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Intravenous Fluids: Types of IV fluids

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.

Intravenous fluids featured image

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)

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.

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.

Related article: “The Cranial Nerve Assessment for Nurses”

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:

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.

Intravenous fluids Pinterest pin

How to Start an IV

How to Start an IV

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

Learning how to start an IV is a very important skill that every nurse needs to know. Inpatient and ER nurses deal with IVs every day – whether they are inserting them, removing them, or administering fluids or medications through them. If you are new to nursing, then you will need to learn how to insert an IV with confidence and knowledge!

How to start an IV: Feat

When to put in an IV

The short answer to this is “when an IV is ordered”. However, it is important to critically think as a nurse, and anticipate what will need to be done. Especially as an ER nurse, you may see your patient before the Provider and can start placing an IV if indicated.

If you work as an inpatient nurse, most patients should have at least an IV, midlines, PICC lines, or other central access. These IVs often go bad, and you will need to know how to start an IV in these settings as well.

Indications for an IV:

  • IV fluids or medications – this is the usual reason
  • Diagnostic Imaging – CTs or MRIs often require an IV for IV contrast to help visualize the anatomy and any potential pathology
  • Inpatient Admission – usually required unless refusal

Contraindications:

There is no outright contraindication to placing an IV, but certain factors will exclude specific locations. These include extremities with:

  • AV Fistulas or grafts (dialysis patients)
  • Previous mastectomy or lymph node dissection
  • Blood clots
  • Significant burns or edema
  • Overlying infection (cellulitis)

It may be best to avoid limbs with significant motor or sensory deficits, as there is unclear evidence that may suggest increased DVT in these extremities. If their arm is numb, they also may not feel when it is infiltrated.

Choosing the IV Size

The IV gauge will determine how big the actual needle and catheter are. The bigger the IV – the faster fluid can be administered. Unfortunately, bigger sizes are also more painful and usually more difficult to insert. Bigger IVs also come with increased risk of phlebitis and can cause some serious irritation to the vein.

24 gauge: The Baby Needle

These are typically used for babies and generally should be avoided in adults. They are very short, flimsy, and won’t last long.

  • Good for: Infants
  • Bad for: Most other scenarios

22 gauge: The Safe Choice

This is used for many kids and adults, especially older adults with fragile “easily-blown” veins. These are usually OK for IV contrast dye as well, but not for CTA. These are also generally easier to place.

  • Good for: Peds, many Med-Surg adult patients, easily blown veins
  • OK for: IV contrast, blood return
  • Bad for: Massive trauma or fluid resuscitation needs, CT Angiography

20 gauge: The One-Size-Fits-All

20g IVs are an ER nurse’s best friend. This is because a 20g IV is adequate for multiple fluid boluses, IV medication infusions, and most CTA requirements. They often give great blood return and labs can often be drawn without hemolysis.

  • Good for: Most adult patients, CT Angiography
  • OK for: Emergency situations (code blues, RRTs)
  • Bad for: Massive trauma or fluid resuscitation needs

18 gauge: The Big Daddy

18g IVs are your standard “large bore” IV. These are great in critical situations as they provide for rapid administration of fluids or blood products, rapid infusion of critical medications. The down-side is they tend to be a little more difficult to place in the absence of large veins.

  • Good for: Critical or emergency situations, rapid fluid administration, CTA, severe sepsis, burns, acute MI, etc
  • Bad for: Small, fragile veins

14-16g: The Monsters

The 16g and 14g IVs are very large, and unnecessary for most indications. However, in critical situations these may serve you well.

  • Good for: Rapid fluid resuscitation or critical situations as above
  • Bad for: Small veins – Unnecessary for most indications

Clinical Tip: Some nurses may tell you to place the largest IV catheter that the vein can support. However, this is contrary to good nursing judgment. If you ask my friend Brian (@TheIVGuy), he will tell you that you should choose your size based on the appropriate ordered therapy and anticipated needs. This means that for most patients, a 20-22 gauge is likely the best and safest choice.

How-to-start-an-IV-IV-gauges

IV Insertion Equipment

Before learning how to start an IV, you need to first know which equipment you will need. This becomes like second nature, but when starting out as a new nurse, this is often important to memorize. For an IV insertion, you will need:

  • IV Insertion Kit, which usually includes:
    • Chlorhexidine / ETOH swab
    • Tegaderm dressing +/- securement device
    • 2×2 gauze
    • Tourniquet
  • IV catheter of choice (18-22g)
  • Blood transfer device (Vacutainer) – if drawing blood
  • Extension Loop or cap
  • 1-2 10cc flush
  • Tape

Once you have your equipment, you are ready to know how to start an IV.

How to Start an IV

Prepare the Patient

To start an IV, you will first want to wash your hands (always the right starting point). You will also want to use universal precautions, so put on a pair of clean gloves as you will be possibly interacting with the patient’s blood.

You should already have an idea of where you are going to place the IV and which size IV catheter you are going to use.

Place the tourniquet on the patient’s arm proximal to the area of cannulation. Look for straight, large veins. Palpate them as veins may not always be visible but can still be felt. Strong veins will have a good amount of bounce to them.

Once you are happy with your vein selection, you can start prepping your area. Use a chlorhexidine (CHG) or alcohol swab to gently clean the surrounding area for 30 seconds, and allow to completely dry. Start with the center and move outward in a circular fashion with alcohol, while CHG requires a back and forth scrubbing action.

With deeper non-visible veins, some nurses will also apply alcohol to a finger of their non-dominant hand to help palpate during the procedure without “contaminating” the site. Please note that this is not the best practice for infection control. You should never tear off the finger of your glove either, instead – learn to palpate with your gloves on.

Preparing the IV

While your site is drying, open your 10cc flush and your extension loop and/or cap. If you are drawing blood, hook up the blood transfer device to the dry extension loop or cap. Otherwise, you can connect the flush and prime the loop or cap. Set this aside back into your kit to keep it clean.

Open up your IV, take off the needle cap, and twist the end of the catheter to make sure it is loose and ready for cannulation.

Inserting the IV

Hold the skin taut with your non-dominant hand to secure the vein. This helps to stabilize the vein and prevent it from rolling. Place the tip of the needle against the skin at a 10-30 degree angle. If the vein is deeper, use a slightly more angular approach initially. With the bevel up, puncture the skin and advance through to the vein.

If done correctly, you should see a flashback of blood in the flash chamber and/or catheter. This location will depend on the brand and size of the specific IV catheter. Once flashback is seen, lower the angle even more parallel with the skin, and advance the whole unit about 2-6mm. Now advance only the catheter forward, sliding it off of the needle and cannulating the vein. If done correctly, the catheter should easily slip into the vein without resistance. If there is dimpling of the skin, the IV is likely within the extravascular space.

Clinical Tip: If you initially don’t see flash of blood, pull the needle and catheter both out almost completely (but do not leave the epidermis). Re-palpate the vein, adjust your angle and advance again. This is termed “digging” and some patients will not tolerate this well. However, oftentimes it may only take 2 or 3 “digs” until success.

Before pressing the activation button to retract the needle – take off the tourniquet and apply digital pressure beyond the catheter tip. Some brands will have a septum or shield function with gauges 20-24, which prevents the backflow of blood and negates the need for venous compression. Press your activation button to retract the needle.

Draw Blood

If ordered, now is the point where you will draw your blood. Hook up your loop/cap with the blood transfer device to the IV hub. Draw your blood tubes, and flush with a 10cc pulse flush afterward.

Clinical Tip: Blue Tops for coags (PT/PTT) are often drawn first, and it is necessary to fill these tubes up completely for the lab to run the tests. If you have an extension loop, that .5-1cc in the loop can unfortunately cause the tube not to be full enough and you will need to redraw it. Best practice is to waste a tube first.

If you are not drawing blood, skip this step and instead just connect the primed cap or extension loop to the IV and flush. After flushing a few mLs, make sure you can pull back blood return. This is reassurance that the IV is in the correct place. Then pulse flush the remaining amount through.

Secure the IV

Secure the IV with a securement device or tape, and a dressing like Tegaderm. Make sure the insertion site is covered. If you used an extension loop, secure the loop with tape as this can easily get caught on something and pull out the IV.

If the patient is confused or may try pulling the IV out, wrap the IV with Coban, only leaving the cap accessible.

Administer any medications or fluids through the IV as ordered.

How to start an IV: infographic

How to Remove an IV

If the patient is discharged or if there is a compilation with the IV, it will need to be removed. Removing the IV is easier, and can be performed by a nurse or a patient care assistant.

1. Collect 2×2 gauze and tape or bandaid

2. Wash your hands and don clean gloves

3. While holding the catheter in place, start peeling off the Tegaderm and/or tape. Use an alcohol pad if very sticky and painful.

4. Once the dressing is no longer secured to the skin, place a 2×2 gauze over the insertion site, and pull out the IV in a smooth fashion.

5. Hold pressure for 1-2 minutes until bleeding as stopped

6. Dress with gauze and tape or bandaid

    How to start an IV

    10 ER Nursing Hacks You Need to Know

    10 ER Nursing Hacks You Need to Know

    ER nursing hacks can be just what you need to make your shift go from terrible to not-as-terrible. As nurses, we aren’t afraid to get our hands dirty. We take charge, do what needs to be done, and then find a way to laugh about it in the end.

    Working in the Emergency Department can be especially draining – physically, mentally, and emotionally. However, just because nursing is HARD doesn’t mean we can’t utilize tips and tricks to make that 12-hour shift a little bit more bearable. Use these “10 Nursing Hacks Every ER Nurse Should Know” to save time, save your senses, and save your sanity!

    Please keep in mind the following hacks are anecdotally based. You must use these within your own judgment and within your facility’s protocols. You can read more about this on my disclaimer page.

    ER Nursing Hacks: Featured 2

    1 ER Nursing Hacks: Double-Glovin’ in the Oven

    As you know, personal protection equipment including clean gloves and gowns are absolutely necessary in a hospital environment. For some procedures, clean gloves are “good enough”. However, for high-risk infection procedures, sterile gloves are necessary.

    Foley catheter insertion is one of those procedures, as catheter-associated infections are very common. While putting in a Foley catheter can become like second-nature rather quickly, there can be some difficulties with the sterile procedure.

    ER Nursing Hacks 1: Double Glove

    For one – those cheap sterile gloves that come with the foley kit are typically a size 5.0. So unless you have baby-hands, I’d recommend grabbing an appropriately sized package of latex-free rubber gloves. You might want to go a half-size above your normal for this method.

    After grabbing your foley kit and sterile gloves, position the patient, and then wash your hands (duh). Afterward, put on a pair of clean gloves FIRST, then proceed to open your kit and apply your sterile gloves, and continue the insertion per normal.

    Using this nursing hack, once you insert the foley and blow up the balloon, you can take off your previously sterile gloves which are now likely dripping with Betadine and other fluids. Luckily – you still have a pair of gloves underneath to secure the cath-secure, position the foley bag, and clean up your pile of trash! Once that’s done, slip off the gloves, wash your hands, and you’re done! Easy-peasy-Kegel-Squeezy.

    2 Burp that Bolus

    This concept is a little more confusing, but it can save time! In the ER, we hang A LOT of boluses and every ER nurse knows that pumps are harder to find than a rectal thermometer. So naturally, ER nurses are resourceful and use gravity. Patients often require multiple boluses, and Lord knows you are almost always sometimes just too busy to switch out bags before the bag runs out and half of the tubing is now air.

    In this predicament, you could flush out the rest of the line in a trash can, then unspike and re-spike your new bag, and THEN re-prime the line. Or you could get a whole new tubing set and just throw out the old bag/tubing. As you can see – this wastes either valuable time or equipment/money! 

    But what if I told you there was an ER nursing hack to solve this? When you go to prime the original bolus, clamp your tubing and spike your bag. Do NOT squeeze fluid into the drip chamber yet. Now, turn the bag upside down. Unclamp the tubing, and “burp” out the excess air at the top of the upside-down bag.

    ER Nursing Hacks 2: Bolus Burp

    Once the air is gone and some fluid is forced into the drip chamber, turn the bag right-side-up. Now prime the tubing as normal and hook the patient up. You’ve essentially created a vacuum so that the fluid will stop flowing before it empties the drip chamber – ready for your second bolus when you are. 

    3 Juice cup? Change it up!

    ER Nursing Hacks 3: Juice cup

    Unless you work at an adult-only ER, you are likely seeing patients that span the clinical spectrum – this includes pediatric patients. One thing about pediatric patients is that they HATE taking their medications.

    One particularly difficult medication to give a child PO is Dexamethasone oral solution. Unfortunately, it’s usually made with a good portion of alcohol content, and it smells and tastes like…vodka?

    After forcing it down, kids often vomit it up – all your hard work for nothing. One ER nursing hack to avoid having to give an IM shot is swapping oral Dexamethasone for the IV solution.

    IV medications cannot always be used orally, but sometimes they can! IV Dexamethasone has successfully been administered mixed with cherry-syrup, juice, or followed by a popsicle – and children take the medicine MUCH easier! Don’t forget though, you must run this by the provider before trying it, as studies are somewhat mixed on the efficacy (pharmacokinetic info here).

    4 Septic Sock

    Now I KNOW you have smelt some SMELLS in the ER (or anywhere in the hospital for that matter). There is nothing stronger than a nurse’s nose. C-diff, fungi, and bodily secretions aside – sometimes the worst smell comes from down under (the feet – ya nasty).

    Unfortunately, working 12-hour shifts where you are constantly on your feet and running around, you might find yourself with some STANKY feet. The good news is, even if you don’t have stinky feet, this ER nursing hack can help you deal with a patient’s particularly putrid piggy-toes. But first, a quick science lesson.

    While sweat is the main cause of foot odor, sweat doesn’t actually smell. Instead, it creates a perfect medium for bacteria. These bacteria include Brevibacteria and S. epidermidis (known for their cheese-like smell), as well as propionibacteria (known for its vinegar-like smell).

    Regardless of which bacteria are causing the odor, they are all highly acidic. So here’s the hack: If you or one of your patients has particularly powerful foot odor – use an antacid! Lather Maalox or Mylanta on the feet, put surgical booties over top, and you won’t believe how fast it can help! Another option is to scrub the feet with Hibiclens or betadine for antibacterial action. Better yet – do both!

    Fair warning though, if there is any fungi growing – these methods might not work as well. To prevent foot odor, it’s recommended to wear breathable shoes, breathable socks (cotton or wool), and wash and exfoliate your feet frequently. A little dab of foot-powder in your shoes every few days never hurt anyone either (Gold Bond anyone? #NotSponsored)

    Related Article: Six Steps for Sepsis Management

    5 Thinking Outside the Vial

    Every nurse knows that lidocaine is extremely helpful as a topical anesthetic for suturing , regional blocks, and even intra-articular injections to numb pain. However, lidocaine is not limited to only these uses. While not quite a “nursing hack”, these alternative uses of lidocaine are important to know so you can offer suggestions to the attending when indicated.

    Gastritis

    OK, you probably knew this one – viscous lidocaine is often mixed with an antacid and sometimes an antispasmodic to create a “GI cocktail” to help with the pain of gastric or esophageal etiology. This is always a good suggestion for those young chest pain when GI etiology is suspected.

    NG Tube Insertion

    They have done research to see if lidocaine gel, nebulized lidocaine, and anesthetic spray have been useful for NG tube insertion. Not too surprisingly, patients who get lidocaine gel or spray administered intranasally/orally had significantly less pain with insertion – but can have a more difficult NG experience. Additionally, nebulized lidocaine has proven to decrease pain and increase comfort during NG tube insertions, but can increase the chances of nosebleeds.

    Cough

    Sometimes with persistent laryngospasm, nebulized lidocaine can be used effectively to help with a cough. However, there isn’t a significant amount of research on this, so you likely won’t see it ordered often and will depend on the Provider.

    Oral Pain

    Those experiencing pain in their mouth from a painful lesion such as an aphthous or herpetic ulcers can benefit from viscous lidocaine “swished” and either swallowed or spit afterward.

    Foley Insertion (males)

    This is also more common, but the provider may order 5-10ml viscous lidocaine to inject into the urethra before a difficult-anticipated foley insertion in males. Luckily, this usually comes pre-packaged in a syringe called a Uro-Jet. This should be injected directly into the urethra a few minutes before attempting the foley insertion. This can help reduce pain and be especially helpful in patients with a small meatus, anatomical abnormalities, or prostate enlargement.

    Renal Colic ER

    While meds like morphine and Dilaudid are used frequently in the ER and hospital, sometimes there are effective alternatives to opioids that actually work really well. Slow infusion of low-dose IV lidocaine can be used effectively for kidney pain. It’s recommended for use if NSAIDs and Opioids are contraindicated or risky. One study even indicates that IV lidocaine at appropriate doses safely lowered the patient’s pain more than morphine.

    Related Article: Opioid Alternative Analgesics in the ER

    6 Alcohol Swab Nursing Hacks

    There are a few things we nurses usually load up our pockets with. Usually, these consist of tape, band-aids, paper, pens, and alcohol pads. But did you know how versatile alcohol pads can truly be?

    Blood Cleanup

    This is more of a no-brainer, but when you accidentally make a mess with blood while putting in an IV, patients appreciate it if you help clean up your mess. Busting out an alcohol swab can easily clean up dried blood on their skin. If alcohol doesn’t do the trick, sometimes using KY jelly lube works even better. Alternatively, you could use hydrogen peroxide.

    Nausea Nursing Hack

    Did you know that a few whiffs of alcohol pad can relieve nausea almost immediately? Sure – Zofran is still our bread and butter, but this nursing hack works pretty quickly!

    When your patient is nauseous, break open an alcohol swab and place it right under their nose. Tell them to take 3-4 deep slow breaths. Before you know it – they should start feeling somewhat better. In fact, clinical research suggests that alcohol may even be more effective than oral zofran, or at least a useful adjuct.

    Scientists don’t exactly know why this works. Some think it’s purely due to “olfactory distraction” – distraction while following the instructions, taking deep breaths, and relaxing the body.

    Pseudoseizure Nursing Hack

    In the ER, the nurses frequently experience patients who have not-so-believable “seizures”. These “fake” seizures are termed pseudoseizures, and the patient might not even know that they are “faking”. Typically when this happens, we bust out an ammonia salt and place it underneath the patient’s nose. This tends to stop their “seizures” pretty much immediately. But what do you do if you don’t have an ammonia inhalant on hand?

    Not every ER utilizes ammonia salts, and sometimes they can be hard to find. If you experience a patient with what you believe to be a pseudoseizure, try opening an alcohol pad and placing it directly beneath their nose. This may distract them and bring them out of their “seizure”. Please note this is anecdotal and is not in the literature. 

    Save your Senses (ER Nursing Hack)

    Clostridium Difficile (C-Diff) is a common diarrheal infection which can make people pretty sick. We often see these patients in the ER and hospitals. Unfortunately, C-diff is very contagious and tends to run rampant in nursing homes and hospitals. As we all know, C-Diff has a pretty distinct and powerful smell which can be hard to erase from our noses!

    Before going into a C-diff patient’s room, add a mask to your PPE. Break open an alcohol swab and place it inside the mask. This way, the isopropyl alcohol overpowers the C-diff smell and you save your senses – or at least make it more tolerable.

    If alcohol swabs are too strong for you, you can try rubbing toothpaste or Vix rub inside a double-layered mask. This nursing hack works well for C-diff, but also for other smelly situations including I&Ds, rotting flesh, nasty wounds, and fungal infections.

    7 IV Stick Trick

    Putting in IVs is super common in hospitals, especially within the emergency department. If one thing is sure – patients hate getting stuck! Some tense up, others look away, and then there’s those who shake, cry, and even syncopize. Ironically, the latter is usually buffed up guys with tattoos all over their bodies! People don’t like needle sticks because the needles hurt. But what if I were to tell you that there’s a way you can decrease pain, without any medication or extra equipment?

    This ER nursing hack will help your IV insertions go more smoothly! After you clean the IV site, place the needle flush with the skin right where you are going to poke. Press the needle into the cleansed skin with the bevel up for 3-5 seconds before you puncture the skin. The longer you wait – the more desensitized their pain receptors will become – this should decrease the pain felt.

    ER Nursing Hack: IV desensitization

    With less perceived pain, the patient may tell you “is that it?!” or “I could barely feel it!”. It also takes away the “shock” factor, making the patient less likely to jump! For most patients, this technique will be effective, however, some patients still will have a high amount of perceived pain, especially if you dig.

    Related Article:

    8 BP not Enough? Use the Bedside Cuff

    Vital signs are an important aspect of nursing care and patient monitoring. Blood pressures have a tendency in the ER to be very high or very low. When very low, we give large amounts of fluids as fast as we can. While pressure-bags are a great option and ensure fast infusion, they are not always available.

    Many ER rooms have bedside manual blood pressure sphygmomanometers. In place of a pressure-bag, use the blood pressure cuff around the middle to top of the bolus and pump it up until it flows nicely. Like the pressure bag – you will have to occasionally pump in more air as the bag empties.

    Related Articles: “5 Vital Sign Errors to Avoid”

    9 Neb-wick Air Freshener

    After a particularly smelly patient leaves, sometimes the aroma sticks around in the air. Unfortunately, Lysol sprays don’t always cut it. Now I personally am not a huge believer in the essential oil craze, but this nursing hack requires someone on staff to have essential oils or strong smelling lotion.

    Take a used nebulizer adapter and squirt some water or saline in the medication chamber. Next, add a few drops of an essential oil of your choice. Turn the oxygen on high and viola. This nursing hack will have the room smelling Glade-scented fresh in no time. Talk about Oxy-Clean!

    ER Nursing Hacks 9: Neb-wick

    10 The Dependable Bedpan Nursing Hack

    Many patients cannot or should not ambulate while they are in the ED. This is fine until they have to use the bathroom. Bedpans can be successfully used for both #1 and #2, but unfortunately, they have a tendency to cause messes. Whether you are using a fracture pan or a regular bedpan, line the pan with an adult diaper or absorbable pad. Secure it with tape or rubber bands. You can also use a large pull-up inverted inside-out and secure it over the bedpan. Place the bedpan underneath the patient as normal.

    This way, any urine or liquid stools are absorbed in the material and do not splash, spill, or cause messes. It also allows for easy cleanup! If you need to collect a urine or liquid stool sample – this method should not be used.

    Related Articles: “Comprehensive Urinalysis Interpretation”

    Hopefully, you found these 10 ER nursing hacks to be useful. Implementing them in our everyday shifts should help save our senses and our sanity, not to mention our time! As a nurse, we are pulled in so many different directions at once and expected to always be on top of our patient care. Utilizing these hacks will hopefully help.

    What are your personal nursing hacks which help save you time and make you a more efficient nurse? Let me know in the comments below, and share this article with your nursing friends!

    Check out more general nursing hacks over at FRESHRN here!

    ER Nursing Hacks: Pin 2