Calling the Doctor – Giving Nurse to Provider report

Calling the Doctor – Giving Nurse to Provider report

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When I first started working as a bedside RN, one of the aspects of the job that gave me a deep sense of anxiety was having to call the doctor on a patient. Sure – some of them were super nice – but many of them were impatient and rude. Not giving the correct phone report in a format that the physician or Advanced Practice Provider (APP) is looking for can create tension and miscommunication. If you utilize my technique for giving phone report to the physician – the patient’s situation will be more effectively communicated and the encounter will go much smoother.

In this article, I am going to share with you all an effective method for giving a quick report to the physician or APP when you call them in the inpatient setting! I am uniquely positioned to help with this because I work as a Nurse Practitioner in the hospital and receive 20-30 calls per night from floor nurses. I have noticed many improvements that can be made to improve communication – so keep reading!

Step 1: Introduce yourself and the patient

“Hi, My name is Michelle and I’m calling from 1G. I’m the nurse taking care of Anita Lopez in 230-2. Are you familiar with her?”

First you need to introduce who you are, where you’re calling from, and who you’re calling about. I can’t tell you how many times the nurse has called me and launched into a full explanation about the patient and then I have to ask “Who is the patient!?” Oftentimes the inpatient Provider is at the computer and can look up the patient’s chart while the nurse is talking.

Sometimes over the phone it is difficult to understand last names – especially if accents are involved. When you say the patient’s name, it helps if you say “Anita Lopez, that’s L-O-P-E-Z”. Spell out the last name because oftentimes we have censuses pulled up from each floor or hospital which are ordered alphabetically. We usually do not need the spelling of the first name.

It also can be helpfult to include where they are located – their unit and room number. Additionally – the Provider you are calling may only cover certain attending physicians (as is the case at my job). If this is so – give the attending physician as well.

The next step is to ask if they are familiar with the patient. If I just admitted the patient – I don’t need a full explanation of why they’re here and what their medical history is. However, many specialists or Providers who are on call may not be very familiar with the patient yet. It always helps to ask and most Providers won’t give you an issue by asking.

Step 2: Brief Medical History

“She’s a 78 year old female who came in on 11/28 for a COPD exacerbation. She has a PMHx of COPD, Smoking, Hypertension, Hyperlipidemia, and afib which she’s on Coumadin for”

In the inpatient setting – I always want to know why the patient was admitted. This gives some context to the patient’s situation. If a patient who came in for COPD exacerbation is complaining of a headache – that typically deems less investigation than a patient who came in for a TIA or a mechanical fall and is now having a headache.

Additionally, a brief overview of their medical history should be given with emphasis on important/related diseases. Hit the following:

  • Cardiac: HTN, CAD (any stents or CABG?), Afib (anticoagulants?), CHF
  • Pulmonary: COPD, asthma, Lung cancer
  • Renal: AKI, CKD, ESRD (on dialysis?)
  • Vascular: DVT/PE, PAD/PVD

You usually don’t need to go into any details regarding surgical history unless it is directly relevant to this admission in some way.

Step 3: Why You’re Calling (SITUATION)

“The patient is complaining of increased SOB”

This is pretty simple. Why are you calling the Provider in the first place? Usually this is due to :

  • A new complaint: Chest pain, SOB, Headache
  • A medication need: sleeping medication, breathing tx, pain medicine
  • A change in the patient’s status: Respiratory distress, Unresponsive, confusion
  • A critical lab value : elevated troponin, elevated lactic, positive blood cultures

No matter why you’re calling – simply state it and then jump into the following step – the background of the situation.

Step 4: Situation Background

“They are ordered duonebs q6h but has nothing ordered PRN”

By this point you already given the important information such as who you are, who the patient is, where they are, why they were admitted, and why you’re calling. Now you can get to the heart of the call and give context to the situation at hand.

In this instance, the patient is SOB and has COPD. Are they ordered breathing treatments and how often? No matter why you’re calling, it helps to ask these questions:

  • Has this happened before and what was done? Did it help?
  • Are they currently on any medication for the situation?
  • What trends have been occurring (i.e. if you’re calling for high BP, how have their BPs been?)

Investigating the background of the situation can really help communicate the correct need to the Provider.

Step 5: Assessment

“The patient’s RR is 24 rpm and SPO2 is 90% on 2L NC. They’re breathing is non-labored, lung sounds show expiratory wheezes throughout”

As the nurse, you are responsible for assessing the patient first when there is a change in their status. This doesn’t mean you need to do an entire nursing assessment and report that, but get their vital signs and a do a quick physical assessment of the systems involved (I.e. If you’re calling for SOB – tell me how they are breathing and what their lungs sound like).

Please make sure you get an UPDATED set of vital signs whenever there is a change in patient status. Their vital signs from the 3-4 hours ago are not helpful to the current situation (depending on why you’re calling). That’s just good practice.

Step 6: Recommendations

“Can you please add albuterol PRN for inbetween scheduled duonebs”

Nurses are the eyes, ears, and hands of health care. They are on the front lines, are well-educated, and usually have great recommendations to help their patient. Maybe you know just what the patient needs to feel better.

Another important recommendation is asking if the Provider can evaluate the patient in-person. Sometimes it is difficult to convey your uneasiness about how a patient looks – even if their “numbers” look fine. Asking the Provider to personally evaluate the patient (if needed and indicated) is a great way to ensure the patient is in good hands.

Related Content: Tips for New Nurse Practitioners

– – – – – –

So Yes, it is SBAR, but with some important introductory steps beforehand. But what if you’re a Provider and need to know how to call consults to other Providers? I’m going to let you in on a secret – these steps are exactly what I do when I call a Provider for a consult as an NP. There really is no difference between a good nurse-to-provider report or a provider-to-provider SBAR.

As long as all the relevant information is conveyed in a concise and organized manner, you will be sure to impress the Providers you are calling, and ensure that proper communication is maintained – giving your patient the best possible care.

Six Steps for Sepsis Management

Six Steps for Sepsis Management

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

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

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

1. Recognition and Early Intervention

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

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

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

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

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

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

2. Fluid Resuscitation!

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

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

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

3. Timely Antibiotic Administration

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

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

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

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

4. Hemodynamic Management

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

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

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

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

5. Monitoring

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

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

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

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

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

6. Patient Disposition and Follow-Up

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

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

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

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

 

10 IV Insertion Tips for Nurses

10 IV Insertion Tips for Nurses

IV Insertion is a skill that most nurses will need to become familiar with.

Nurses in the hospital use IVs every day to infuse fluids and medications, as well as to draw blood. While IVs are very useful, sometimes IV insertion can be difficult, – especially for the new or inexperienced nurse.

With time and experience, your IV skills will improve. In the meantime, use these 10 IV insertion tips to help you start an IV and sink those IVs like a pro.

1. IV Insertion: Location Location Location

AC

IV insertion - vein anatomyThe best location of your IV insertion really depends on which setting you are in, as well as the specific patient’s chief complaint.

It is common for inpatient nurses to be upset with AC lines, but the fact of the matter is an AC line is likely an ER nurse’s best friend.

If a patient presents with anything that can even possibly get a CTA – You’re better off choosing the AC. The LAST thing anybody wants to do is have to unnecessarily poke someone again.

So – if the patient has a neurological complaint (stroke s/s), cardiac complaint, or pulmonary complaint – a CTA may possibly be ordered and most hospital facilities/radiology staff won’t inject the high-pressured dye unless there is at least an 18g or 20g in a large vein (aka AC and above).

Additionally, patients who are hemodynamically unstable should receive a 16g – 18g in an AC for large fluid resuscitation.

If the patient is getting continuous infusions and the patient occlusion alarm keeps going off, ask the patient if you can place another IV preferably in the forearm or hand.

Forearm

Forearms are the perfect location for continuous fluids because they don’t kink with arm bending.

However, not everyone has great forearm options.

Additionally, forearm veins do not always reliably give great blood return for bloodwork, although this may mainly be a consideration in the ED where they typically draw blood work during IV insertions.

Hand

Hand IVs are sometimes the easiest veins to see. However, they are usually relatively small veins, and placing an 18g here may be somewhat difficult.

They are great for short periods of time, but can easily become irritated.

Additionally, they limit the use of the hand and are more likely to start hurting the patient – especially with vasocaustic infusions such as vancomycin or potassium.

2. Small veins? Make them Larger

Heat

Heat is great because it causes vasodilation. When veins dilate, they become bigger.

Applying a warm compress or hot pack can help you visualize the vein, palpate the vein, and can even make threading the IV easier when starting an IV.

Just ensure the compress is not too hot to cause thermal burns.

Gravity

Putting the arm in a dependent position forces blood pooling in the distal veins, which will make them bigger and easier to see and palpate.

This should make IV insertion easier with a higher chance of success.

Also Read: “10 ER Nursing Hacks you Need to Know”

Nitroglycerin Ointment 2%

A small amount of 2% Nitroglycerin can be topically applied to a small area in order to dilate the peripheral veins.

In a small study, those with 2% Nitro ointment applied to the dorsum of their hands required fewer needle sticks than the controlled group.

Please note that this is a medication, so you need an order!

3. IV Insertion with Fragile Veins

Change your Selection

Sometimes, elderly patients tend to have crappy veins.

Sure, you can see them alright, but once you stick them – they blow immediately (even with a 22g).

This is definitely a good time to look for larger more proximal veins, as IV insertion in these veins tends to be more stable and not blow immediately.

Forget the Tourniquet

If you can visualize or palpate the vein without a tourniquet – try the IV insertion without the tourniquet.

Tourniquets are great for engorging the vein and causing it to dilate, but they also add pressure to the vein.

Already fragile veins will have an increased tendency to blow with the added pressure from the tourniquet. Never forget to remove the tourniquet before flushing the IV!

4. Don’t Give Up during IV Insertion

OK – some people HATE digging when starting an IV – and this is understandable. However, sometimes it is minimally painful and you can thread the catheter within a few seconds of “digging”.

The trick is to not “dig” blindly – but instead use your fingers to palpate the accurate direction of the vein.

After inserting the needle with the catheter, if you do not get a flash of blood, pull the needle and catheter back out to almost out of the skin, re-palpate the vein, and aim again in the direction of the vein.

I can’t even count how many times I missed on the first pass, but immediately threaded the IV on the 2nd or 3rd advancement.

The patient also experiences some desensitization of their pain receptors and it is usually less painful than being poked again.

However, some patients really do NOT tolerate this, and they will let you know not to “dig”.

Quick Note: It is not recommended to retract only the needle while leaving the catheter in place, and then re-advancing the needle. This leads to a risk of fracturing the catheter and can possibly lead to a foreign body in the patient’s body!

Related content: “How to Start an IV”

    5. Go Big or Go Home

    Smaller is not always easier. Sometimes 22g and below are too flimsy.

    When the veins are sclerosed, hardened, or there is scar tissue – choosing a 20G might be a better bet in order to thread the catheter without any issues.

    Besides – 20g IVs are better in an emergency and are more durable.

    Related content: “5 Vital Signs Error to Avoid”

    6. Arterial Stick

    When inserting an IV, you can accidentally hit an artery instead of a vein.

    First, if the IV is pulsating – take it out immediately. It’s possible the vein is just right next to the artery, but it is likely you are actually in the artery.

    This is usually accompanied by blood filling up the catheter VERY quickly – depending on the patient’s mean arterial pressure.

    Arterial blood tends to be a bright red, versus the darker red of venous blood.

    So what’s the harm? Access is access, right?

    Well, sure that makes sense on the surface. But peripheral IVs inserted in arterial lines tend to have much higher complications – the worst of which being thrombophlebitis.

    You can literally cause a blood clot in the patient’s arm. This is even more of a risk if medications are infused through it.

    Remove the catheter and try again in an actual vein.

    7. Inserting the IV Outside the Box

    Or rather – think outside the lower arm.

    If you can, look at the upper arm as sometimes there are large veins close to the surface.

    Most facilities prefer you to stick an IV in an arm, but there are exceptions. If the patient is an extremely hard stick and needs access, you can look at lower extremities, but caution against it as these are high risk for infection.

    No – don’t go for these strange areas initially, but in an emergency, any access is better than none.

    However, in a code situation – temporary placement of an Intraosseous (IO) catheter is preferred.

    If a better IV site still cannot be obtained, someone skilled with ultrasound-guided IV placement should try, or a PICC/Central line should be considered.

    8. Angle Danger

    I have watched MANY nurses and nursing students miss when inserting an IV purely because of their technique.

    They hold the skin taut, stabilize the vein, and insert – but they go right through the vein and can’t thread the catheter.

    I have seen that this is often from approaching the vein with too much of an angle.

    You should really aim to be near parallel with the skin (10-30 degrees). Gliding the needle into the vein with this angle means once you get a flash, the needle is likely still within the vein and the catheter can be advanced.

    The exception is if you are aiming for a deeper vein – you may need to increase the angle accordingly.

    If you find that you insert the needle and cannot float the catheter in, despite having a “good” flash of blood – try pulling the needle and catheter out just a millimeter or two, and try advancing just the plastic catheter again.

    Related content: “How to Start an IV”

    9. Rollie Pollie Ollie

    Sometimes patient’s veins just like to roll – and the patient will likely forewarn you about this. There are a few things you can do to minimize this.

    First, pick a larger more proximal vein. These veins tend to be more stable.

    Second, make sure you stabilize the vein by holding the skin taut with your non-dominant hand.

    Lastly, make sure the patient does not tense up their muscles during the insertion. Tensing of muscles will cause movement of the veins. To minimize muscular contractions – use the tip below!

    10. Patient Comfort

    This IV insertion tip is really more for patient comfort than anything else. After you clean the IV site, place the needle flush with the skin right where you are going to poke.

    Press the needle with the bevel up into the cleansed skin for 3-5 seconds before you poke. The longer you wait – the more desensitized their skin receptors will become – this theoretically should decrease pain.

    With less perceived pain, the patient is less likely to tense up and should lead to a smoother successful IV placement. When I was an ER nurse, I used this technique every time and seemed to have good results.

    Well, there you have it – 10 IV insertion tips to improve your IV game! If you have any additional tips that I didn’t mention – leave a comment below letting everyone know!

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