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Published: February 10, 2022
Last Updated: March 23, 2023
A pulmonary embolism, frequently abbreviated as a PE, is a blood clot that lodges into the pulmonary vasculature of the lungs. Sometimes this can be asymptomatic, often there are mild-moderate symptoms, and other times patients can go into cardiac or respiratory arrest.
No matter the symptoms, pulmonary embolisms can be deadly, and it is important for nurses to understand this disease and how to treat and monitor your patients with pulmonary embolisms.
This article is part of a new series where we outline various medical conditions and the nursing assessment and management involved with each condition.
A pulmonary embolism is a blood clot that lodges within the lungs. These are more commonly abbreviated to PEs. These can be very large or very small; only one, or many at the same time.
The larger and more PEs that there are, the more dangerous this can be on the body. This can put significant strain on the heart, and can even cause cardiac arrest.
Remember that a Thombus is one of the Hs and Ts to think about when a patient is coding!
Pulmonary embolism‘s are highly associated with Deep Vein Thrombosis (DVT). You might hear the term VTE, which is an umbrella term for any blood clot within the body including DVTs and PEs.
There are many different causes that can cause a PE to develop, but it all goes back to Virchow’s Triad.
Virchow states that in order for blood clots to form within the body, there needs to be at least one of three things:
Anything that causes blood to “sit still”
Damage to the vascular system (arteries & veins)
Something that increases likelihood for clotting
Breaking down Virchow’s Triad, common risk factors for blood clot formation includes:
Patients with pulmonary embolisms usually present to the hospital or emergency department with shortness of breath.
This is because an area of their lungs are not able to exchange gas normally. They are able to breathe in adequate oxygen, however they are unable to exchange that oxygen with carbon dioxide wherever the PE is, leading to a ventilation perfusion mismatch.
Common symptoms of a PE include:
Also referred to as shortness of breath, and may be with exertion or at rest
Usually pleuritic, aka worse with deep breaths or coughing
Usually not productive, but may have pinky frothy or bloody sputum
Syncope with chest pain and SOB is suspicious for PE
Hemoptysis is not nearly as common of a symptom in a PE as your nursing textbook may have led you to think!
If a patient has CP/SOB and just recently had surgery or is pregnant, always think PE!
Patients with PEs often have pleuritic chest pain as well, so they’re unable to take full breaths without significant pain. This can increase the respiratory rate as they compensate by taking more frequent, shallow breaths.
Patient’s pulse ox will often be normal unless there is significant respiratory distress. Patients may have a low-grade fever as well.
Patience with PEs will often have tachycardia – which is a heart rate greater than 100 bpm.
Blood pressure is often normal, but may be high secondary to pain. However very large PEs can put significant strain on the heart, causing significant hemodynamic compromise including hypotension and shock.
When auscultating the lungs, a lot of times you aren’t really going to hear any specific bad breath sounds. You may hear some diminishment in the lung with the PE. Sometimes you may hear crackles and rarely wheezing.
Place all patients with chest pain or SOB on a cardiac monitor to detect any arrhythmia that may occur and monitor heart rate.
Patients with PEs will often have sinus tachycardia that does not completely improve with fluid administration.
Patients with PEs can have all sorts of arrhythmias including:
All patients presenting with chest pain and/or SOB should have an EKG obtained within 10 minutes of arrival.
This is primarily to rule out any STEMI or ischemia. However, large PEs can cause significant righ theart strain.
While they occur in < 10% of patients, signs of right heart strain on an EKG include:
If the patient is significantly hypoxic or tachypneic, apply 2-4 L/min NC. If this is not enough to titrate SPO2 > 90%, apply a non-rebreather.
In these cases, BIPAP or Intubation may be needed.
Start a peripheral IV at least 18-20g in an AC line, as there is a high likelihood that these patients will be needing a CTA. These large bore IVs are needed to inject high-pressure dye.
While drawing blood, make sure to draw a blue top as D-dimer may be ordered, as well as a PT/INR.
The Wells’ Criteria for PE is a clinical tool that is able to be used to determine the risk of a PE.
This assigns points to each of the following:
Once you calculate their score, you can stratify their risk into one of the following:
Scores of 4 or less with a negative D-dimer can effectively rule out a PE.
One way to minimize radiation is to obtain a D-Dimer in a patient with low to moderate suspicion of a PE.
A D-dimer is a byproduct of fibrin which is increased in the blood whenever there is a blood clot.
While this is a great test to see if there is a possibility of blood clots within the body, it is not very specific. This means that a negative D dimer (less than the threshold) is a pretty good way to tell if someone doesn’t have a blood clot. However, a positive D-dimer doesn’t necessarily mean there IS a blood clot in the body.
Any bruise or minor injury can cause elevations in D-dimer, as well as pregnancy, heart disease, infections, and more.
This means that if a D-dimer is above the threshold (around 230 but depends on your lab), then the Provider is pretty much forced to get a CTA to see if their truly is a PE.
If a D-dimer is less than the threshold, then a PE can usually be ruled out. However, this is only the case is clinical suspicion is low to moderate.
In patients who have a high liklihood of a PE, a D-dimer can miss a PE up to 15% of the time!
A troponin should be ordered in patients with chest pain and/or SOB. This can sometimes be mildly elevated in PEs, or significantly elevated if a PE causes a STEMI or NSTEMI.
A BNP may be ordered if there are s/s of heart failure.
Renal function should be checked before a CTA can be done, to make sure their kidneys can handle the dye. A GFR > 30 is usually adequate to obtain a CTA.
Coagulation studies may be performed inpatient to see if there are any genetic mutations predisposing the patient to forming thrombi.
An ABG may be obtained if the patient is in significant respiratory distress or has altered mental status.
With a PE causing significant distress, you’ll typically see the following results on an ABG:
A chest x-ray (CXR) will almost always be ordered on patients who are suspected of having a PE, because these can rule out some other causes of chest pain and SOB such as a pneumothorax or pneumonia.
However, a CXR is not going to pick up a pulmonary embolism. A CXR may show nonspecific signs including atelectasis or effusions, but often will be completely normal.
In order to actually see the pulmonary embolism, a CT pulmonary angiography (CTPA or just CTA) is required.
Angiography is when a radiopaque dye is injected into the patient’s vein in order to get a good look at the patient’s vasculature during a CT scan. This can be timed to look at specific areas of the heart.
CT Pulmonary Angiography is when this is done to look at the pulmonary arteries and veins. This means the radiologist can directly visualize pulmonary embolisms.
If the patient’s GFR is <30, we generally avoid contrast dye. However, this may be completely facility dependent.
If a patient cannot be given the dye (GFR < 30 or anaphylactic reaction), the alternative test is to obtain a V/Q Scan.
A VQ scan is a nuclear medicine test where they use radioisotopes in conjunction with X-rays to see if there are any ventilation/perfusion mismatches. Well this is not as definitive as a CTA, it does give probabilities of their being a PE, such as a “very low probability”.
The patients CXR really should be a clear study, otherwise the VQ scan will be poor quality. So if the patient has significant consolidation or pleural effusions, the VQ scan is unlikely to be very sensitive to finding a PE.
Treatment of a patient with a PE who is hemodynamically stable will generally consist of admission to the hospital, parenteral anticoagulation, and then transition onto an oral anticoagulant.
Patients who have significant hemodynamic compromise may require reperfusion therapy.
Treatment for pulmonary embolisms primarily involve anticoagulation.
In the hospital setting this is usually IV unfractionated heparin. This Heparin is given as a Heparin drip, which is titratable depending on PTT levels. Each facility should have their own heparin drip protocol.
In general, a bolus dose is given IV (can push fast), and then a slow drip is started. The PTT levels are usually checked every 6 hours but will depend on the protocol.
SQ Lovenox is an alternative to IV heparin, and is given in a dose of 1mg/kg BID.
But how does anticoagulants really help if the blood clot is already there? The role of the anticoagulants are to prevent further clots from forming, as well as to stabilize the clot from moving. This can be especially helpful if there is a DVT or an atrial thrombus within the heart. These can embolize and cause further PEs or even strokes.
I’ve found that usually IV heparin is ordered because this is more easily titrated and can be stopped quicker in case there is any bleeding or procedure that need done while inpatient.
Sometimes the patient can be started directly on an oral anticoagulant and discharged home if they are otherwise stable, but this will depend on the Provider and the facility standards.
Once the patient is stable enough for discharge, they are started on long-term oral anticoagulation, such as Eliquis or coumadin.
Patients with very recent surgery, hemorrhagic stroke, or active bleeding are not started on anticoagulation.
Patients will often need to stay on the anticoagulation for at least 3 months, but sometimes longer. The blood clot should be reabsorbed by the body in about 6 weeks, but will depend on the size of the thrombus.
Some patients will require life-time anticoagulation if they are found to have any genetic predispositions to blood clots. This is also true for patients with atrial fibrillation.
An inferior vena cava filter, commonly referred to as an IVC filter, is a device that is sometimes placed to “catch” clots before they enter the right atria.
This is usually placed in for patients who cannot be on anticoagulation, or those who have gotten repeat PEs despite anticoagulation therapy.
They can be temporary and need removed eventually, but some that are placed are permanent.
In patients who are hemodynamically unstable from their PE, thrombolytic therapy can be given to dissolve the clot. This is like TPA in a stroke, but given for a PE.
However, there are many contraindications to thrombolytic therapy, and there is a risk of bleeding.
An Embolectomy can be performed if needed and if the facility is capable of doing so, particularly when thrombolytic therapy is unsuccessful or cannot be used due to contraindications.
There are additional procedures that can be done to retrieve / break up the clot including:
Many facilities will not have these capabilities, but most should have thrombolytics.
A Saddle pulmonary embolus is a very large PE located at the bifurcation of the main pulmonary artery. These PEs are rare but likely to cause significant hemodynamic compromise and cardiopulmonary respiratory arrest!
Monitor their oxygen status by respirations and pulse oximetry. Stable patients may only need q4h vitals.
If their oxygen is low or if there is significant respiratory distress, titrate up their oxygen levels.
A BIPAP or Intubation may be needed in severe cases.
Monitor their blood pressure per department protocol.
If hypertensive, treat with analgesics and antihypertensives.
If hypotensive, treat with fluid boluses, paying careful attention to respiratory and cardiac status.
Vasopressors may be required in severe cases.
These patients should have telemetry ordered.
Monitor their cardiac rhythm per department protocol, and notify any changes to the Provider.
These patients are usually placed on anticoagulation as above. Be sure to place the patient on fall precautions, and monitor for any bleeding.
Titrate the heparin drip according to protocol, and a high PTT may require that you stop the heparin drip for some time.
If the patient begins to deteriorate, be sure to notify the physician or APP and/or call an RRT.
Remember that PEs put strain on the heart, so patients can go into flash pulmonary edema. Those with pre-existing CAD may have heart attacks.
Do you have any crazy PE stories? Let us know in the comments below!
Haag, A., et al (2022). Pulmonary embolism. In R. I. Donaldson (Ed.), WikEM, The Global Emergency Medicine Wiki. https://wikem.org/wiki/Pulmonary_embolism
Sharma, R. (2022). Pulmonary embolism | Radiology reference article. Radiopaedia.org. Retrieved February 8, 2022, from https://radiopaedia.org/articles/pulmonary-embolism
Tapson, V. F., & Weinberg, A. S. (2022). Treatment, prognosis, and follow-up of acute pulmonary embolism in adults. In T. W. Post (Ed.), Uptodate. https://www.uptodate.com/contents/treatment-prognosis-and-follow-up-of-acute-pulmonary-embolism-in-adults
Thompson, B. T., Kabrhel, C., & Pena, C. (2022). Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism. In T. W. Post (Ed.), Uptodate. https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism
Thompson, B. T., & Kabrhel, C. (2022). Overview of acute pulmonary embolism in adults. In T. W. Post (Ed.), Uptodate. https://www.uptodate.com/contents/overview-of-acute-pulmonary-embolism-in-adults
If you want to learn more about cardiac arrhythmias, I have a complete video course “ECG Rhythm Master”, made specifically for nurses which goes into so much more depth and detail.
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Published: January 16, 2022
Last Updated: March 23, 2023
Blood transfusion reactions are common within the hospital setting because so many blood products are given. Transfusing blood products that are lacking or actively being lost (i.e. GI bleed) is literally life-saving treatment.
In this article, we will talk about the different blood products, why they are given, and then dive into each type of blood transfusion reaction, what causes them, their signs and symptoms, and how to manage them as the nurse.
There are multiple different blood products that are transfused within the hospital, and each one can have adverse reactions called blood transfusion reactions.
Packed Red Blood Cells or PRBCs are given to patients when their hemoglobin levels are low. This is called anemia. Some common causes of anemia that may need a transfusion include:
PRBCs are usually ordered when hemoglobin levels drop below 7g/dL, but it depends on the nature of the patient’s anemia as well as their medical history and their hemodynamic stability (are their vital signs normal?)
1 to 2 units will be ordered of PRBCs depending on how low the patient’s hemoglobin level is, as well as if there is active blood loss. Each unit of PRBCs should increase the hemoglobin by about 1g/dL.
Before blood products are given, a type and screen is done to verify the patient’s blood type and screen for any antibodies that may require special blood. The exception is if the patient has significant ongoing hemorrhage and the patient needs emergent blood. In this case, O Negative blood is given as they are the universal donor.
Each unit of blood will take about 2 hours to transfuse, but the maximum amount of time is 4 hours when the blood will expire. In emergencies, blood can be run as fast as needed, often with pressure bags.
Fresh Frozen Plasma or just Plasma is the portion of whole blood that doesn’t include the red blood cells, which contains clotting factors.
Some reasons FFP may be ordered for your patient include:
In massive transfusions, you replace 1 unit of FFP for every unit of PRBCs replaced (along with 1 unit of platelets).
Platelets are a blood product that help the body form blood clots and prevent bleeding.
These can often become low from various autoimmune disorders, cancers and chemotherapies, medication reactions, and liver disease.
Platelets are replaced when platelet levels are low, termed thrombocytopenia. Platelets are usually ordered for:
Most platelets that are given are obtained by “apheresis”. One apheresis unit is equal to 4-6 “pooled random donor units”. 1 unit of platelets by apheresis should increase the platelets by about 30K.
Blood products are given whenever the blood levels are too low, or when there is acute bleeding. While this will depend on each specific patient and clinician, blood products are generally given when:
Because we are infusing blood products from a donor, this adds an increased risk of adverse reactions to occur.
Because of this, nurses must monitor their patients very closely during blood product transfusions. The nurse must stay with the patient the first 15 minutes of a blood transfusion (may change depending on specific facility protocol), and frequently check vital signs.
There are common blood reactions, and then there are more rare and severe reactions that can occur.
An acute hemolytic transfusion reaction is a rare life-threatening blood transfusion reaction to receiving blood, specifically PRBCs.
This happens when incompatible blood is accidentally infused with the patient. This is why the patient’s blood type is checked in the first place so that an appropriate donor can be given.
Compatible blood is outlined below:
When having a true acute hemolytic reaction, the patient will quickly experience:
This is a severe reaction as the patient’s own immune system and the donor’s immune system attack each other, destroying blood products and causing damage in the process. The patient may experience hemodynamic instability including life-threatening hypotension.
If this reaction occurs, the nurse should:
If an acute hemolytic reaction is suspected, the nurse should:
The Provider should guide treatment, but these are serious reactions and would likely need monitoring in the ICU.
Your facility should have a specific protocol in the event of significant blood transfusion reactions, which often involves re-testing the patient as well as re-testing the blood unit itself.
An anaphylactic transfusion reaction is a severe allergic reaction to something within the blood product. These are rare, with an estimated 1 in 20-50K transfusions.
This reaction occurs seconds to minutes after starting the transfusion.
The recipient is severely allergic to something within the donor blood, which they may have antibodies against, specifically those who are IgA deficient or haptoglobin deficient.
Signs of an anaphylatic reaction include:
Treatment involves immediately stopping the transfusion, and then treatment with standard anaphylactic medications. These medications include:
More significant interventions may be needed, including:
The blood cannot be restarted, and additional testing will need to be performed, and blood from another donor will have to be given.
An urticarial transfusion reaction is a less severe allergic reaction to a component within the blood products, but much more common, occurring in 1-3% of blood transfusions. This is an antigen-antibody interaction, usually with donor serum proteins.
Patients with this blood transfusion reaction will develop urticaria (hives) with no other allergic signs/symptoms such as wheezing, angioedema, or hypotension.
When an urticarial transfusion reaction occurs:
When an urticarial transfusion reaction is diagnosed, stop the blood for 15-30 minutes, give IV antihistamine like Benadryl, and then restart the infusion once hives resolve but slowly and cautiously. Check your specific facility’s protocol.
A febrile non-hemolytic transfusion reaction is exactly what it sounds like – the patient develops a fever after/during a transfusion, but they are not experiencing other signs of a hemolytic reaction.
This is usually due to a systemic response to cytokines which developed during the process of storing the blood.
These are very common, occurring in .1-1% of all transfusions.
This fever will occur 1-6 hours after the transfusion begins.
If the temperature is more than 39°C or 102.2°F, consider a hemolytic transfusion reaction.
Whenever there is a fever present, the main thing to consider is if this could be the first sign of a more serious transfusion reaction such as a hemolytic reaction, TRALI (see below), or Sepsis.
If there is just a fever and no other significant reaction is suspected, antipyretics should be be given, usually Acetaminophen 650-975mg PO. The transfusion can usually be continued but monitored closely.
Future transfusions should be “leukocyte reduced”, which is a process that removes most of the white blood cells within the blood.
Transfusion-Associated Acute Lung Injury, known as TRALI, is a rare but one of the severe blood transfusion reactions that can occur after transfusion of a blood product.
This is when the transfused product activates the recipient’s neutrophils, causing acute lung damage.
Patients at risk for TRALI include patients with:
The patient will experience sudden and severe respiratory failure during or shortly after a transfusion, but up to 6 hours after the transfusion. This is often associated with:
New bilateral infiltrates on CXR are often seen.
When TRALI is suspected, the nurse should:
Sometimes steroids are given, although evidence is not great.
These patients may need to be intubated and will likely need to be transferred to the ICU and closely monitored.
They do not seem to be at increased risk for TRALI to occur again with a different transfusion in the future, however, donors who are implicated are banned from donating ever again.
Transfusion-Associated Sepsis is a life-threatening blood transfusion reaction that can occur with the administration of contaminated blood products which are infected with bacteria.
The patient will start developing signs or symptoms within 5 hours after the infusion, but usually around 30 minutes.
Signs/Symptoms of transfusion-associated sepsis includes:
Remember that Transfusion-associated Sepsis, Acute Transfusion Hemolytic Reaction, and TRALI can all have similar symptoms.
If transfusion-associated sepsis is suspected, the nurse should:
Transfusion-Associated circulatory overload, also known as TACO, is when the patient develops acute volume overload after administration of blood products.
This blood transfusion reaction is fairly common, occurring in up to 1% or more of transfusions. This can occur up to 12 hours after the transfusion is given, and risk factors include patients with:
The more units transfused and the quicker transfused, the higher risk of TACO (just like with IV fluids).
Patients will develop symptoms of respiratory distress which include:
The patient will also usually develop hypertension.
Remember TRALI can have similar symptoms, as well as a pulmonary embolism.
When TACO is suspected, the nurse should:
In milder cases, the patient may just require diuretics and supplemental oxygen. More severe cases may require Bipap or intubation.
It is a smart idea for the Provider to order 20mg IV Lasix in-between units when multiple units of blood are ordered in someone with a history of CHF or who is very old. If it is not ordered and you feel it may benefit the patient, offer this suggestion to the Provider as it can prevent TACO from occurring.
“Hey this is Jan calling from Med-surg, I just wanted to make sure you didn’t want any Lasix in-between blood units for Mark Smith in 147-2, as they have a history of CHF?”
Primary hypotensive reactions are very rare, but occur when there is a sudden drop in systolic blood pressure >30 mmHg within minutes of starting a transfusion.
The blood pressure normalizes once the transfusion is stopped. While rare, other severe blood transfusion reactions can also have hypotension, so the patient will need to be evaluated to rule those out as well.
Patients who take an ACE inhibitor like lisinopril are at increased risk for this to occur.
This is also more common with platelet administration.
And those are the acute blood transfusion reactions that can occur when administering blood in the hospital.
Keep in mind that there can also be transmission of infections such as HIV and hepatitis, although very rare and will not present itself during the transfusion or shortly after.
Kleinman, S., & Kor, D. (2022). Transfusion-related acute lung injury (TRALI). In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-related-acute-lung-injury-trali
Silvergleid, A. (2022). Approach to the patient with a suspected acute transfusion reaction. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/approach-to-the-patient-with-a-suspected-acute-transfusion-reaction
Silvergleid, A. (2022). Immunologic transfusion reactions. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/immunologic-transfusion-reactions
Silvergleid, A. (2022). Transfusion-associated circulatory overload (TACO). In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-associated-circulatory-overload-taco
Spelman, D., & MacLaren,G. (2022). Transfusion-transmitted bacterial infection. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-transmitted-bacterial-infection
A charge nurse is so important in keeping a hospital department running smoothly. Whether in the ER, ICU, or inpatient floor settings – the charge nurse is essential to the team.
Many times being a charge nurse comes with years of experience, but sometimes it comes with less than 1 year! (believe me – I was one of them!) Many units may have high turnover, and you can find yourself being a charge nurse with a year or less experience.
While this is nerve-wracking, it is possible to do a good job as a charge nurse, even with not-so-ideal nursing experience.
Here are some charge nurse tips to help you on your way to becoming an amazing charge nurse to serve as a resource to your team.
A charge nurse is the “nurse in charge” on the unit. They are the leader of the team (at least for the shift). They are often the nurses on the floor during the shift that has the most experience and knowledge.
Their job will differ depending on which unit they work in, but usually involves:
In the emergency department, a major role of the charge nurse is throughput. That means keeping the department moving: getting patients who are admitted, discharged, or transferred out of the department, and making space for new patients coming in.
They may even need to take some of their own patients on a busy day/night, and may need to function as a triage nurse after certain times during night shift or when short-staffed (which let’s be real – is basically the norm).
A major job of a charge nurse is to know the policies inside and out. This is basically the rules of flow of the specific department, aka “how it all works”.
This includes policies related to the admission, discharge, and transfer process; medication administration policies, transfusion policies, and more.
These policies will be specific to each facility and department, and a nurse will naturally learn these over time with experience on the floor.
However, each facility should have some sort of intranet (online database) or printed resource with policies, which you can look up, print, and save as needed.
While it’s ideal to have a charge nurse who has years of experience on the floor, this is just not always possible. Nursing turnover is real, and many departments struggle with nurse retention, especially on night shift.
You may find yourself becoming a charge nurse on night shift with as little as one year of experience or less.
As a nurse with a year of experience or less, you simply cannot be expected to know everything, including all of the policies and how to troubleshoot any situation that arises.
While this can be terrifying, there are resources that are available to you if you just don’t know the answer.
Even though you are the charge nurse of the floor, there should be a “higher-up” that you have access to.
During dayshift, you may have access to the department director or nursing managers. They can often be contacted by telephone if needed even after they end their workday.
During night shift, there is usually a nursing supervisor of the hospital as who can answer questions.
You can also call other charge nurses on other departments to ask for advice during a situation.
If there is an in-house hospitalist team, they can also be used as a resource for medical concerns, or you can call the attending.
I moonlight as a night shift hospitalist, and had a charge nurse on a med-surg unit with less than 1 year experience reach out to me as she was concerned with a patient’s HR going in the 30s during sleep. This patient was asymptomatic and had been bradycardic in the 50s while awake. She was concerned because she had never seen a HR consistently that low, even during sleep. I reassured her that this was okay and even expected in this specific patient, and if he developed any symptoms or abnormal rhythm to notify us immediately.
A charge nurse’s primary responsibility is to keep the department moving. This is super important in the emergency department but is important on any nursing floor.
Patients come into the ER and often need IVs started, labs drawn, transported to imaging and back, medications administered, call bells answered, and discharge instructions given. Patients who are admitted need report called and need to be transported to the floors.
Delays in throughput are common, especially within the ER, and may be due to:
A charge nurse can help minimize many of these delays and keep the department moving by being proactive.
They can discuss transport patients, clean stretchers, make phone calls, help out their nurses, and remind the Provider to reevaluate and disposition their patients! These are all ways the charge nurse can help become an expert at throughput.
The nurses in the department are busy and overworked. You can say that again!
Being chronically understaffed is all too common. This means nurses are often behind in their assessments, procedures, medication administration, and charting. This can seriously impact throughput as well as patient satisfaction and worst of all, patient outcomes.
As the charge nurse, you will need to find time to help out your nurses wherever they need it. You may need to place IVs, transport patients to or from radiology or the floors, obtain EKGs, triage patients, and give medications that are ordered.
Not only does this make you a good team player, it helps the whole department run smoothly.
There’s nothing worse than a charge nurse who seems to sit there and do nothing the whole shift… DON’T BE THAT CHARGE NURSE!
As a charge nurse, it is your job to lead by example. You may not have a formal manager position, but your selection as a charge nurse for a shift means that you are the team leader, at least for the shift.
Don’t do one thing and expect another from your nurses. Constantly help out when you can, maintain good rapport with the patients, providers, and ancillary staff, and conduct yourself with professionalism and integrity.
It is so important to stay calm during emergencies and crises as a nurse, but especially a charge nurse.
It will be your job to put out fires left and right, as well as make sure the nurses on your unit handle emergency situations appropriately.
Emergency situations happen in the hospital all the time – it’s the name of the game. But it’s not just life and death that will test you.
Families may be yelling at you because they’re angry or frustrated, and patients will literally be trying to die on you.
Staying calm is easier said than done, but one thing that helps you stay calm is KNOWING YOUR STUFF.
If you know what the policies are, and what to do in specific emergency situations like cardiac arrhythmias or codes, then you will be more prepared. This should give you a sense of calm, especially when these emergencies inevitably arise.
There is nothing more stressful than uncertainty.
Being a good team player is important for any nurse, but especially a charge nurse. There are many ways to be a good team player.
Be a hard worker and willing to help out other nurses. Don’t expect them to return the favor later, but if they are a good team player they eventually will.
As a person who is in “charge”, it’s important to not play favorites. The nurses will resent you, and you need to be as fair to them as possible. This means don’t give your “besties” easier assignments or fewer admissions.
Always have your teams back. Understand situations from their point of view and give them the benefit of the doubt. Nurses aren’t perfect and do make mistakes, but be sure to support them however you can. Don’t immediately throw them under the bus.
These traits are important for not only charge nurses but any leadership position.
Staying organized is so important for nurses. Charge nurses have an even bigger need to stay organized, because they aren’t just managing their own patients. They are managing the entire department or floor!
Knowing who has what assignment, which patients they have, and what needs to be done is important. In stressful environments, it can be easy to know you have so much to do, but not even know where to get started.
Staying organized is key. Get there early if you need to, make lists and prioritize what needs to be done. Chart in real-time to avoid the backlog of charting weighing you down and making you more stressed.
Also check out: How to Stay Organized as a New Nurse
As the charge nurse, you will be used as a resource. Your nurses will come to you if they have difficulty placing an IV or other procedure, or if they have never done the procedure before.
It is a great idea for the charge nurse to be great at IVs – because this is a common need on any department, but especially within the ER.
Placing lines and drawing blood work is essential for throughput and good patient care, and excelling at this procedure is a great skill set for the charge nurse to have in their scrub pocket.
Practice, practice, practice. Make sure you know all the IV tips and tricks as well.
Probably the most stressful part of being a charge nurse is having the pressure of knowing what to do during emergency situations. These are usually intubations, code blues, or other emergent cardiac arrhythmias.
Knowing your cardiac ECG rhythms is so important for every nurse, but many nurses struggle with this. As the charge nurse – you need to be an expert at this as your nurses will be coming to you for advice or interpretation.
You should know all about each drawer of the code cart, the code cart meds, and how to reconstitute them, and definitely know how to use the defibrillator!
This includes knowing:
You should also be familiar with the basics of how to recognize a STEMI.
If you feel like your ECG rhythm interpretation and cardiac arrhythmia procedure knowledge can use some work, I have a digital course that I think you’ll find super helpful!
If you want to learn more, I have a complete video course “ECG Rhythm Master”, made specifically for nurses which goes into so much more depth and detail.
With this course you will be able to:
I also include some great free bonuses with the course, including:
Check out more about the course here!
Author | Nurse Practitioner
A STEMI is an ST-Segment Elevation Myocardial Infarction – the worst type of heart attack. This type of heart attack shows up on the 12-lead EKG.
An NSTEMI (or Non-STEMI) does not have any ST elevation on the ECG, but may have ST/T wave changes in contiguous leads.
Patients with STEMI usually present with acute chest pain and need to be sent to the cath lab immediately for reperfusion therapy – usually in the form of a cardiac cath with angiography +/- stent(s).
Ruling out a STEMI is the main reason 12-lead ECGs are obtained, and it is critical that you learn to identify them – even as nurses.
While Physicians/APPs should be laying their eyes on ECGs relatively quickly, this isn’t always the case. The sooner a STEMI is identified, the better the chance for survival for the cardiac tissue as well as for your patient!
The coronary arteries lie on the surface of the heart (the epicardium).
These arteries deliver vital blood flow and oxygen to the myocardial tissue to keep the heart perfused and beating.
The three main coronary arteries are the left anterior descending artery (LAD), the circumflex artery (Cx), and the right coronary artery (RCA).
The RCA travels down the right side of the heart in the groove between the right atrium and right ventricle. The RCA supplies blood to
The Left coronary artery begins thicker and is called the left main coronary artery. This branches off into the LAD and the Cx.
The LAD lies on the surface of the heart between the right and left ventricles. It often extends to the inferior surface of the left ventricle in most patients. The LAD supplies blood to:
The Cx wraps around the left side of the heart in the groove between the left atrium and left ventricle in the back (the coronary sulcus). The Cx supplies blood to:
The posterior descending artery usually branches off from the RCA, although less commonly from the Cx. Whichever one does form the posterior descending artery is considered the “dominant coronary artery”.
Acute coronary syndrome (ACS) is an umbrella term referring to any condition which causes decreased blood flow to the heart – also known as ischemia. Prolonged ischemia can lead to infarction – which is cell death of the heart tissue.
This cell death causes the release of troponin into the bloodstream, an enzyme that is not usually found in the systemic circulation.
Cardiac ischemia is usually secondary to atherosclerosis which is a buildup of plaque within the coronary arteries. This is usually caused by unhealthy eating habits, obesity, sedentary lifestyle, hyperlipidemia, smoking, and genetics.
This plaque can rupture, releasing contents into the bloodstream which causes a local inflammatory reaction as well as begins a coagulation cascade.
This blood clot can completely occlude an artery – leading to infarction.
A Non-ST segment elevation myocardial infarction (NSTEMI) refers to a complete occlusion of a coronary artery that does not cause ST-segment elevation on the ECG.
While some heart tissue dies, this is usually less extensive than a STEMI. The infarction is usually limited to the inner layer of the myocardial wall.
NSTEMIs will often have nonspecific changes on the EKG. These changes include T wave inversion or ST-segment depression with or without T wave inversion in anatomically contiguous leads. However, NSTEMIs could also present with a completely normal ECG.
Troponin levels will be elevated indicating myocardial cell death. However, the ECG does not have ST-segment elevation.
An ST-segment Elevation Myocardial Infarction (STEMI) refers to a complete occlusion of a coronary artery that causes more significant infarction that extends the entire thickness of the myocardium (termed transmural).
A STEMI will have ST-segment elevation in at least 2 contiguous leads on the ECG.
Where this elevation occurs will indicate which heart wall is infarcting, as well as within which coronary artery.
You may also like: “Cardiac Lab Interpretation (Troponin, CK, CK-MB, and BNP)”
The ST-segment is the segment on the ECG right after the QRS segment and before the T wave. This represents the initial phase of ventricular repolarization and should be at the isoelectric line.
The TP-segment should be used as the isoelectric baseline, but you can use the PR segment if the TP is difficult to see.
The J-point is the point on the ECG where the QRS complex meets the ST segment. This is important for recognizing ST segment elevation.
ST-segment depression most commonly identifies cardiac ischemia, as well as reciprocal changes in an acute MI.
It can also indicate heart strain, digitalis effect, hypokalemia, hypomagnesemia, or even be rate related. However, these changes are usually more diffuse as opposed to localized to at least 2 contiguous leads.
ST-segment depression is defined as ≥0.5 mm depression (1/2 small box) below the isoelectric line 80 ms after the J-point (2 small boxes).
Horizontal and Down-sloping ST-segment depression are more specific to cardiac ischemia, whereas up-sloping tends to be less serious although still could indicate ischemia.
De Winter T waves can be seen in 2% of acute LAD occlusions without significant ST-segment elevation. Instead, there will be ST-segment depression at the J-point with upsloping and tall, symmetric T waves in the precordial leads (V1-V6).
ST-segment elevation usually indicates myocardial infarction when appearing in at least 2 contiguous leads.
Other possible causes of ST-segment elevation include coronary vasospasm, pericarditis, benign repolarization, left BBB, LV hypertrophy, ventricular aneurysm, Brugada syndrome, ventricular pacemaker, increased ICP, blunt chest trauma, and hypothermia.
ST-segment elevation is defined as ≥1 mm elevation (1 small box) above the isoelectric line at the J-point. However, in leads V2 and V3, it needs to be > 1.5mm in women, > 2mm in men >40, and > 2.5mm in men < 40.
Concave ST elevation is considered less ominous and sometimes can indicate benign variant called early repolarization, especially when diffuse.
Convex upward ST elevation is almost always indicative of a large MI. This is termed “tombstoning”.
Q waves are the initial positive deflection of the QRS complex indicating septal depolarization. These are normal in all leads except V1-V3.
Pathologic Q waves are abnormal Q waves that indicate underlying pathology – usually a current or previous MI.
Pathologic Q waves are defined as >40ms wide (1 small box) and >2 mm deep (2 small boxes).
Any Q waves seen in V1-V3 are always pathologic.
Q waves can begin hours to days after an infarction begins, and can last for years, even forever.
Recognizing ST-segment elevation or depression can be difficult in the case of a left bundle branch block (LBBB) or ventricular paced rhythm. This is because there is normally some associated ST-elevation and discordant T waves with these conduction abnormalities.
To determine possible ischemia or infarction in a patient with these conduction abnormalities, one of the following should be present:
These are not always present, but if they are – you should highly suspect ACS in a patient with a pre-existing LBBB morphology.
This is why a new LBBB and acute chest pain or SOB is concerning for acute MI.
You may also like: “How to Read a Rhythm Strip”
STEMIs typically have a normal progression that will be seen on the ECG.
Hyperacute T waves are first seen, which are tall, peaked, and symmetric in at least 2 contiguous leads. These usually last only minutes to an hour max.
Then, ST-segment elevation occurs in at least 2 contiguous leads at the J-point, initially concave, and then becomes convex or rounded upwards.
The ST-segment eventually merges with the T wave and the ST/T wave becomes indistinguishable. This is a “tombstone” pattern.
Reciprocal ST depression may be seen in opposite leads.
The ST segment then returns to baseline after a week or so.
Q waves eventually develop within hours to days, followed by T wave inversion which could be temporary. Over time, the Q wave deepens.
STEMIs are classified based on where they are located anatomically – so which leads are they are affecting on the ECG.
Contiguous leads simply means leads that are pertaining to the same anatomical region of the heart.
The following leads pertain to each region of the heart:
The precordial and lateral leads are often affected together as the area of infarction is not always exact.
As an example, the EKG below is an inferior wall STEMI:
STEMIs are true medical emergencies.
The patient is at a high risk of significant conduction disturbances and arrhythmias including cardiac arrest.
The longer you wait – the more heart cells will die, leading to worse cardiac outcomes as well as increasing the possibility of patient death.
A 12-lead ECG should be obtained within 10 minutes of any patient with significant cardiac symptoms including chest pain or SOB.
Women, older adults, and diabetics may have atypical presentations including a “silent” MI, where they don’t even have chest pain.
There are many actions that need to be taken in a short amount of time, and many medications that will need to be administered before the cath team gets there.
A code STEMI should be activated (or whatever your facility’s version of it is), so the interventional cardiologist and the cath team can be alerted ASAP.
The patient should be hooked up to the monitor, vital signs obtained, IV access x 2 should be established (preferably an 18g), labs drawn and sent including troponin and PT/PTT, and the defibrillation pads should be applied.
Any abnormal vital signs should be addressed, and any arrhythmias should be managed via ACLS guidelines.
Oxygen should be administered to maintain O2 >90%.
Aspirin 324mg should be chewed and swallowed. A rectal suppository of 300mg can be given if the patient cannot tolerate PO for some reason.
Antiplatelet therapy with P2y12 receptor blockers such as Plavix or Brilinta should be given in addition to the aspirin.
Nitroglycerin should be administered 0.4mg SL x 3 q5min if the patient has persistent chest discomfort, HTN, or signs of heart failure.
However, do not give if they have used phosphodiesterase inhibitors like Viagra or Cialis within the last 24h.
Don’t give Nitro if they have a low blood pressure, if they have severe aortic stenosis, or if there is a possibility of a right ventricular infarct (sometimes presents with inferior wall MIs). Nitro can cause severe hypotension in these patients.
For persistent symptoms, an IV nitro drip can be used.
Anticoagulants like an unfractionated heparin drip should be given. Other options include Lovenox.
If the patient has signs of left heart failure, treat with nitro as above, loop diuretic like Lasix, +/- Bipap.
Morphine 2-4mg slow IVP q5-15min can be given for persistent severe chest pain or anxiety. However, there is research indicating an increased risk of death when morphine is given in STEMI.
It is possible that morphine may interfere with the antiplatelet effect of P2y 12 receptor blockers. So morphine should be avoided unless absolutely required for pain control.
Atorvastatin 80mg PO should be given ASAP, preferably before PCI in those who are not already on a statin. If the patient on it already, their dose should be increased to 80mg.
Primary percutaneous coronary intervention (PCI) is the preferred reperfusion method and should happen ASAP.
This is when the interventional cardiologist will take the patient to the cardiac cath lab and perform angiography and stent placement to open up the occluded vessel.
Fibrinolytics can alternatively be given, specifically if there is no access to a cath lab within a reasonable time frame (120 min), as long as symptoms < 12 hours and no contraindications (i.e. risk of bleeding).
Beta-blockers are initiated within 24 hours, unless they are contraindicated such as with bradycardia, HF, or severe reactive airway disease. This can be started after PCI.
You may also like: “Adverse Drug Reactions Nurses Need to Know”
As the name suggests, an NSTEMI does not have ST elevation seen on the ECG, but it is still a heart attack.
An elevated and rising troponin level is associated with an NSTEMI.
The ECG can be completely normal, or it can have nonspecific T wave changes or even ST depression in contiguous leads.
Management of an NSTEMI is similar to a STEMI in terms of medications. However, they are not given fibrinolytic and are not emergently brought to the cath lab. They may or may not get a cardiac cath during their hospital stay.
Instead, medication therapy is maximized like the ones described above. The patient is continued to be monitored, and troponin levels are trended usually every 6-8 hours.
STEMIs and NSTEMIs are critical emergent events that nurses need to know well! You will be running into this at some point in your nursing career, and you want to know exactly what you’re doing when it happens! Being able to recognize a STEMI on the ECG is the first step!
ECGs Made Easy (6th ed.) <<< this is my favorite ECG PDF
Ekgs for the nurse practitioner and physician assistant
Overview of the acute management of ST-elevation myocardial infarction
ECG tutorial: Myocardial ischemia and infarction
“Coronary Blood Vessels” by OpenStax College is licensed under CC BY 2.0, changes were made.
If you want to learn more, I have a complete video course “ECG Rhythm Master”, made specifically for nurses which goes into so much more depth and detail.
With this course you will be able to:
I also include some great free bonuses with the course, including:
You can use the code “SPRING2021” for a limited time 15% discount, exclusive to my readers!
Check out more about the course here!
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Author | Nurse Practitioner
Med-Surg nurses can utilize nursing hacks to their advantage in order to save them time and make their shift more manageable!
Nursing hacks are tips and tricks of the trade, sometimes new and sometimes old, which help “get the job done” quick and efficiently, while still maintaining quality care!
If you’re not using these Med-Surg Nursing hacks, you are missing out!
Ok – Med-Surg isn’t all bodily excrement – but you will run into pee and poop this in most aspects of nursing within the hospital.
There are so many poop and pee hacks to read through, you might need to take a bathroom break afterwards.
It is no secret that it can be difficult to insert a urinary catheter into some female patients.
This is because there is so much variation in each patient’s anatomy, and the patient’s body habitus can make things difficult to see.
Positioning, lighting, and assistance are all important, but sometimes it can still be difficult to hit the mark (in this case – the urethra).
If you are in position and are having trouble finding where to go, have the patient clear their throat and cough. This should cause the urethra to “wink” at you if visible, making your target stand out.
If you think you know where you’re going, or if you go in blind and end up in the vaginal canal – you may need to try again.
One thing you should NEVER do is take the foley out, and then reinsert the same foley into the urethra (hello UTI!).
Instead of taking out the first failed foley – leave the foley in place in the vaginal canal and open up a new kit, aiming above the catheter within the vaginal canal.
This can help you hit the mark. Second times a charm – right?
No – I’m not talking about metoprolol.
In a foley kit, there should be a betadine swab or stick that is used to clean the area before insertion of the catheter.
After cleaning the area correctly, leave the betadine stick in the vaginal canal. Similar to the double foley trick, this should “block” the vaginal canal.
If you aim above this – this could increase your chance of success! Don’t forget to remove the betadine stick when you’re done!
Every patient on Med-Surg is different, and sometimes variations need to be made!
For patients with larger vaginal canals, you could use a thicker material such as a clean roll of kerlix to essentially “block” the vaginal canal and helping you enter the urethra without much difficulty.
When putting on a foley, sterile technique is required to prevent infection.
However, the cleanup once the foley is inserted can be messy, and your sterile gloves will be saturated with lubricant, betadine, and body fluid.
To make it easy, before applying sterile gloves, put on a clean pair of gloves after washing your hands.
Then apply sterile gloves as needed (you may need a bigger size).
Once the foley is inserted and you are ready for cleanup, take off the soiled sterile gloves, and clean up everything else with your second set of clean gloves.
You should be able to secure the foley with these clean gloves as well.
It’s inevitable with Med-Surg nursing that your patient will need to be transported all over the hospital for tests.
Additionally, they will usually be encouraged to ambulate to keep up their strength and prevent blood clots.
Transportation can be challenging with a foley and the last thing you want to do is have the foley get caught up on something and rip out, so this is where this nursing hack comes in handy!
If your patient wants to get up and walk, tie a glove around an IV pole at a level below the bladder.
Hook the foley onto this glove to use as a portable hook!
Not so much a nursing hack – but more of a reminder.
Don’t forget that foley catheters are not the only option you have, and they do come with risk as they are invasive and often can lead to infection.
Many hospitals have Purewick catheters which hook up to suction to prevent the patient from lying in their own urine and causing skin breakdown.
This can be a great option for elderly female patients with urinary incontinence.
Also check out: 10 Nursing Hacks Every ER Nurse Should Know
Another unfortunate aspect of Med-Surg nursing – you will have to clean patients up when they poop themselves.
It’s honestly not a big deal, and you will quickly not even think twice about it.
BUT – there are nursing hacks that can help you in some of these instances!
Foley’s aren’t the only instance where double gloving comes in handy!
When cleaning up a messy poop situation, be sure to double glove or even triple glove with clean gloves!
Your gloves will inevitably become soiled and you will then be able to remove the soiled pair and continue cleaning the patient without issues.
Additionally – imagine if you only had one pair on and one of them ripped. Dead.
We should be checking on our patients often and making sure they do not sit in their own pee or poop for too long.
However, med-surg nursing is busy, and sometimes the poop becomes dried onto the patient’s skin and can be difficult to remove.
Bust out some shaving cream which you should be able to find in the clean utility.
Apply the shaving scream to the crusty poop on the skin, give it a few minutes, and wipe it off with soap and water or cleaning wipes.
It should wipe off without issue!
The only person more concerned with a patient’s bowel movement than you is the patient themselves (better yet – their family members).
If the patient is worried they may be constipated and are hoping to have a bowel movement, you could reach out to the physician and ask for something
If the patient is truly uncomfortable, reaching out to the Provider is the best option.
Another option is to get prune juice, put some butter in it, and microwave it for 20-30 seconds.
This will melt the butter and the prune juice should be warm.
The best part is this often works, there are no significant side effects, and you don’t need an order for it.
Of course, if your patient is having significant abdominal discomfort or nausea/vomiting, you should be reaching out to the Provider regardless!
It was my first week off of orientation as a brand new nurse on a Med-Surg nursing floor, and I had a patient complain of rectal pain.
I checked it out and WOW – that did NOT look right. What I was seeing was my first-ever rectal prolapse.
This specific patient had a history of this from happening, and you can reduce the prolapse as a nurse.
This can be done by applying some lubricant and applying firm pressure toward the patient’s rectum.
However, sometimes large prolapses can be difficult to reduce.
For this nursing hack, sprinkle some sugar on the prolapsed rectum and allow to sit for 15 minutes.
This dehydrates the prolapse, causing it to shrink and making reduction easier.
Nasogastric (NG) tubes are a nursing procedure that is unpleasant but often necessary. This is usually ordered for small bowel obstructions (SBO).
Sticking a tube into the patient’s stomach from their nose allows suction to decompress the stomach, alleviating symptoms such as nausea, vomiting, and bloating.
It also decreases intrathoracic pressure and improves the venous return to the heart when the patient is ventilated, as well as reduces the risk of aspiration.
While NG tubes can really help your patient, unfortunately, the insertion procedure can be somewhat difficult. There are some nursing hacks that you can use on your med-surg nursing floor when an NG tube is ordered!
During insertion of an NG tube, sometimes the tube has a tendency to curl in the oropharynx and not enter the esophagus as intended.
In order to help this, curl the distal portion around your finger, and freeze it in ice water for 10-15 seconds. This will help it keep its curled shape.
Insert the NG tube (with lube of course) with the curl in the direction of the pharynx (downward).
Right before the oropharynx, twist the tube 180 degrees. This ensures now that the “hook” is facing posteriorly, and shouldn’t curl out the mouth.
NG tube insertions are uncomfortable for the patient, but once it is in they should get some relief.
In order to make an NG tube insertion more tolerable, you can numb up the area first, and there are a few ways to do this.
You can get a Urojet with 2% viscous lidocaine and squirt it up the patient’s nare in which you intend to insert the NG tube.
Do this 5 minutes beforehand (you will need an order). While this is proven to decrease pain, it can increase the difficulty of the insertion (sticky!). See here for the full technique!
Additionally, 3-4mL of lidocaine (2-10%) can be placed in a nebulizer and given to the patient until gone. Then immediately insert the NG.
While this does reduce pain during insertion, it can increase the risk of epistaxis.
This one is interesting, but it can make crushing meds for a PEG tube easy!
Open an empty 10mL syringe. Take out the plunger completely, and place the pills inside.
Re-insert the plunger up to the pills, and then aspirate 3-5mL or so of tap water.
Next, plug up the end with a clean gloved finger, and pull back the plunger, creating a vacuum. This should crush the pills inside!
You can then squirt this into a larger volume before administration into the Peg tube.
If you need help visualizing this, check out this quick video!
PICC lines are central lines placed peripherally in the hospital setting. These are often placed on patients with very difficult access or those who will require long-term therapy such as antibiotics.
With med-surg nursing, you will have to become comfortable dealing with PICCs: administering medications through them, as well as drawing blood.
Unfortunately, PICC lines can get clogged up which can make either task difficult.
But fear not – there are some nursing hacks that can help!
Whenever you are having a difficult time flushing or aspirating blood from a PICC line, there are some maneuvers that the patient can do which may be able to help.
A central line occlusion can be mechanical (think kinks!), Postural (based on positioning), from medication precipitates, or from small blood clots (a thrombus).
Often, this is positional and simple maneuvers can help with flushing or blood aspiration. Moving the arm position (raising it above their head) sometimes can help.
You can also have the patient turn their head in the opposite direction, take a deep breath, and cough. This can increase pressure and change the positioning of the catheter and lead to successful flushing or aspiration.
Sometimes there is a partial or complete occlusion of the central line by a thrombus. You will notice significant resistance when flushing or aspirating (or complete resistance).
In this instance – Alteplase can be used. This is the same medication as TPA given for strokes, but at a much lower dose and intended to remain within the central line.
When there is a partial occlusion, alteplase (also known as Cathflo in this instance) can be instilled into the PICC (2mg in 2mL). Allow to dwell for 30-120 minutes, however long it takes to successfully resolve the blockage.
If there is a complete occlusion (aka you can’t flush it at all), you can use a three-way stopcock, create negative pressure with an empty syringe, and then slowly flush the alteplase through. This can take some time, and make sure you follow your facility’s policies and procedures.
When you have given it 30-120 minutes, aspirate 4-5mL of blood and waste, then flush through with sterile saline.
This can be repeated twice in a row if not successful the first time.
Also check out: 20 Tips for New Nurses In the Hospital
Blood is something that all nurses will have to deal with in some capacity – especially nurses within the hospital.
Whether our patients are bleeding, we are drawing their blood, or a procedure causes bleeding – it will inevitably get all over.
Of course, nurses should be using universal precautions and hopefully, the bleeding is controlled. However, sometimes it can get messy and be difficult to clean up.
Dried blood can be very difficult to clean, and there are a few nursing hacks that can help!
A well-prepared nurse always has alcohol swabs in their pocket.
If you have trouble getting a small amount of dried blood off of a patient’s skin, bust out the swab and start scrubbing.
This is somewhat effective, although soap and water or cleaning wipes will likely do just as well. So this is especially useful for small amounts of blood.
Hydrogen peroxide can be used to get dried blood out of clothing and off of skin.
When hydrogen peroxide meets your blood, oxygen is created and bubbling/foaming is seen. This breaks down the blood and allows for it to get out of your clothing and off of dry skin.
Following up with soap and water or cleaning wipes is beneficial.
Lube is useful for so many activities (both in and out of the hospital), but did you know it can also help with blood?
Specifically, it helps get rid of dried blood on the patient’s skin.
Leave the lube in place for a few minutes and then come back and wipe it up. This will usually make the removal of the blood a piece of cake. Ultrasound Gel works too!
Many patients on a Med-Surg nursing floor will have telemetry / cardiac monitoring ordered. This is a great tool we can use to monitor a patient’s heart rate and rhythm, but sometimes there can be difficulties obtaining a good tracing.
Poor tracing of a cardiac rhythm is termed “artifact” and there are many different potential causes.
Artifact can be from excessive patient movement, tremors, or shaking; but it can also be from improper application of the electrodes.
If your patient’s monitor has excessive artifact despite not moving or shaking, try these ECG nursing hacks:
The electrodes could be old and dry, decreasing the conduction and quality of the ECG tracing.
Electrodes should typically be replaced every day.
Dead skin cells, dirt, and grime can all interfere with the conduction of the ECG.
Before applying the electrodes, try washing the patient’s chest with soap and water or a cleaning wipe.
In a pinch, using an alcohol wipe over the areas in which you are placing the electrodes can help exfoliate the skin.
Allow to dry before applying the new electrodes.
Hair can be a big interference when conducting cardiac activity.
If the patient is excessively hairy in the areas where you need to place the electrodes, you may need to shave them to get good conduction.
Sometimes the wires or equipment is the problem. Switch out the equipment or wires and see if you get a better result.
Electrical signals from other equipment can interfere with the telemetry monitor and cause artifact.
Make sure the wires and telemetry box are not in close contact with any other equipment such as an IV pump.
Make sure the patient’s electrodes are not overtop of a pacemaker or ICD!
Sometimes no matter what you try, there still may be some artifact. Try adjusting the amplitude and changing the lead view to obtain the best view with the least amount of artifact.
I also have a video course all about how to read ECG rhythm strips, which you should check out if you’re interested!
Now this is a section that deserves it’s own post, and lucky for you I have one here!
On a Med-Surg nursing unit, you won’t have to put in IVs as much as the ER, but it is still a skill that you will have to use and improve on. Patient’s IVs go bad all the time and they may need replacement.
I will outline some basic hacks here, but be sure to read the full article as well if this interests you!
Use gravity to your advantage! Hang the extremity below the level of the heart (off the bed).
This will cause vasodilation of the veins and increase your target vein! This will make it easier to see, feel, and cannulate!
If Gravity isn’t enough, you can try a nice warm compress or hot pack! This will also cause vasodilation and increase your chance of success
You can obtain an order for a small amount of 2% Nitroglycerin ointment to be applied to the area in which you plan to cannulate. This will also cause vasodilation.
Using a bedside blood pressure cuff can help you from blowing a vein. Pump the pressure cuff just above the patient’s systolic pressure.
This will prevent excess pressure from the tourniquet, but still enough to engorge the veins.
If you don’t see a flash of blood on your first advancement, don’t give up just yet.
Pull the needle and catheter back, re-palpate the vein, and attempt to insert in the direction of the vein again. If the patient can tolerate this, it will prevent extra pokes.
Also check out:
Lidocaine gel as an anesthetic protocol for nasogastric tube insertion in the ED.
Nebulized lidocaine decreases the discomfort of nasogastric tube insertion: a randomized, double-blind trial
Central lines: Recognizing, preventing, and troubleshooting complications
Facilitated intravenous access through local application of nitroglycerin ointment
“De-Noise move (CardioNetworks ECGpedia)” by CardioNetworks is licensed under CC BY-SA 3.0
If you want to learn more about how to read an ECG and 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!
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Published: November 25, 2020
Last Updated: March 29, 2023
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 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 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.
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 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.
Before diving into the different types of IV fluids, there are a few important underlying concepts we need to understand.
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 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.
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, 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:
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.
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:
LR is preferred over NS in certain situations, including:
LR should be avoided in:
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.
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:
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:
When given, make sure the patient’s sodium levels are monitored daily, as this can cause hyponatremia.
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:
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”
Dextrose can be added to any of the fluids mentioned above, as well as to water. Dextrose solution is usually ordered for:
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:
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:
Dextrose should not be used in:
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.
Sometimes potassium may be added to each liter bag of fluids. Potassium may be added to maintenance fluid in:
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”
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!
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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/