, 55(3), 313–318. https://pubmed.ncbi.nlm.nih.gov/25047428/

IV Fluid Cheat Sheet

Everything you need to know about IV Fluid including the different uses and contraindications of each type of IV Fluid! It's absolutely free.

William Kelly, MSN, FNP-C( Author )

I am an ER Nurse Practitioner who creates content for bedside nurses and clinicians, making practical application of nursing education. Read more!

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