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Published: March 1, 2023
Last Updated: March 19, 2023
IV infiltration and other catheter complications are very common. If you work in the medical field, you know how vital these IV catheters are. But, as with any medical procedure, there are always potential complications that can occur. In this blog post, we’ll discuss IV Infiltration and other common IV catheter complications and how to manage them in your patients. With this information, you’ll be better prepared to handle any IV complications!
IV catheters are small, thin tubes placed into a vein with a needle that is then retracted, leaving only the plastic catheter in place. This is used to administer medications and fluids directly into a person’s bloodstream.
IV catheters are invasive, which can lead to some level of risk for the patient. This is why assessment of the IV site is essential to ensure our patients’ safety and ensure there is no IV infiltration or any other complication occurring!
Nursing assessment of the IV site is an essential part of managing IV catheter complications. As nurses, it’s important to monitor the IV site regularly and assess for any signs or symptoms of potential complications like IV infiltration.
When assessing the IV site, nurses must inspect and palpate not only the IV site, but also the IV dressing and any tubes or lines that the patient has attached.
Change IV Dressing per facility protocol
Since IVs are so common within the hospital and ER, IV catheter complications like IV infiltration are also common.
Some of these IV catheter complications include IV infiltration, IV extravasation, IV site cellulitis, superficial thrombophlebitis, and IV catheter breakage. These complication rates are increased if improper technique is used while Inserting the IV.
IV Infiltration is when IV solution infuses or infiltrates surrounding tissue adjacent to the vein it is supposed to infuse into. This usually occurs when the IV catheter is malpositioned either during IV insertion or after being dislodged. This is why proper placement and securement of the IV, dressing, and tubing are important!
IV Infiltration generally refers to when this happens with normal fluid that is not damaging to the tissue. When the medication does cause damage to the tissue, these medications are called vesicants, and the infiltration is then referred to as extravasation.
IV infiltration and other catheter complications are very common. If you work in the medical field, you know how vital these IV catheters are. But, as with any medical procedure, there are always potential complications that can occur. In this blog post, we’ll discuss IV Infiltration and other common IV catheter complications and how to manage them in your patients. With this information, you’ll be better prepared to handle any IV complications!
Signs and symptoms of IV infiltration will depend on what has infiltrated, and include:
With IV infiltration, the patient may complain of pain at the IV site, especially with certain medications that are damaging to the tissue, known as vesicants, or medications that aren’t quite as bad but still known as irritants (see lists below).
Local swelling near their IV site the most common symptom of IV infiltration.
There are often temperature skin changes with IV infiltration. This often is cold from the IV fluid being room temperature compared to their body temperature, but may also be warm in the setting of extravasation.
IV infiltration will usually cause pallor, but may cause erythema or bruising as well.
Interventions of IV infiltration and IV extravasation will depend on what has infiltrated, but will generally include the following steps:
Once you realize that the IV is infiltrated, stop the fluid to prevent further fluid/medicine from infiltrating.
Make sure the IV site is truly infiltrated. For a good assessment, you should try to to pull back blood return to see if it is still within the vein. Avoid applying pressure on the site.
Elevate the extremity above the level of the heart. This encourages drainage of the fluid into the vasculature where it should be, instead of in the extravascular space.
If a medication has infiltrated (aka extravasation), first notify the Provider / pharmacy BEFORE you remove the IV. This is because certain vesicants need to be irrigated or have the antidote administered into the IV before removal!
If the fluids had medication in it, it is a good idea to notify the provider and pharmacy to ensure no additional steps need to be taken.
After notifying the Provider and Pharmacy, you will have orders for treatment. For a simple IV infiltration with fluids, a compression wrap and time are usually sufficient.
For IV extravasation with a vesicant, sometimes certain antidotes are ordered and administered into the IV and locally infiltrated into the tissue surrounding the extravasated area.
Remove the bad IV and insert a new IV in a different location. If using the same extremity, it is best to use a site proximal to the infiltration.
Below if a list of some commonly administered IV medications in the hospital which are vesicants and can cause tissue damage if extravasation occurs:
Some medications cause irritation but not the same level of tissue damage as vesicants. These include:
Superficial Thrombophlebitis is when there is inflammation of the veins (phlebitis) with some thrombus formation (blood clots) in a superficial vein. This occurs in superficial veins where the IVs are placed, and is different than Deep Vein Thrombosis (DVT) and is managed differently as well.
There is always inflammation and an immune response whenever anything “doesn’t belong” in the body. In the case of IV catheters, this is usually not extreme, but sometimes the body reacts more significantly. This inflammation can lead to blood clot formation.
Some causes or factors increasing the likelihood of thrombophlebitis to occur is:
You’ll notice that these risk factors are similar for a patient developing DVTs and other blood clots. You can read all about Virchow’s triad here!
Remember that larger IV bores are associated with more endothelial vein wall damage and are more likely to cause issues like thrombophlebitis. Just another reason to only place the IV size that is appropriate, and bigger is not always better.
The signs and symptoms of thrombophlebitis are what you’d expect – redness, pain, and swelling, which is associated with most inflammatory states. Generally there won’t be as much swelling as with IV infiltration.
A patient with superficial thrombophlebitis from an IV will complain of pain at and surrounding the IV site
As with other inflammation, redness occurs and is visible on the skin and surrounding areas surrounding the IV site. You may notice this redness follow the vein specifically.
You may notice some mild edema, but not as significant as with IV infiltration. This shouldn’t cause dramatic distal edema like DVTs.
Like other cases of inflammation, you’ll notice the skin may feel warmer than the surrounding area.
Remember that inflammation occurs when there is a suspected injury or foreign object. Your body activates your immune system and releases local chemicals (like histamine) and other inflammatory mediators, which cause capillaries to “leak”, increasing swelling and recruiting more white blood cells to fight the infection or foreign body. This leads to pain, redness, and swelling.
When superficial thrombophlebitis is suspected, it will depend on the Provider on what kind of diagnostics are done. Generally, symptoms can mimic a DVT and a DVT should be ruled out.
Stop all meidcations or any infusions that are currently infusing into the vein.
Notify the Provider of suspected inflammation. If the pain or signs are significant, a DVT may need to be ruled out. This would be ruled out by a Venous Duplex of the upper extremity.
Insert a new IV in a different location. If using the same extremity, it is best to use a site proximal to the infiltration.
Most cases of superficial thrombophlebitis don’t require treatment with an antiocoagulant like a DVT would. Removing the IV, elevation, warm or cool compresses, and NSAIDs are part of symptomatic treatment.
Cellulitis is when there is a local skin and soft tissue bacterial infection. This can occur anywhere on the skin, and is usually caused by a “break” in the skin barrier. Since an IV (and anything invasive like that) breaks the skin integrity, this offers a pathway for bacteria to enter the skin and lead to infection.
This is why it’s so important to follow an aseptic (aka sterile) technique when placing an IV catheter. Just like improper technique can lead to IV infiltration, it can also lead to IV site cellulitis if you aren’t careful!
Certain patients more prone to developing cellulitis are those with immunocompromised conditions and states, which commonly include uncontrolled diabetes.
Cellulitis from a peripheral IV has the same signs and symptoms as cellulitis in any other area. These changes to the skin are associated with inflammation and infection, and include:
A patient with cellulitis will often complain of pain around the IV site.
Patient’s with infections like cellulitis often present with fevers, which may indicate early sepsis.
Discharge around the IV insertion site can occur with cellulitis.
Redness to the area is pretty prominent with cellulitis.
There may also be some mild edema at the site, but generally not as much as IV infiltration.
The surrounding area is usually warm or hot compared tot he surrounding skin temperature.
When you suspect IV site cellulitis, you should do the following:
Stop all medications or any infusions that are currently going through the vein (remember they can also have IV infiltration, thrombophlebitis, or something else going on too).
Do a full set of vitals including a temperature to make sure the vitals are stable and see if there are any fevers.
Notify the Provider of suspected infection. They will determine if antibiotics are necessary.
Remove the IV from the patient.
Insert a new IV in a different location. If using the same extremity, it is best to use a site proximal to the infiltration
Most cases will require antibiotics – either IV or PO. IV antibiotics that commonly are ordered include:
IV breakage is a rare but serious complication of IV therapy. The breakage can occur due to several reasons, such as catheter damage, improper insertion technique, or excessive catheter manipulation.
It is important to prevent this, as the broken catheter tip can embolize to the heart or the lungs.
The signs and symptoms of IV catheter breakage can vary depending on the location and size of the broken catheter piece. If the broken piece is small, the patient may not experience any symptoms. However, if a larger piece breaks off, the patient may experience pain, swelling, redness, or tenderness at the site of the breakage. In severe cases, the broken piece can embolize through the bloodstream and lodge in other into the cardiac or pulmonary vasculature, which can obviously be bad news.
The main sign will occur when you take the IV out and notice that the entire catheter is not intact!
When you notice that the IV catheter not fully intact, you must act quickly and notify appropriate personnel.
The first step is to never pull out the IV if you are getting resistance. Cover the area with a sterile bandage and apply a warm compress to the area to relax the vein. After 5 minutes you can try to remove the line again very gently. If there is still resistance, contact the Provider / Vascular surgery or interventional radiology immediately!
Keep the arm still and below the level of the heart. We are trying to prevent the catheter piece from traveling up the veins to the heart or lungs.
Apply a tourniquet near the armpit. This is to close off the veins and prevent the catheter piece from passing by. Make sure to check a radial pulse to make sure the tourniquet is not too tight.
Notify the patient’s Hospitalist/Attending and/or Vascular surgery or interventional radiology.
Imaging such as X-rays or ultrasounds may be performed, and removal will occur by the specialists. Monitor the patient for acute chest pain, SOB, or vital sign changes which may indicate embolization of the catheter.
Early recognition and quick nursing intervention of IV catheter complications like IV infiltration can go a long way in saving your patient. Nurses play a critical role in identifying and taking prompt action to manage these complications. Proper monitoring, assessment, and management of IV catheter complications and IV infiltration can help prevent further harm to patients and improve their overall outcomes. By recognizing the signs and symptoms of IV catheter complications and following best practices for IV therapy, nurses can ensure that patients receive safe and effective care.
Published: August 25, 2022
Last Updated: March 6, 2023
Foley catheter insertion is one of the main procedures you will learn as a nurse in school, and you will have to put in a LOT of foley catheters if you work as a bedside nurse in the hospital.
The term ‘catheter’ is just a term that refers to a flexible tube that is inserted into a part of the body. Some examples include an intravenous catheter (IV), cardiac catheterization, and urinary catheters.
Foley catheters are also referred to as indwelling urinary catheters. These are essentially just a tube that is inserted into the bladder to allow urine to drain into a bag instead of staying in the bladder.
A foley is intended for both short and long-term use, both within and outside of the hospital.
Foley catheter insertions are ordered for various reasons, but long story short. -they are ordered when the patient cannot effectively drain their bladder. It’s also ordered when this is anticipated (like with surgery… see below).
Also called a bladder outlet obstruction, this is when something is blocking or obstructing the ability of the bladder to empty.
Common causes include Benign Prostatic Hyperplasia (BPH), tumors, blood clots, or severe constipation. Other causes include infections, scarring, strictures, or trauma.
This is when the bladder doesn’t work normally due to a central cause – aka there’s something with the brain. This could be from a stroke, degenerative diseases like MS, spinal cord injuries, or nerve damage.
Certain medications can lead to the bladder being unable to fully empty itself, requiring a foley catheter insertion.
Medications that weaken the bladder muscles include anticholinergics like Tricyclic antidepressants and diphenhydramine (Benadryl).
Medications that increase the tone of the prostate and bladder neck include decongestants, stimulants, or other sympathomimetics.
There are many other medications that can cause urinary retention, including muscle relaxers, certain antipsychotics, hormones, or even NSAIDs and opioids.
If a patient has significant bleeding in their urine, a foley catheter insertion can be ordered to monitor their output.
When there is significant amount of bleeding, this often clots, causing an obstruction and a distended bladder, along with severe discomfort.
A three-way catheter is usually placed and CBI (continuous bladder irrigation) is started to prevent the patient’s urinary tract from obstructing again.
Patients who need strict I&Os done may have a foley catheter insertion ordered. This is often critically ill patients in the ICU, like with severe CHF or renal failure.
For hourly output, make sure your foley bag has a urometer. This way the urine first drains into the urometer, then each hour can be emptied into the main collection bag.
Patients who are intubated and many of those who are critically ill are unable to empty their bladder on their own. To prevent skin breakdown as well as monitor their urinary output, foleys can beneficial.
After intubation, once the endotracheal tube is placed, that isn’t the last tube you have to worry about.
Immediately after intubation, you will need to place a foley catheter, as well as an Nasogastric or Orogastric tube to decompress the stomach and prevent aspiration.
Foleys are placed before/during surgery to monitor fluid status and prevent bladder overdistention.
Patient’s who are immobilized from spinal cord injuries, strokes, or pelvic fractures often have foley catheters placed.
Hip fractures will almost always be going for surgery anyway, so a foley can help offer quite a bit of comfort.
If the patient is incontinent and has open sacral or coccygeal wounds, sitting in their urine can make the breakdown worse and make it more difficult to heal. A foley can help promote wound healing in these cases.
Patients who are reaching their end of life often are very weak and uncomfortable, and a foley catheter insertion gives them one less thing to worry about and can make them feel more comfortable overall.
Foley catheters really shouldn’t be used to manage urinary incontinence. This is an inappropriate use of foleys and the potential complications and longer hospital stay outweigh any benefit.
There really is only one absolute contraindication to a foley catheter insertion, which is trauma with hematuria. This should be managed by a urologist.
There are some relative contraindications, which include urethral strictures, recent UTIs, or artificial sphincters.
Of course, benefits and risks should always be weighed. Introducing anything invasive into the body increases the risk of causing infection, which is very common but can be lethal. See monitoring parameters below.
While this article specifically focuses on foley catheter insertion, there are other types of urinary catheters that work similarly but may be used for alternate scenarios.
This indwelling catheter is placed in the bladder and left in place. This foley catheter insertion is ordered when ongoing use is anticipated. It is secured to the patient’s leg and drains into a leg bag or a larger collection bag that hangs on the patient’s bed.
Sometimes referred to as intermittent bladder catheterization, this is for once or as needed emptying of the bladder. This often ordered for short-term urinary retention, where the benefits of putting in an indwelling foley don’t outweigh the risks (i.e. infection).
This drains into a plastic collection chamber for drainage. Once the urine is completely drained, the catheter is immediately removed.
This is when a catheter is surgically placed through the peritoneum by a urologist or general surgeon. You’ll see this stitched in place below their belly button. This is placed in some patients with chronic incontinence/urologic issues. Nurses should never replace these.
No – this isn’t THAT kind of Three-way…
Also called a triple-lumen catheter, this is essentially a larger catheter that has 3 tips.
A three-way is typically only ordered for significant hematuria when clotting and obstruction are occurring or trying to be prevented.
This is a catheter with a special-shaped tip that helps you maneuver past an enlarged prostate.
Make sure nurses are able to use coude catheters at your facility. This may be reserved for Providers or Urology to use.
There are some alternatives to foley catheter insertion that can sometimes be used. These are non-invasive so they do not carry the same risks as causing infection. These are excellent solutions when the main issue is incontinence.
Also called a condom catheter, this fits over a man’s penis that drains incontinent urine into a suction canister.
This is the same concept but placed in incontinence women attached to suction.
Just like IV sizes and gauges, foley catheters have specific sizes as well. For foleys, these sizes are called “French units”. Each french unit increases the size of the diameter of the catheter by 0.33mm
For most adult patients, a 14-16 Fr catheter is standard. If you are worried about obstruction from sediment, a larger size is better. If you are worried about blood clotting, a three-way may be a better option.
Your facility may or may not have specific foley catheters for infants, depending on which facility and unit you work on.
Some units may use the purple kangaroo PVC nasogastric tubing to catheterize infants and toddlers. These are also sized in French units, so using a 5 french is common. Make sure you are always following facility and unit protocols.
Make sure you have all of the required equipment for the procedure. This usually includes:
Make sure to explain the procedure and obtain verbal consent from the patient. Also verify there is an order (verbal or otherwise) to insert the foley.
Ask or help the patient remove everything from the waist down, and place them in a hospital gown. Position them supine.
If they are female, have them extend their legs in a “frog” position. Males can remain with relaxed legs.
Setting up for the actual procedure may be just as important as actually performing it. Make sure you have proper lighting in order to see where you need to go. If the room has one of those adjustable overhead lights, this would work perfectly.
Wash your hands and open your foley kit, which is best placed in-between the patient’s legs. Open up the sterile drapes of the kit so you can have access to the sterile contents inside once you get sterile.
Apply sterile gloves as this is a sterile procedure. This minimizes the risk of introducing pathogens into the patient’s bladder, which can cause infection.
The foley tray kit usually comes with gloves, but these are small and not very stretchy, and often rip (especially for someone with larger hands).
This is where an additional pair of sterile gloves come in handy. You can choose your specific size, and these gloves are much stretchier and easier to maneuver (anyone else a 7.5?)
Once your sterile gloves are on, utilize the sterile drapes inside the kit to carefully place underneath the patient’s buttock, and place the fenestrated drape over their vagina/penis. Be careful not to touch the patient or bed with your sterile gloves.
Remove the catheter from its plastic covering, and place it inside a sterile lube package. The lubricant will help glide the catheter into the urethra, and placing it in the package will help keep your catheter from flopping around.
Your kit may instead have a pre-filled syringe with lube. If so, this is squirted onto your sterile tray, and stick the catheter in the lube where it isn’t going to fly off.
Attach the 10mL pre-filled syringe to the balloon port on the foley.
It used to be standard practice to test the balloon by inflating. the full 10mL into the balloon and then allow it to flow back into the syringe. This is no longer recommended and has the potential to stretch and distort the catheter and lead to more trauma during insertion.
Using pre-packaged betadine swabs, or betadine and cotton swabs/forceps, gently cleanse the region surrounding the urethra.
In females, swab in one direction front to back on the left, then the right, and finally down the middle.
In males, swab in one direction around the left side of the glans, then the right, then down the middle.
Now that everything is ready, it’s time to get ready to insert the catheter.
In females, spread apart the labia with your non-dominant hand to better visualize the urethra and make sure nothing gets in the way.
In males, retract any foreskin and stabilize the penis between your rounded hand.
Insert the catheter into the urethra with steady force. Advance until you see urine in the tube. Once you do, advance a little more before blowing up the balloon.
If you meet resistance, do NOT try to apply more pressure and force it through. Remove it and consult the Provider/urology, as the patient’s prostate is likely enlarged or there are tracts or strictures.
In women, if you don’t see any urine backflow within about 5-6 centimeters, you are likely in the vagina. Do not reuse this same catheter as this will likely cause an infection. Leave the foley in place and get a new sterile kit to retry the procedure. Aim superior to this foley.
Steadily push the 10mL syringe to blow up the balloon. Inflating the ballon should keep it in place within the bladder.
Gently pull back on the foley until light resistance is met. This is. to ensure the balloon is resting right at the bladder neck.
Secure the foley to the patient’s thigh using a cath secure, stat-lock, or tape. This is to ensure that the foley doesn’t get caught on anything or cause urethral trauma.
Place the collection bag below the level of the bladder but off of the floor. This prevents backflow which could lead to infection.
Collect any urine that you may need and send it off to lab, otherwise measure and empty the urine, and document accordingly
Removing a foley should be quick and easy. Verify the order before doing so, or if the patient insists it be removed then remove it regardless (as long as they aren’t confused).
Assessments of the catheter should be performed each shift along with your head-to-toe assessment. If there are any new or related symptoms or discomfort, this should be assessed more frequently.
The biggest thing to watch out for is signs and symptoms of a UTI, as foley catheters increase this risk.
Assess the urine. Is it draining? What color is it? Is there any blood, pus, or sediment?
Is there any skin breakdown, erythema, or discharge near the insertion site?
Assess the tubing and collection bag, checking for any leakage. Make sure it is secure and in place, and that the collection bag always remains below the level of the bladder.
The main thing you are going to monitor for is the development of infection (UTI) and sepsis from the foley catheter. This is usually evidenced by fevers, tachycardia, and frequently altered mental status in the elderly hospitalized patients.
During and after foley catheter insertion, be on the lookout for complications that may occur.
Infections are a common complication of UTIs. While common, UTIs can be severe and even kill patients, so preventing this is very important.
Using sterile technique is super important during the procedure to decrease the risk of infection. Also, make sure the collection bag remains below the level of the bladder at all times to prevent backflow.
Foley catheters can rarely lead to epididymitis in males and sometimes extend to orchitis (infection and pain of the testicle).
While rare, catheters can cause a bladder perforation. If so, the patient will develop extreme pain, bloody urine, and signs of peritonitis (abdomen rigidity and rebound tenderness, etc).
Bladder stones can form due to the presence of a foreign body within the bladder. This can lead to obstruction and pain.
Urea-splitting bacteria (like proteus mirabilis and Pseudomonas aeruginosa) are more likely to cause these stones.
A fistula is when a false passage forms between two different organs due to chronic inflammation, such as with a chronic Foley catheter. These are rare but can lead to significant complications, and infections, and will need surgery to fix it.
Managing a foley catheter after the foley catheter insertion is just one more aspect of the patient that you will need to care for.
The foley should be assessed with each head-to-toe shift assessment. You should be monitoring for things as below.
Clean the insertion area with soap and water daily
To secure the tube in place and prevent any urethral trauma, secure the foley to the patient’s leg. Many facilities will have Cath secures, but basic medical tape can also be used instead.
Keep the bag below the level of the bladder to prevent backflow. This should be drained often as well.
See if the patient is ordered I&Os, and chart how many mLs are emptied each time.
If a UA is ordered, you can now obtain and send this after the foley catheter insertion.
Everything online will tell you NOT to use the collection bag to obtain urine samples, as they may be contaminated. But nothing seems to distinguish a foley that was just placed or one that has been already drained and in place for some time.
However, if you just put in the foley, the bag should still be sterile, so some nurses do consider this first urine as a sterile sample. Whether or not this is appropriate is unsure, but always follow your facility protocols.
The recommended method to collect urine from a foley is to clamp the foley and withdraw urine from the collection port with a needle and large syringe, then transfer the urine to a sterile specimen cup.
To learn how to actually interpret the UA results, you can check that out here!
There is no reason to change a foley catheter simply based on time. There is no evidence to support routine change, and it is not recommended by the ISDA or the CDC. Foley’s are often ordered to be changed if there is obstruction, it is not working correctly, there is infection, or if it is being discontinued altogether.
And now you know exactly how to place a foley like a pro! Let us know in the comments if you have any other helpful tips or questions!
If you’d like to download this article in PDF form, click here!
Complications of urinary bladder catheters and preventive strategies
Placement and management of urinary bladder catheters in adults
FP notebook (Urethral Catheterization)
The Royal Marsden Manual of Clinical Nursing Procedures, Professional Edition (Royal Marsden Manual Series) 10th Edition
Published: March 3, 2022
Last Updated: March 23, 2023
Blood pressure is one of the 5 vital signs, and it is so important to understand what normal and abnormal blood pressures are, and how we manage them (don’t get me started on the “6th” vital sign…).
Within the hospital, vital signs are typically checked every 4 hours, and you will frequently run into both high and low blood pressures.
Low blood pressure is often much more worrisome, and you may want to call an RRT if the BP is significantly low, especially when the patient is altered or has significant symptoms.
High blood pressure is common, but often is not considered a big deal unless VERY high. In these cases, we want to slowly decrease the blood pressure instead of too quickly.
As you probably know, blood pressure is not the pressure of your blood, but rather the pressure within your vascular system.
The vascular system refers to your arteries and veins. When speaking of systemic blood pressure, we are specifically talking about the pressure in the arteries.
This pressure temporarily increases with each heartbeat, and decreases in-between each heartbeat.
The pressure in your arteries when your heart beats or contracts is called the systolic blood pressure. Systolic just means during the heartbeat. Systolic blood pressure can never be below the diastolic pressure.
When the heart is not beating, the pressure “rests” back to its normal baseline pressure. This is called the diastolic blood pressure. The diastolic blood pressure should never be 0.
This pressure is measured in millimeters of mercury (mmHg).
As we said above, systolic is the pressure during contraction of the heart, and diastolic is the pressure in-between beats. When looking at a blood pressure reading, there are two numbers: a numerator and a denominator. The numerator or top number is the systolic blood pressure. The denominator or the bottom number is the diastolic blood pressure.
Normal systolic blood pressures are between 100 – 120 mmHG. Normal diastolic pressures are between 60-80 mm Hg. Traditionally 120/80 mmHg was considered the “gold standard” for blood pressure, but now its recommended to be at most 120/80 mmHg.
A “good pressure” is relative. In the ER, a pressure below 160/90 tends to be considered pretty good and usually won’t require any medications. However, a pressure of 160/90 is considered very high if that is the normal daily blood pressure at home, and should be started on medications.
We check people’s blood pressures in the hospital, in the outpatient office setting, and pretty much every area of patient care. Nowadays, we have machines that do most of it for us. But machines aren’t perfect, and its an essential nursing skill to know how to check blood pressure.
In general, there are 3 main ways to check someone’s blood pressure:
A manual blood pressure is checked using a sphygmomanometer and a stethoscope. The stethoscope if placed over the brachial artery, and the cuff is placed on the patient’s bicep.
The cuff is pumped up to about 160 or 180 (in most people unless BP is very high). Slowly release the cuff pressure while you auscultate the brachial artery.
Systolic blood pressure is identified by the first Korotkoff clicking sound. The diastolic is noted when you can’t hear anything left.
You can palpate the patient’s radial artery when a machine or cuff is pumping up or down. When the radial artery disappears, this is your systolic pressure. There is no way to check diastolic with palpation
An automated blood pressure is checked by a machine, often a portable Dinamap or a bedside monitor. These machines essentially perform a manual BP on their own.
They have a sensor which detects tiny oscillations from your pulse. So when the pulse goes away – this is your systolic pressure. When the pulse reappears, this is your diastolic pressure.
Arterial lines are commonly placed in the ICU for strict BP monitoring. This is the most accurate way to check a blood pressure because it is directly measured by a sensor within the arteries, instead of indirectly like with the methods above. This gives you real-time changes in blood pressure.
If you’ve been working for a bit, or in clinicals, you may hear about the term “MAP”. While systolic blood pressure is often considered the most important part of the blood pressure, the actual important number is the MAP.
The MAP stands for Mean Arterial Pressure. This is the average pressure in the arteries from one cardiac cycle (systolic + diastolic). This is measured by a calculation:
But don’t go busting out your calculators. The bedside monitors should automatically calculate this for you, or possibly your EMR. If you need to calculate it, there are plenty of good online calculators to quickly do it.
MAP is a great indicator of tissue perfusion. If the MAP stays above 65 mmHg, then this should be enough pressure to provide essential tissue perfusion and prevent anoxic injury (injury from a lack of oxygen to the cells!).
Nurses and Providers in the ICU will care much more about MAP than systolic blood pressure, especially when looking at low blood pressures.
Hypertension, also known as high blood pressure, comes in many different forms. While often thought of as “not a big deal”, it really is the silent killer, and can put a lot of strain on the heart, vasculature, and kidneys.
Overtime, this organ damage becomes more pronounced, placing the patient at risk for heart disease, strokes, kidney failure, and more!
Another reason why it’s termed the silent killer is because it often is asymptomatic – meaning there are no symptoms. But just because there aren’t any symptoms doesn’t mean it isn’t dangerous, especially in the long run.
In medicine, we use JNC8 guidelines to classify and manage hypertension.
Blood pressure levels include:
Normal: < 120 / 80 mmHg
Stage 1 HTN: 130 – 140 / 80-89 mmHg
Stage 2 HTN: > 140 / 90 mmHg
Hypertension can be chronic or acute. Its also important to know if the patient is having any symptoms such as chest pain, SOB, headache, etc.
3 main types of hypertension that we’ll talk about include:
Primary hypertension, previously referred to as essential hypertension, is a chronic hypertension that has no clear cause, but is thought to involve genetic, dietary, and lifestyle factors. This is what most people are diagnosed with when they have high blood pressure. Risk factors include:
Hypertensive urgency is a very high blood pressure > 180/110 mmHg. While there is no evidence of organ damage (i.e. lack of symptoms or lab abnormalities), the patient is at risk for organ damage or strokes to occur.
Hypertensive emergency is a very high blood pressure > 180/110 mmHg when there IS evidence of organ damage. The patient should have at least one of the following signs or symptoms:
Treatment of hypertension is often not aggressive, and is often made by slow gradual changes to outpatient medication regimens.
However, if the patient is symptomatic, blood pressure medications should be given.
At home blood pressures should be checked, as patients BPs are often higher in emergency and urgent care settings, and “White coat hypertension” is common.
Some oral medications used to lower BP include:
In hypertensive urgency and when in the hospital, sometimes IV medications may be required including:
In general, blood pressure should never be lowered too fast. In severe cases, the goal should be to lower the MAP by 10-20% within the first hour, then another 5-15% over the next day. In many cases, this is less than 180/120 in the first hour, and less than 160/110 after 24 hours.
Lowering the blood pressure too quickly can actually cause ischemic damage in patients who have had elevated blood pressure for a long time. Basically the body becomes used to that high pressure, and while it is dangerous to have high blood pressure in general, lowering it too quickly can cause damage as well.
When it comes to blood pressure (and even heart rates while we’re at it), its always important to ask the patient if they have any symptoms. Ask about any CP, SOB, dizziness, palpitations, headache, numbness/tingling/ etc.
Hypotension is when the blood pressure is too low. Low blood pressure is defined as any pressure less than 100/60 mmHg. However, this is often not considered true hypotension until below 90/50 mmHg.
Patients who are small in stature and thin may have borderline low blood pressures at baseline.
Worried about the patient’s BP? Trend what their BP has been this hospital visit, as well as previous hospital visits. If their BP is 92/48 but they always run around there and are asymptomatic otherwise – this is reassuring.
Remember if the MAP is less than 65 mmHg, this places the patient at risk for tissue ischemia and organ damage.
Low blood pressure is often a serious sign, especially in the hospital setting. Common causes of hypotension include:
Septic shock is when there is a severe systemic response to infection. These patients will have persistent hypotension despite adequate fluid resuscitation (30ml/kg bolus). They usually require IV vasopressors, a central line, IV antibiotics, and ICU admission.
Anaphylactic shock is a type of distributive shock that occurs with a severe allergy. Release of inflammatory mediators causes massive systemic vasodilation, swelling, and hypotension. This is treated with IV steroids and antihistamines, +/- epinephrine.
When the patient loses enough blood, they will become hypotensive. These patients need STAT blood, usually O negative blood that hasn’t been crossmatched.
Cardiogenic shock occurs when the heart can’t keep up with the body’s demand. This can occur in severe CHF or bradyarrhythmias.
Maintenance medications given for blood pressure can cause low BP, especially if taken in wrong doses or if they become toxic. Some other medications have hypotension as a possible side effect such as amiodarone.
Patients with a history of adrenal insufficiency will often require stress-dosed steroids to maintain their blood pressure.
Dehydration needs to be severe before the patient becomes hypotensive. This can occur in those with DKA or diabetes insipidus, or really anything that causes dehydration.
Treatment of hypotension will involve treating the underlying cause, but generally involves 2 steps:
If fluid boluses do not improve blood pressure, or if the BP drops back again once its done, then the patient may need vasopressors in the ICU.
Depending on the cause, the underlying cause should be addressed, including:
You are going to run into TONS of patients who either have high blood pressure, or low blood pressure. Managing vital signs is a huge part of our jobs as nurses and doctors, and its so important to understand how to manage blood pressure!
Remember these important concepts when it comes to blood pressure:
Double check your blood pressures. If it doesn’t seem right – check a manual BP. The provider may ask you to do this anyway.
If your patients BP is high or low, ask them if they have any symptoms. Focus on any headache, chest pain, shortness of breath, dizziness, lightheadedness, palpitations, syncope, etc.
Remember high blood pressure shouldn’t be corrected too quickly. Look at previous trends. Don’t freak out about blood pressures that are high unless the patient has symptoms. Worry more about low blood pressures!
Basil, J., & Bloch, M. J. (2022). Overview of hypertension in adults. In T. W. Post (Ed.), Uptodate. https://www.uptodate.com/contents/evaluation-of-and-initial-approach-to-the-adult-patient-with-undifferentiated-hypotension-and-shock
Calder, S. A. (2012). Shock. In B. B. Hammond & P. G. Zimmerman (Eds.), Sheey’s manual of emergency care (7th ed., pp. 213-221). Elsevier.
Gaieski, D. F., & Mikkelsen, M. E. (2022). Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock. In T. W. Post (Ed.), Uptodate. https://www.uptodate.com/contents/overview-of-hypertension-in-adults
Roe, D. M. (2015). Cardiac emergencies. In B. A. Tscheschlog & A. Jauch (Eds.), Emergency nursing made incredibly easy! (2nd ed., pp. 97-197). Lippincott Williams & Wilkins.
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!
This post may contain affiliate links, which means I get a commission if you decide to purchase through my links, at no cost to you. Please read affiliate disclosure for more information
Author | Nurse Practitioner
Learning how to read an EKG rhythm strip is an essential skill for nurses!
This skill becomes especially handy for nurses on Med-Surg, Telemetry, the Emergency Department, or Critical Care units.
If reading an EKG rhythm strip is new to you – this is the perfect place to start!
An EKG or ECG stands for Electrocardiography, which is the electrical activity of the heart traced on paper (or a monitor).
A rhythm strip is at least a 6-second tracing printed out on graph paper which shows activity from one or two leads.
Leads are “views” of the heart. There are 12 leads that are traditionally obtained with a 12-lead EKG, but most portable and bedside monitors only monitor 3-5 leads at a time.
Luckily – interpreting a single rhythm strip is much easier than a 12-lead EKG. Most rhythm strips are interpreted from Lead II as this gives a great view of the heart.
The goal of reading an EKG rhythm strip is to determine the rate and rhythm of the patient. This is great for identifying baseline cardiac rhythm as well as any arrhythmias or ectopy that may occur (like a premature beat).
A 12-lead EKG also looks at the rate and rhythm, but additionally gives nearly a complete 360° view of the heart.
This means it can be used to assess for things like cardiac ischemia or infarction, conduction delays, and even enlarged chamber size.
As I said earlier – an ECG Rhythm tracing is the electrical activity of the heart recorded on paper or a monitor.
This is traditionally printed out on a 6-second strip. This can make it easy to determine the rate of an irregular rhythm if it is not given to you (count the complexes and multiply by 10).
Thick black lines are printed every 3 seconds, so the distance between 3 black lines is equal to 6 seconds.
As you can see, a printed ECG rhythm strip is comprised of boxes – both small boxes and large boxes. 5 small boxes make up one large box.
Each small box is 1mm wide, signifying 0.04 seconds or 40 milliseconds (ms).
Each large box is 5 small boxes, signifying 0.20 seconds or 200ms.
This becomes important to remember when determining the rate of regular rhythms. The boxes and lines are also important in recognizing whether a rhythm is regular or irregular.
Okay so that covers the paper, but what about the actual tracings? That’s where the alphabet comes into play. By alphabet – I mean PQRST.
An electrical tracing of the heart is made up of waves, lines, complexes, and intervals, and each of these represents specific conduction within the heart. This is the key to interpreting a rhythm strip.
P waves represent atrial depolarization. This means that the electrical signal that starts in the SA node (the normal pacemaker of the heart) is traveling through both atria (top chambers of the heart) during the P wave.
A P wave should look smooth and upright in most leads including lead II.
The 3 things you’ll want to specifically look for in P waves in a rhythm strip are:
Keeping these 3 questions in mind will help you determine where the rhythm originates from (i.e. the sinus node), if there are any potential extra beats, or if there could be certain heart blocks present.
An inverted P wave means there is anterograde conduction to the atria (backwards direction). This means the electrical impulse originates from near, at, or below the AV node. Examples of this include Junctional rhythm, certain PACs, and PJCs.
The QRS complex represents ventricular depolarization. This means that the electrical signal is traveling through both ventricles (the bottom chambers of the heart). In a healthy heart – this should correlate with the pulse.
The QRS complex is actually made up of 1-3 waves, the Q wave, the R wave, and the S wave. Depending on which lead you look at and the specific heart, any combination of these waves may be present.
In lead II, usually all three waves are present. This includes an initial downward deflection (Q wave), an upward deflection (R wave), followed by a downward deflection (S wave).
The presence of a QRS complex indicates that the ventricles are receiving the electrical signal. These should follow shortly after a P wave in a sinus rhythm.
The main abnormality that can occur is a wide QRS complex. This either means that there is aberrant conduction (like a bundle branch block), or that the electrical signal starts in either the left or right ventricle (i.e. a PVC or Ventricular Tachycardia).
A bundle branch block just means there is a delay in the conduction tissue transmitting the signal to either the right or left ventricle. If the widened QRS is preceded by a P wave, it is probably a sinus rhythm with a BBB.
If there is no preceding P wave, you may have a PVC or even VTACH if it is sustained.
The T wave represents ventricular repolarization. This means that the myocardial cells within the ventricles are recovering and “getting ready for the next beat”.
This should be smooth and upright in most leads, including lead II.
Sometimes, the T wave can be inverted or flipped. This is nonspecific but can indicate cardiac ischemia or infarction, especially if it is in at least 2 contiguous leads (pertaining to the same anatomical area of the heart).
People may have flipped waves in certain leads at baseline after a heart attack, with a bundle branch block, or with a PVC, VTACH, or ventricular paced rhythms.
Tall or tented T waves are those that are > 1 large box in lead II and may be particularly pointed. This could be normal for the patient, but can also indicate hyperkalemia (high potassium).
The PR interval is from the beginning of the P wave to the beginning of the QRS complex. This represents the time it takes for the electrical signal to reach the ventricles from the SA node.
This should be 3-5 small boxes or 120-200ms. If longer, this is considered a first degree AV block.
A short PR interval could be from a a PAC, a junctional rhythm (associated with an inverted P wave), or Wolff-Parkinson-White syndrome.
The QT interval is the time between the start of the QRS complex to the end of the T wave. This will change depending on the heart rate, so a QTc (QT corrected) is calculated.
This should be 350-440ms in men, and 350-460ms in women. A QT interval >500ms predisposes the patient to deadly ventricular arrhythmias such as Torsades de Pointes.
QT prolongation can be caused by ischemia, electrolyte abnormalities, or from medications such as psych medications, Zofran, Azithromycin, Cipro, etc.
While you can calculate the QT interval from a single strip, a 12-lead EKG should be obtained and it will be listed on the EKG for you. Otherwise, there are online calculators which can be used to determine the corrected QT interval for the heart rate.
An arrhythmia is any abnormal rhythm other than normal sinus rhythm – the baseline rhythm of the heart. This can be a benign variant (like sinus arrhythmia), or it could be deadly (like ventricular fibrillation).
In order to know how to read an EKG rhythm strip, you need to first be able to understand what normal sinus rhythm (NSR) looks like.
You should be comparing every rhythm strip to NSR. Recognizing where the rhythm differs from NSR will help you identify the rhythm.
Normal sinus rhythm is the gold standard. This is what a normal functioning heart beat should look like.
The “sinus” in the name indicates that the electrical signal is coming from the Sinoatrial node (SA node), the “normal” pacemaker of the heart.
The presence of sinus rhythm means the cardiac conduction system is functioning appropriately (although certain blocks may still be present).
The rate of NSR is 60-100 bpm. Slower is sinus bradycardia, and faster is sinus tachycardia. This just means that the heart is functioning at altered rates, possibly due to sleep, medications, infection, exercise, etc.
All sinus rhythms should be regular, meaning each of the QRS complexes are mapping out.
You can do this by measuring the R-R interval between any two beats, and then making sure the R-R interval stays constant throughout the strip. Some people use calipers, but I recommend a good old-fashioned alcohol pad or piece of paper and a pen.
Additionally, a P wave should precede each QRS complex.
The QRS complex should be narrow unless there is a bundle branch block present.
To read an EKG rhythm strip, you should do so in a systematic way, so that you don’t miss anything.
Using this systematic approach should help you interpret what each rhythm is. But you need to be familiar with most of the arrhythmias out there.
Other sinus rhythms are rhythms that may still “normal”. I include paced rhythms in this section as this replaces NSR once a pacemaker is placed.
Sinus bradycardia is the same as NSR, but the HR is <60bpm.
This can be normal for well-conditioned individuals like athletes, can be normal if the patient is on a beta-blocker or similar medication, and can also be normal while sleeping.
The most important thing when the patient has SB is
Since this is often a normal variant – if the patient is asymptomatic there’s usually nothing that needs to be done.
Make sure a slow HR is actually SB and not a heart block!
Sinus tachycardia is the same as NSR, but the HR is >100bpm and usually <150bpm, at least while at rest.
This can often be seen with exercise, but ST at rest often indicates anxiety, certain drugs, sepsis, dehydration, or volume loss. ST is usually a response to an underlying cause within the body.
You never treat the ST, but rather treat the underlying issue (i.e. give fluids with volume depletion).
Paced rhythms will look different depending on the location of the leads. If the lead is in the right atria, the rhythm will appear like NSR but with a pacer spike before the P wave.
If the lead is in the right ventricle, it will look like a slow VTACH with a pacer spike before the QRS. There can also be both of these at the same time.
Some monitors only show the pacer spike if you turn that function on – if you see a very slow VT – ask the patient if they have a pacemaker and adjust the monitors appropriately.
Heart blocks are when there is significant delay or blockage in transmitting the signal from the atria to the ventricles. This is usually associated with a junctional or ventricular escape rhythm.
First degree AV block is generally “no big deal” and common in older age and with beta-blockers. The PR interval is consistently >200ms.
Second degree type 1 AV block or Wenckebach, is when there is a progressive lengthening of the PR interval which eventually leads to a dropped QRS complex.
Second degree type 2 AV block or Mobitz II is when there is a consistent PR interval but QRS complexes are randomly dropped.
Third degree AV block or complete heart block is when there is complete dissociation of the atria and the ventricles.
Atrial Fibrillation is a very common type of arrhythmia that you will definitely run into in the hospital. AF could be new-onset, RVR (rapid ventricular response), could be intermittent (paroxysmal), or chronic/persistent.
AF is an irregularly irregular rhythm, meaning that there is no rhyme or reason for the regularity of each QRS complex.
This is usually from a structurally diseased heart where both atria are quivering rapidly, termed fibrillation. This leads to fast ventricular rates (AF RVR), as well as poor blood flow through the atria – predisposing the patient to blood clots.
This is why these patients are started on rate-control medications such as metoprolol or Cardizem, and usually anticoagulants like heparin, Eliquis, etc.
AF will not have p waves but instead, have a fibrillatory baseline. The QRS complexes will usually be narrow, and will not map out with each other in any way.
Rates >100bpm are considered AF RVR.
Atrial Flutter (Aflutter) is similar to Atrial fibrillation and is treated largely the same.
This is when the atria aren’t fibrillating but rather “fluttering”. This is usually from a reentrant loop near the AV node.
This will usually lead to a conduction ratio of 2:1, and a HR around 150bpm. Conduction ratios can be 3:1 (100bpm), 4:1 (75bpm) and variable as well.
You will see saw-tooth P waves termed “f waves”. Depending on the conduction ratio, you will see 2 (3 or 4) F waves per QRS complex. Aflutter is usually regular.
Supraventricular Tachycardia is an umbrella term referring to any fast tachycardia that originates above the ventricles. However, in clinical terms, this usually refers to AV Nodal Reentrant Tachycardia (AVNRT).
This occurs when there is an abnormal pathway of conduction tissue near/within the AV node, termed a “reentrant loop”.
If a PAC or PVC comes at the wrong time, this can send the electrical signal around and around this loop of conduction tissue, leading to very fast heart rates.
SVT can be as “slow” as 140bpm to as fast as 220bpm. The faster the heart rate, the more symptomatic the patient usually is.
In SVT, P waves are usually not present, there is usually ST depression, and the rhythm is regular with narrow QRS complexes.
Treatment for this involves vagal maneuvers and often adenosine or Cardizem.
Ventricular Tachycardia is a fast tachyarrhythmia originating within the ventricles. This leads to very fast heart rates with or without a perfusing rhythm.
This means the patient may not have a pulse and may be a code blue. Either way, VT is a very serious arrhythmia.
VT is usually caused by Coronary heart disease, like a previous or current MI.
The rhythm is regular, and the rate is anywhere from 100-330bpm, and the QRS complex is wide (>140ms).
P waves are usually absent or undetectable, but 60% of cases can have AV dissociation present.
If there is no pulse, you use ACLS cardiac arrest algorithm.
If there is a pulse, you utilize the ACLS Adult tachycardia with a pulse algorithm.
Ventricular Fibrillation is a deadly ventricular arrhythmia. There will not be a pulse, and the patient will be coding.
VF is a similar concept as AF, except the ventricles are the ones fibrillating. Coronary artery disease is again one of the main causes of VF. Severe electrolyte abnormalities can also cause VF.
VF is irregular and has no pattern. There is either coarse or fine fibrillation, eventually degenerating into asystole if not shocked back into a normal rhythm.
These patients need fast defibrillation, high-quality CPR, Epinephrine, antiarrhythmics, etc (Code blue algorithm).
Asystole is the absence of cardiac activity. This is essentially a straight wavy line but may have occasional p waves initially. The patient is dead. Follow ACLS algorithms as above.
PEA appears like a normal rhythm (Usually NSR or SB), but there is no actual mechanical contraction (no pulse). The patient will be unresponsive, pulseless, and this is a code blue as well (follow ACLS).
ECG Interpretation made Incredibly Easy (5th ed.)
ECGs Made Easy (6th ed.) <<< this is my favorite ECG PDF
The Only EKG Book You’ll Ever Need (5th ed.)
Tintinalli’s Emergency Medicine: A comprehensive study guide (8th ed.)
Rapid Interpretation of EKG’s (6th ed.)
Hopefully this gave you a good idea about how to read an EKG rhythm strip. Unfortunately, I couldn’t include every single arrhythmia or detail, but this definitely should give you a good understanding of the basics!
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