How to Read an EKG Rhythm Strip

How to Read an EKG Rhythm Strip

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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!

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What is a Rhythm Strip?

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.

The ECG Rhythm Strip Tracing

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.

The PQRST

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

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:

  • Are there P waves before each QRS complex?
  • Are there any P waves that do not have a QRS complex that follows?
  • Do all the P waves look the same / have the same shape?

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.

QRS COMPLEXES

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.

T WAVES

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).

PR INTERVAL

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.

QT INTERVAL

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.

Arrhythmias on the ECG Rhythm Strip

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 (NSR)

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.

The ECG Rhythm Strip Interpretation

To read an EKG rhythm strip, you should do so in a systematic way, so that you don’t miss anything.

  1. Is the rhythm regular? Is every R-R interval equal?
  2. What’s the rate? This is usually printed for you
  3. P wave: Are there P waves before every QRS?
  4. PR interval: Is it wide >200ms?
  5. QRS: Is the QRS narrow or wide (>100-120ms)?
  6. T waves: Are the T waves upright and normal-appearing?

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.

Systematic approach to reading a rhythm strip

Other Sinus Rhythms

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 (SB)

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

  1. Is it new or severe (<40bpm or so)
  2. Are they symptomatic? (dizziness, lightheadedness, syncope, SOB, chest pain, etc)

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 (ST)

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 Rhythm

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.

Other Cardiac Arrhythmias

Heart Blocks

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 (AF)

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

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 (SVT)

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 (VTACH or VT)

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 (VF or VFIB)

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

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.

Pulseless Electrical Activity (PEA)

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).

Want to learn more?

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!

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:

  • Identify all cardiac rhythms inside and out
  • Understand the pathophysiology of why and how arrhythmias occur
  • Learn how to manage arrhythmias like an expert nurse
  • Become proficient with emergency procedures like transcutaneous pacing, defibrillation, synchronized shock, and more!

I also include some great free bonuses with the course, including:

  • ECG Rhythm Guide eBook (190 pages!)
  • Code Cart Med Guide (code cart medication guide)
  • Code STEMI (recognizing STEMI on an EKG)

You can use the code “SPRING2021” for a limited time 15% discount, exclusive to my readers!

Check out more about the course here!

You may also like:

Heart Blocks EKG Rhythm Infographic

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20 Tips for New Nurses In the Hospital

20 Tips for New Nurses In the Hospital

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

Lets be real – you can use some tips for new nurses! Nursing school is tough, and actual nursing is even tougher! 

There is so much to learn, so much responsibility to have, and so much stress!

Use these tips for new nurses to help you become an organized, efficient, well-liked, and hard-working new nurse!

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TIPS FOR NEW NURSES:

 

1. Get there early

As a new nurse – you still have so much to learn. Unfortunately, you’re probably going to need to arrive at work 30 minutes early to begin preparing for your shift.

They should have your patient assignment ready, and you can begin looking through the chart. Make sure you write down important information like admission diagnoses, their attending physician or care team, when medications are due, and trends in vital signs.

See if they have any upcoming procedures or tests that you need to be aware of. This will help you stay organized. It also gives you more context when you get report from the previous shift.

tips for new nurses - a nurse writing down important information

2. Come prepared

Make sure you come prepared for your shift!

This means make sure you get plenty of sleep and have the mental alertness to care for 4-6+ patients simultaneously!

Additionally, it means bringing your must-have nursing gear. If I ever forgot to bring one of these, my shift was always negatively impacted.

This nursing gear includes:

Related Content: Essential Nursing Equipment for 2021

3. Have a positive attitude

Working as a new nurse is anxiety-provoking and stressful! No matter how stressed you get, make sure to maintain a positive attitude.

A negative attitude will rub off on your patients and on your coworkers. As a new nurse – don’t get into the habit of complaining. This can tarnish your reputation and is not a good look for a new grad.

Now – this doesn’t mean you can’t speak up for yourself or your patients!

Even if everyone else is constantly complaining, make sure you stay positive!

4. Say yes!

One of the most important tips for new nurses is to always say yes!

No – I’m not talking about when they call you in to work overtime. I mean say yes to new learning opportunities.

If someone asks if you want to watch or assist with a procedure – say yes! As a new nurse, there is still so much to learn and so much experience to gain. You will only get this experience by saying yes.

This also looks very good and gives a good impression, because new grads are expected to be eager to learn.

5. Develop your own system

Developing a system is important as a new nurse. Humans are habitual in nature, and once you develop a system, the rest will fall more easily into place.

Write important information down on your patient care sheets so you have quick access. If you don’t write it down – you most likely won’t remember! This is especially true when you are juggling 4-6 patients at a time.

Keeping all your patients straight takes time and experience. So until then – you need to be extra sure to write it down and develop your own system.

Related Article: How to Stay Organized as a New Nurse

6. Don’t obsess over charting

Getting comfortable with the charting system can take a while. This means charting will take you a bit longer when you’re first starting out.

As nurses, you will have so many tasks and responsibilities to manage at the same time. The thought of all the charting you have to do in the back of your mind is only going to stress you out even more.

Focus on patient care first, and then the charting.

On the other hand, I also recommend real-time charting when possible, especially once you are proficient at charting. This will increase your efficiency.

Even then, pressing patient care matters more than charting, so always prioritize!

Related Article: Top 6 Charting Tips for Newbie Nurses

7. Look everything up

This isn’t nursing school anymore – you’re allowed to look everything up!

Nursing is an open-book occupation!

If there is something you’re not sure of, either ask someone or look it up. There are so many valuable resources that you can use as a nurse when it comes to your patients.

8. Know Which Resources to Use

Don’t just use Google or Wikipedia. There are better evidence-based resources to use as a medical professional!

Most facilities will have an UpToDate subscription. You might even be able to download this on your phone after making an account and logging in at your facility. This can be somewhat difficult to follow, but it has the most accurate up-to-date medical information out there for medical providers!

Other online free resources include:

Drug information can easily be found on Uptodate or Epocrates.

Some great nursing textbooks to have are:

Make sure to also look at your facility protocols. These are often jam-packed full of great information as well as how your facility expects you to perform certain procedures or handle certain clinical situations, specific to your facility.

Related Article: Top 5 Apps for ER Nurses

Nurse looking up metoprolol drug information uptodate on the computer

9. Don’t be a know-it-all

Humility is so important at this stage.

Even if you’re really smart and did great in nursing school – you have so much still to learn.

Some people overcompensate when stressed by acting like they are very comfortable with everything and already know everything.

This is one of the biggest mistakes to make as a new nurse and one of the most important tips for new nurses.

Letting your pride stand in the way of learning is dangerous to your patients.

Even if someone teaches you something you already know – don’t say “Yeah I know” – just say “thank you”.

This leaves a good impression and lets everyone know that you are committed to learning and becoming a great nurse.

10. Ask for help

Don’t be afraid to ask for help!

If you aren’t comfortable with a procedure – ask for assistance! Nobody expects you to be an expert.

You are a new nurse and you are expected to speak up if you don’t know something. If you don’t – this can potentially harm your patient and you will not learn for the future.

Additionally, if you are drowning and need some help, ask another nurse or the charge nurse for assistance. They will help you as best as they can.

Nurse drowning at work

11. Bounce ideas

And speaking of asking for help, another one of the tips for new nurses is to bounce ideas off of each other.

Sometimes you might not be 100% sure what to do in certain clinical situations, but you might not necessarily need to ask the Provider.

Your patient’s blood pressure is high but you’re not sure if it’s high enough to worry? Ask another nurse, preferably one with more experience.

This can save you the stress of calling the doctor for every little thing. With time, you will learn what you can just note or document, and then what you will need to notify a Provider about.

But for now – don’t be afraid to ask another nurse’s opinion!

Nurses discussing a case with each other

12. Keep studying

Even if nursing school is over – that doesn’t mean you can stop studying! Another one of the tips for new nurses is to keep studying.

Use some of the resources listed above to read on your days off. Don’t spend all day studying – but always be committed to learning.

That means you need to take initiative and put your continued education as a top priority.

I attribute a large part of my success as a nurse and then as a young NP.

13. Give great report

Learning to give a good report can take time, and not every report you hear from an experienced nurse is the model of what you should be following.

This additionally becomes important when relaying information over the phone to a Provider or specialist who may not be very familiar with the patient.

In nursing school we are taught SBAR, but I always felt like this left some gaps (maybe I just wasn’t using it right).

I modified the SBAR to the IMSBAR. This is perfect to use if the Provider or other health professional is not very familiar with your patient.

This means you need to include the patient’s information, their relevant medical diagnoses, and then the reason you are calling with the SBAR.

You can read more about this here.

A nurse giving a great report on the phone at work

14. Delegate appropriately

As a nurse, you now have the responsibility of delegation.

This means you can request certain tasks be completed by other CNAs or technicians, LPN/LVNs, and sometimes even other RNs.

This does not mean that they have to do anything you say, even if they’re below your paygrade. Never have an elitist attitude.

When you delegate, make sure the task is appropriate for their skill level and the patient is stable. Provide any instructions clearly.

15. Don’t be lazy

Make sure you are not delegating tasks that you can easily do yourself.

If you are busy providing medications or are very busy – of course, delegate a task like placing a patient on the bedpan or doing an EKG.

However, if you have the time – just do it yourself. This leaves a great impression and your CNAs and patient-care technicians will appreciate that. They are busy too, and we are a team!

Always have a kind demeanor when delegating, and never talk down to someone – even if they give you an attitude.

If they refuse, delegate to someone else or do it yourself, and bring your concerns to the attention of your charge nurse.

Your hard work will show to your colleagues and Providers, and they will respect that.

16. Take your breaks

Nursing is hard work! Time flies and work can feel like a tornado of stress and anxiety.

Your department should have a system set up where you are entitled to your breaks.

Don’t refuse these. Even if you have so much charting left – take your break, eat your food, and relax as best you can.

Most facilities will give one 30-minute break and two 15-minute breaks for a 12-hour shift.

And don’t chart during your break – use that time to de-wind and get ready for the remainder of your shift!

17. Prioritize your body

Like Megan Thee Stallion says – Body…ody-ody. Take care of your body while you work.

This means use proper body mechanics while lifting patients. It also means wearing compression stockings and wearing comfortable footwear.

Also, don’t hold your bladder all shift. This is a common nursing joke, but your patients can spare the 2-3 minutes it takes to use the bathroom (aside from a code situation).

Anything you can do to decrease the stress on your body is important. If you “just don’t have to pee”, then you are probably not drinking enough water. Make sure to drink plenty of water throughout your shift!

The number of times my pee was the color of iced tea after a hard shift… NOT healthy!

18. Don’t clock out

I mean – obviously, you’ll have to eventually, but what I mean is don’t clock out too early.

It is common to stay late as a new nurse to finish charting. Unfortunately, this is a necessary evil.

But don’t let anyone guilt you or talk you into clocking out before you actually are leaving.

If you are charting – then you are still working! This is one of the tips for new nurses that is important because your time is valuable!

Clock out when you are on your way out the door – this ensures you get paid for all your hard work.

19. Take time for yourself

On your days off – make sure you prioritize yourself and your mental health.

Take a 2-3 day vacation, travel somewhere fun, stay home and relax and read a book (a non-medical book), or go swimming with your dog.

Whatever it is – make sure you don’t devote all your time off to nursing as well.

Sure – continue to spend time learning and studying even with your time off, but make sure you also have plenty of non-nursing time as well!

20. Never feel pressured to work

Once you come off orientation, you will likely be eligible to work overtime.

Management will take advantage of this. Sure – extra money sounds fun, but is it always worth it?

If you don’t want to work OT and you are being pressured to come in to help the department, don’t.

You don’t owe management or your department your time off.

They are responsible for staffing appropriately, and the blame does not fall on you for your coworkers being short-staffed.

On the other hand – if you want to work the OT and get the extra money – go for it! Just don’t burn yourself out too hard!

Related Articles:

Do you have any tips for new nurses?

Comment down below to let others know!!

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How to Stay Organized as a New Nurse

How to Stay Organized as a New Nurse

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

Learning how to stay organized as a nurse can be challenging, especially as a new nurse

Use these 7 Nursing Tips on how to stay organized to help keep you organized and efficient!

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How to Stay Organized as a Nurse

The learning curve as a new nurse is super high, and we could all use some tips on staying organized.

There is so much to remember when it comes to all of our patients, and we are expected to know all of their information and often have to recall it in high-pressure situations.

Organization as a nurse takes time and experience, but if you are diligent – you can become that organized nurse that you’ve always wanted to be!

1. Get There Early

On my first day as a nurse, I arrived at 6:50 am bright and early to my new Med-Surg unit – excited to make a good impression.

I walked over to my preceptor and she looked at me and said “you’re late. I’m already getting report. You’re expected to be here at 6:30 tomorrow”.

I had NO idea that I needed to get there so early? But why?

One major tip on how to stay organized as a nurse is to adequately prepare and “read up” on your patients. This takes time, which may mean needing to get there early.

This is especially important on Med-Surg units when you will be caring for multiple patients at once.

Most facilities will have some type of print-out with the patient’s medical information on it including their attending physician, allergies, diagnoses, and their medications.

Using these sheets, look through their medical record for information like:

  • Why they’re admitted and what they’re being admitted for (Look in the H&Ps)
  • Their vital sign trends
  • Their IV access (gauge and location)
  • Their active orders (diet, activity, code status, etc)
  • Any other information you deem to be important

If your facility doesn’t have these printouts, or if you prefer to use your own – bring your own!

I always made my own that I would use. You can sign up for my free patient organization sheets here.

Now when you get nursing report from the previous shift, you will have some baseline information to go off of.

Make sure to have space to write down important information that the previous shift’s nurse gives you.

I would say as a new nurse it is important to get there about 30 minutes early to start writing up on your patients. However, as you gain skills and become more proficient, 5-15 minutes early will likely suffice.

Also, understand that you are not getting paid for this time. Being so – it is not mandatory, but it will help your shift go more smoothly.

Quick note: What worked well for me was briefly reading up on my patients, looking at their vital sign trends, and their main admission diagnoses.

I would get report, assess each patient and pass meds, and then when I got time later on I would read more deeply into the H&Ps, writing down important information to pass along to the next shift.

2. Learn To Prioritize

Learning to prioritize is essential in figuring out how to stay organized as a nurse.

As nurses, we have so many tasks that we need to accomplish, and figuring out which order to do them is can mean the difference between life. That seems extreme, but sometimes can be true!

First, prioritize which patients you should see first.

A patient that has more unstable vital signs or more serious diagnoses should be bumped to the top of your list.

You should probably see the patient with CHF on Lasix and oxygen before you are seeing the patient with a broken hip who was recently medicated and is comfortable.

See those who are “more sick” before those who are “less sick”.

This is because those who have more serious diagnoses are more likely to decompensate.

Seeing them quicker can mean faster intervention and prevention of poor outcomes.

Also make sure you are prioritizing your tasks.

Sure – everyone needs to be charted on and their care plans completed, but making sure medications are administered in a timely manner is likely more important.

In the hospital – unexpected situations are inevitably going to occur.

Maybe you need to take a quick pause on your charting to go give pain medication to a patient who is requesting it.

Assessing a patient who is hypotensive takes precedence over giving your other patient their bedtime pills.

Learning to prioritize and being flexible will help you learn how to stay organized as a nurse, especially within the hospital.

3. Make Lists

In order to prioritize tasks, you actually need to know which tasks need to be performed.

As an experienced nurse – this can become second nature. However, as a new nurse – you are prone to forgetting or missing something.

Since it is so new, you need to write it down to make sure you do everything correctly.

I would always have checkboxes on each of my sheets for each patient. These checkmarks would include:

  • Assess
  • Chart
  • Medicate (with times ordered i.e. 9pm | 12am | 5am)
  • Care Plan
  • Rhythm Strip Interpretation

As a new nurse, you will inevitably be task-oriented. This is unavoidable and ensures that all of your tasks get done.

Once you gain experience, you will improve your critical thinking skills, and completing your tasks will become second nature.

4. Real-Time Chart

I know I said to prioritize medication passes and urgent assessments over charting – and that holds true!

But something that made me an efficient nurse is real-time charting!

Essentially this means right after I saw my patient and assessed them, I would park my computer-on-wheels right outside their door and quickly chart my assessment.

This only takes about 5 minutes while the assessment fresh your mind.

As a new nurse, you will forget to assess certain things that are important to assess! If you real-time chart, you can easily just walk back in and complete your assessment.

This does not take as much time as you think. If you have 6 patients, that’s only about a total of 30 minutes of charting.

Anecdotal Note: I would start assessing and charting my patients after getting report around 7:30, and move onto the next patient.

 

Once 8pm hit, I could medicate my patients for their night-time med pass. I would assess, medicate, and then chart.

 

Finally, I would double back on the initial patients to medicate them. This means all my patients would be assessed, medicated, and charted on by 10pm.

 

This leaves the rest of the night for any admissions, to hourly round on your patients, answer call bells, and perform the other tasks needed like care plans and reading up in their H&Ps.

Related Article: Top 6 Charting Tips for Newbie Nurses

5. Investigate Before Notifying

Another aspect of how to stay organized as a nurse is doing proper investigation before notifying a Provider.

This improves the communication and ensures the patient gets what they need. It can also help avoid a negative interaction with a Provider – which we all know can put a damper on the shift.

Learning to organize your thoughts and relay your concerns to the Provider is not inherently easy. The added pressure doesn’t help!

Make sure to investigate any anticipated questions they may ask. Some examples include:

  • If you are calling about high blood pressure, make sure you write down the BP trends, what they are taking for blood pressure, and if anything had needed to be given for high BP before.
  • If you are calling for additional pain medications, make sure you have an adequate assessment of the pain (new or chronic, location, radiation, etc), what they are currently getting for pain, any PRNs or previous medications given for pain, etc.

Make sure to include any recommendations you may have. Make sure to use a proper SBAR format.

“SBAR” always left me a bit confused and wanting more, so I made up an “IMSBAR” format which you can read all about here!

Related Articles:

6. Stock Up

Learning how to stay organized as a nurse also means always being prepared for whatever can happen. This means having the right equipment at the ready!

Important hospital equipment to stash in your pockets include:

  • 10mL saline flushes
  • Alcohol wipes
  • Medical Tape
  • 4×4 gauze

Important equipment that you should be bringing to work and have on you include:

It may be a good idea to also carry with you a bottle or two of lotion or barrier cream, so you’re not always needing to run to the clean utility room.

Having all this equipment will save you time and make you more efficient and keep you organized.

Related Article: 

7. Know When You’re Actually Working

Knowing when you’re working is an important aspect of how to stay organized as a nurse.

I would be lying if I said I never got a call saying “where are you – you’re on the schedule for today”.

I use Nurse Grid to keep track of my schedule. This app is specifically for nurses. What I love is that you can see your colleague’s schedules as well and even request a shift-switch within the app itself.

It’s simple and yet functional. Whatever app or calendar you use – make sure you always know when you’re working!

Related Articles:

nurse grid

Hopefully, you found some of these tips helpful when searching how to stay organized as a nurse! Are there any other tips that have helped you? What other areas do you struggle with?

Let us know in the comments below!

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How to Start an IV

How to Start an IV

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

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

How to start an IV: Feat

When to Start an IV?

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

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

Indications for an IV:

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

Contraindications:

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

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

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

Which IV Gauge to Choose?

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

24 gauge: The Baby Needle

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

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

22 gauge: The Safe Choice

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

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

20 gauge: The One-Size-Fits-All

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

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

18 gauge: The Big Daddy

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

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

14-16g: The Monsters

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

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

Also Check out: “10 IV Insertion Tips for Nurses”

  CLINICAL NOTE

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

An Overview of the different IV gauges and which scenarios they can be used for! #ER #IV #Nursing

What Equipment do you Need to Start an IV?

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

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

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

HOW TO START AN IV

1. Prepare the Patient

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

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

When starting an IV, place the tourniquet above the area where you plan on cannulating #StartanIVPlace the tourniquet on the patient’s arm proximal to the area of cannulation. Look for straight, large veins. Palpate them as veins may not always be visible but can still be felt. Strong veins will have a good amount of bounce to them.

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

With deeper non-visible veins, some nurses will also apply alcohol to a finger of their non-dominant hand to help palpate during the procedure without “contaminating” the site.

Please note that this is not the best practice for infection control. You should never tear off the finger of your glove either, instead – learn to palpate with your gloves on.

2. Prepare the IV Kit

While your site is drying, open your 10cc flush and your extension loop and/or cap.

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

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

3. Insert the IV

Holding the skin taut will help you stabilize the veins when you start an IVHold the skin taut with your non-dominant hand to secure the vein. This helps to stabilize the vein and prevent it from rolling. Place the tip of the needle against the skin at a 10-30 degree angle.

When you start an IV, make sure to approach the vein at a 10 to 30 degree angle

If the vein is deeper, use a slightly more angular approach initially. With the bevel up, puncture the skin and advance through to the vein.

If done correctly, you should see a flashback of blood in the flash chamber and/or catheter. This location will depend on the brand and size of the specific IV catheter. Once a flashback is seen, lower the angle even more parallel with the skin, and advance the whole unit about 2-6mm.

When you start an IV, once you enter the vein you should see a flash of blood

Now advance only the catheter forward, sliding it off of the needle and cannulating the vein. If done correctly, the catheter should easily slip into the vein without resistance. If there is dimpling of the skin, the IV is likely within the extravascular space.

Once blood flash is seen and you insert the needle an additional 2-6mm, then advance only the catheter

Before pressing the activation button to retract the needle – take off the tourniquet and apply digital pressure beyond the catheter tip.

Many IV catheters will bleed if you do not place pressure over the catheter

Some brands will have a septum or shield function with gauges 20-24, which prevents the backflow of blood and negates the need for venous compression. Press your activation button to retract the needle.

  CLINICAL NOTE

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

Draw Blood

If ordered, now is the point where you will draw your blood. Hook up your loop/cap with the blood transfer device to the IV hub.

Draw your blood tubes, and flush with a 10cc pulse flush afterward.

If blood is ordered, you can immediately draw this after placing a new IV

If you are not drawing blood, skip this step and instead just connect the primed cap or extension loop to the IV and flush.

After flushing a few mLs, make sure you can pull back blood return. This is reassurance that the IV is in the correct place. Then pulse flush the remaining amount through.

  CLINICAL NOTE

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

Secure the IV

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

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

Administer any medications or fluids through the IV as ordered.

These are the steps you need to know how to start an IV #StartanIV #IVstart #IV #Nursing

How to Remove an IV

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

1. Collect 2×2 gauze and tape or bandaid

2. Wash your hands and don clean gloves

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

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

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

6. Dress with gauze and tape or bandaid

Want to learn more?

Hopefully this gave you a good grasp on the basics of how to start an IV.

But if you want to learn more and become an IV King or Queen, I HIGHLY recommend The IV Video Course by @TheIVGuy.

The IV Video course is EXACTLy what you need to take your IV skills to the next level

This course includes:

  • 57 Video modules from the IV basics to more advanced techniques, tips, and tricks
  • In-depth notes with each video module
  • Specific video lectures on how to successfully place IVs in challenging patients including geriatric, bariatric, combative, obese, and IV drug users
  • 21 video demos of basically every type of IV insertion possible
  • 2 hours of CEUs by an accredited ANCC provider

I also include some great free bonuses with the course, including:

  • IV Complications: Prevention, Detection, and Management 8-page pdf
  • IV PUSH GUIDE 15-page pdf
  • Nursing Procedure Manual: Chest Tube Insertion 13-page pdf

Check out more about the course here

How to start an IV

Top 6 Charting Tips for Newbie Nurses

Top 6 Charting Tips for Newbie Nurses

The joys of nursing: making a difference, decent pay, and… charting!? Adjusting to the new role as a medical professional is exciting, but unfortunately, there is SO much to learn that nursing school unfortunately just can’t teach you.

One obstacle that new nurses face is learning how to chart quickly and effectively. Learning a new computer system, especially when you’ve never even professionally charted, can be daunting.

Learning time-management and charting skills are difficult enough, let alone actually taking care of the patients! Use these Top 6 Charting Tips for Newbie Nurses to help you transition into the nursing role and help you chart like a pro!

1. Have a System

A critical factor in organization and time-management as a nurse is to have a system for whatever you do. If you go through a literal checklist, you are less likely to miss something, especially as a new nurse!

It can be difficult to chart an entire patient encounter and not miss details, and going through your personal system that you’ve created can help you minimize charting errors. Remember this charting tip throughout the rest of the tips below – developing your personal system is critical in your time-management as a nurse.

Knowing where you write things down, where you chart things, and in what order will help you stay organized in a chaotic environment.

Your system should be flexible as patients and hospitals can be unpredictable. With time, you will be able to adjust your system to be less task-oriented and more holistic.

2. Write it Down

Something that almost EVERY organized nurse does is write down their patient information in some form or another.

You are probably somewhat familiar with this as you likely wrote down every piece of information you could in clinicals. But now you’re in the big leagues – you are responsible for your patient and the information you write down is important.

Seeing multiple patients with similar scenarios, it is easy to forget specific information or mix up information between two similar patients. What you write down will be your brain.

When a physician or other medical professional asks you a question about your patient – the last thing you want is to NOT know! Even if it takes you 10 seconds to find on your paper – this is better than saying “I don’t know”, and physicians and other healthcare staff will respect that.

Many different electronic medical records (EMRs), especially within the hospital, will have printable “patient care sheets” which can provide you with information in the medical record such as the patient’s demographics, medical history, ordered medications, and recent labs.

This can be VERY helpful – but you must have a system in place. Find a specific place to write down the information that isn’t pre-populated.

Where is their IV and what gauge? What is their history of present illness, aka what brought them into the hospital? Find specific places to write this information down on the sheet, and this will help you stay organized and be able to draw accurate information quickly and efficiently for accurate patient charting.

Quickly write down your patient assessments, as well as any new information the patient presents. I also recommend writing down vital signs on your sheets as well to be able to monitor and trend them accordingly. Sometimes when just reading them on the screen, you can miss important information.

Learn your medical abbreviations. If there’s not one – make it up! As long as YOU understand what you are writing – it serves its purpose. This will save you time AND wrist-pain.

If you’d like, I have free patient care organization sheets which you can print and copy to write down patient information and stay organized. You can sign up with your email for free here.

One last note – write down your times; the time you assessed them, the time you emptied their urinal, the time you assisted them to the bathroom, you get the point.

I can’t even count how much time I wasted trying to estimate what time I performed some sort of patient care because I didn’t write it down.

3. RTC

This is probably my BIGGEST recommendation – learn to chart it in real-time.

This is one of the key skills I’ve learned which tremendously helped my first year on a telemetry floor, and subsequently my time in the emergency department.

This is easier if you have a portable computer on wheels, as many units will. By real-time, I don’t mean while the patient is talking. Focus on the patient and give them your undivided attention and assessment skills.

Chart directly AFTER your patient encounter, exit the room (or stay in), and set aside 5 minutes or so to chart everything that occurred right outside the room.

This accomplishes a few things:

  • Everything is FRESH in your mind, and your charting will be more accurate.
  • If you realize you forgot to ask or assess something and realize it while you are charting, you can just walk right into the room and ask/assess the missing information. This happens much more than you expect!

As a new nurse learning a new charting system, you may not be able to finish the entire chart within 5 minutes. If not, I recommend still setting aside about 5 minutes directly after seeing the patient to chart.

Start with your patient assessment, as this is what will be the most difficult to remember specifics later on (you’re going to be doing 5+ assessments).

If you do not get to your patient care plans, patient education, tasks, or another facility-specific charting, that is okay! You can chart this information when you have some downtime later. Just keep a checklist and know what else needs to be charted to come back to later. You will get quicker with time!

4. Nancy Drew it

Once you get to know the electronic medical record, you can really start to use it to streamline your patient care and investigation skills.

One way you can utilize the system is to find information that you didn’t write down (like you should have). One common way I “Nancy Drew’d It” was when I forgot to write down times I performed patient care.

You can go back into the system and cross-check your times. By this I mean, look to see something already charted in the system that you can relate back to when you performed the task.

Did you administer the patient’s medications 10 minutes after your assessment? Look into the EMAR and see what time the medication was administered (already charted in the system), and subtract 10 minutes. Easy enough right?

Learning the EMR and being able to navigate it quickly and efficiently will help you gather appropriate patient information. Learn to look back at old labs (I’m talking 6-12 months ago.. What exactly is their baseline creatinine?), at old medication lists, at imported data from primary care offices, pharmacy information, and at History & Physicals from previous admissions.

Your specific charting software will limit or expand your ability to do this, but all EMR software will have ways of gathering information which you will learn to navigate with time.

5. Work Smart!

As a nurse, you work hard enough! When you are able, try working smart!

If your EMR allows, duplicate a previous assessment and adjust what needs to be changed based on your assessment. Whether it is your assessment or another nurse’s, it really doesn’t matter – just make sure that the charting reflects your actual assessment.

This mainly just saves you mouse clicks – but also your valuable time.

Providers have shortcuts with charting as well. When dictating or typing their H&Ps, they often utilize “macros” or templates that list out a normal Review of Systems and Physical Exam. They change what needs to be changed and it allows them to chart relatively quickly.

Unfortunately, nurses tend to have to chart in a less convenient way, which usually involves multiple clicks, checkboxes, and forms. This is convenient for coding and billing, as well as for insurance companies for data mining purposes, but it is NOT convenient for the nurses.

When the EMR allows, it will save you a good amount of time by duplicating an assessment. Some EMRs will have offer better functionality in this aspect, and others will not allow it at all. It will also depend on the facility and its policies regarding charting duplication.

6. CYA

Nurses are the backbone of the healthcare industry. Unfortunately, the responsibility of our patient’s health ultimately can trickle down to the RN taking care of them, and this can be stressful.

A nurse can find themselves in legal trouble if a medical error occurs and he or she did not catch it (or worse – caused it).

Due to the unfortunate trend in patients suing hospitals and staff, it is vitally important to cover yourself with your charting. Chart EVERYTHING that you can.

Always document each notification you made to the Provider, and the conversations you have with the patient/family. Use direct quotes when possible, even if what was said might not be rated PG…

When in doubt, inform your charge nurse or director of anything that you don’t feel comfortable with – and CHART it! By initiating the chain of command, you did your duty as the nurse.


Hopefully, with these charting tips, you’ll be a little less stressed about charting and able to focus more on what truly matters – patient care!

Drop a comment below if you have any other charting tips that will come in handy for new and experienced nurses alike! As always, let me know of any other blog suggestions you’d like written about!

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