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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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30 Inpatient Nursing Hacks for Med-Surg Nurses

Med-Surg nurses can utilize nursing hacks to their advantage in order to save them time and make their shift more manageable!

Nursing hacks are tips and tricks of the trade, sometimes new and sometimes old, which help “get the job done” quick and efficiently, while still maintaining quality care!

If you’re not using these Med-Surg Nursing hacks, you are missing out!

Med-Surg Nursing Hack fbs

TABLE OF CONTENTS

URINE HACKS

Ok – Med-Surg isn’t all bodily excrement – but you will run into pee and poop this in most aspects of nursing within the hospital.

There are so many poop and pee hacks to read through, you might need to take a bathroom break afterwards.

1. Cough and Wink

It is no secret that it can be difficult to insert a urinary catheter into some female patients.

This is because there is so much variation in each patient’s anatomy, and the patient’s body habitus can make things difficult to see.

Positioning, lighting, and assistance are all important, but sometimes it can still be difficult to hit the mark (in this case – the urethra).

If you are in position and are having trouble finding where to go, have the patient clear their throat and cough. This should cause the urethra to “wink” at you if visible, making your target stand out.

2. Foley²

If you think you know where you’re going, or if you go in blind and end up in the vaginal canal – you may need to try again.

One thing you should NEVER do is take the foley out, and then reinsert the same foley into the urethra (hello UTI!).

Instead of taking out the first failed foley – leave the foley in place in the vaginal canal and open up a new kit, aiming above the catheter within the vaginal canal.

This can help you hit the mark. Second times a charm – right?

3. Beta-Block it Up

No – I’m not talking about metoprolol.

In a foley kit, there should be a betadine swab or stick that is used to clean the area before insertion of the catheter.

After cleaning the area correctly, leave the betadine stick in the vaginal canal. Similar to the double foley trick, this should “block” the vaginal canal.

If you aim above this – this could increase your chance of success! Don’t forget to remove the betadine stick when you’re done!

4. Kerlix It

Every patient on Med-Surg is different, and sometimes variations need to be made!

For patients with larger vaginal canals, you could use a thicker material such as a clean roll of kerlix to essentially “block” the vaginal canal and helping you enter the urethra without much difficulty.

5. Double Glove

When putting on a foley, sterile technique is required to prevent infection.

However, the cleanup once the foley is inserted can be messy, and your sterile gloves will be saturated with lubricant, betadine, and body fluid.

To make it easy, before applying sterile gloves, put on a clean pair of gloves after washing your hands.

Then apply sterile gloves as needed (you may need a bigger size).

Once the foley is inserted and you are ready for cleanup, take off the soiled sterile gloves, and clean up everything else with your second set of clean gloves.

You should be able to secure the foley with these clean gloves as well.

6. TransPeeTation

It’s inevitable with Med-Surg nursing that your patient will need to be transported all over the hospital for tests.

Additionally, they will usually be encouraged to ambulate to keep up their strength and prevent blood clots.

Transportation can be challenging with a foley and the last thing you want to do is have the foley get caught up on something and rip out, so this is where this nursing hack comes in handy!

If your patient wants to get up and walk, tie a glove around an IV pole at a level below the bladder.

Hook the foley onto this glove to use as a portable hook!

7. Purewick

Not so much a nursing hack – but more of a reminder.

Don’t forget that foley catheters are not the only option you have, and they do come with risk as they are invasive and often can lead to infection.

Many hospitals have Purewick catheters which hook up to suction to prevent the patient from lying in their own urine and causing skin breakdown.

This can be a great option for elderly female patients with urinary incontinence.

Also check out: 10 Nursing Hacks Every ER Nurse Should Know

STOOL HACKS

Another unfortunate aspect of Med-Surg nursing – you will have to clean patients up when they poop themselves.

It’s honestly not a big deal, and you will quickly not even think twice about it.

BUT – there are nursing hacks that can help you in some of these instances!

8. Double Glove Again

Foley’s aren’t the only instance where double gloving comes in handy!

When cleaning up a messy poop situation, be sure to double glove or even triple glove with clean gloves!

Your gloves will inevitably become soiled and you will then be able to remove the soiled pair and continue cleaning the patient without issues.

Additionally – imagine if you only had one pair on and one of them ripped. Dead.

9. Shaving Cream Cleaner

We should be checking on our patients often and making sure they do not sit in their own pee or poop for too long.

However, med-surg nursing is busy, and sometimes the poop becomes dried onto the patient’s skin and can be difficult to remove.

Bust out some shaving cream which you should be able to find in the clean utility.

Apply the shaving scream to the crusty poop on the skin, give it a few minutes, and wipe it off with soap and water or cleaning wipes.

It should wipe off without issue!

10. Constipation Cocktail

The only person more concerned with a patient’s bowel movement than you is the patient themselves (better yet – their family members).

If the patient is worried they may be constipated and are hoping to have a bowel movement, you could reach out to the physician and ask for something

If the patient is truly uncomfortable, reaching out to the Provider is the best option.

Another option is to get prune juice, put some butter in it, and microwave it for 20-30 seconds.

This will melt the butter and the prune juice should be warm.

The best part is this often works, there are no significant side effects, and you don’t need an order for it.

Of course, if your patient is having significant abdominal discomfort or nausea/vomiting, you should be reaching out to the Provider regardless!

11. Prolapse Relapse

It was my first week off of orientation as a brand new nurse on a Med-Surg nursing floor, and I had a patient complain of rectal pain.

I checked it out and WOW – that did NOT look right. What I was seeing was my first-ever rectal prolapse.

This specific patient had a history of this from happening, and you can reduce the prolapse as a nurse.

This can be done by applying some lubricant and applying firm pressure toward the patient’s rectum.

However, sometimes large prolapses can be difficult to reduce.

For this nursing hack, sprinkle some sugar on the prolapsed rectum and allow to sit for 15 minutes.

This dehydrates the prolapse, causing it to shrink and making reduction easier.

GASTRIC TUBE HACKS

Nasogastric (NG) tubes are a nursing procedure that is unpleasant but often necessary. This is usually ordered for small bowel obstructions (SBO).

Sticking a tube into the patient’s stomach from their nose allows suction to decompress the stomach, alleviating symptoms such as nausea, vomiting, and bloating.

It also decreases intrathoracic pressure and improves the venous return to the heart when the patient is ventilated, as well as reduces the risk of aspiration.

While NG tubes can really help your patient, unfortunately, the insertion procedure can be somewhat difficult. There are some nursing hacks that you can use on your med-surg nursing floor when an NG tube is ordered!

12. NG Twisted Ice’d Tube

During insertion of an NG tube, sometimes the tube has a tendency to curl in the oropharynx and not enter the esophagus as intended.

In order to help this, curl the distal portion around your finger, and freeze it in ice water for 10-15 seconds. This will help it keep its curled shape.

Insert the NG tube (with lube of course) with the curl in the direction of the pharynx (downward).

Right before the oropharynx, twist the tube 180 degrees. This ensures now that the “hook” is facing posteriorly, and shouldn’t curl out the mouth.

13. Numbogastric Tube

NG tube insertions are uncomfortable for the patient, but once it is in they should get some relief.

In order to make an NG tube insertion more tolerable, you can numb up the area first, and there are a few ways to do this.

You can get a Urojet with 2% viscous lidocaine and squirt it up the patient’s nare in which you intend to insert the NG tube.

Do this 5 minutes beforehand (you will need an order). While this is proven to decrease pain, it can increase the difficulty of the insertion (sticky!). See here for the full technique!

Additionally, 3-4mL of lidocaine (2-10%) can be placed in a nebulizer and given to the patient until gone. Then immediately insert the NG.

While this does reduce pain during insertion, it can increase the risk of epistaxis.

14. The Medication Pulverizer

This one is interesting, but it can make crushing meds for a PEG tube easy!

Open an empty 10mL syringe. Take out the plunger completely, and place the pills inside.

Re-insert the plunger up to the pills, and then aspirate 3-5mL or so of tap water.

Next, plug up the end with a clean gloved finger, and pull back the plunger, creating a vacuum. This should crush the pills inside!

You can then squirt this into a larger volume before administration into the Peg tube.

If you need help visualizing this, check out this quick video!

PICC HACKS

PICC lines are central lines placed peripherally in the hospital setting. These are often placed on patients with very difficult access or those who will require long-term therapy such as antibiotics.

With med-surg nursing, you will have to become comfortable dealing with PICCs: administering medications through them, as well as drawing blood.

Unfortunately, PICC lines can get clogged up which can make either task difficult.

But fear not – there are some nursing hacks that can help!

15. Switching the Positions for You

Whenever you are having a difficult time flushing or aspirating blood from a PICC line, there are some maneuvers that the patient can do which may be able to help.

A central line occlusion can be mechanical (think kinks!), Postural (based on positioning), from medication precipitates, or from small blood clots (a thrombus).

Often, this is positional and simple maneuvers can help with flushing or blood aspiration. Moving the arm position (raising it above their head) sometimes can help.

You can also have the patient turn their head in the opposite direction, take a deep breath, and cough. This can increase pressure and change the positioning of the catheter and lead to successful flushing or aspiration.

16. CathFlo Bro

Sometimes there is a partial or complete occlusion of the central line by a thrombus. You will notice significant resistance when flushing or aspirating (or complete resistance).

In this instance – Alteplase can be used. This is the same medication as TPA given for strokes, but at a much lower dose and intended to remain within the central line.

When there is a partial occlusion, alteplase (also known as Cathflo in this instance) can be instilled into the PICC (2mg in 2mL). Allow to dwell for 30-120 minutes, however long it takes to successfully resolve the blockage.

If there is a complete occlusion (aka you can’t flush it at all), you can use a three-way stopcock, create negative pressure with an empty syringe, and then slowly flush the alteplase through. This can take some time, and make sure you follow your facility’s policies and procedures.

When you have given it 30-120 minutes, aspirate 4-5mL of blood and waste, then flush through with sterile saline.

This can be repeated twice in a row if not successful the first time.

Also check out: 20 Tips for New Nurses In the Hospital

BLOODY HACKS

Blood is something that all nurses will have to deal with in some capacity – especially nurses within the hospital.

Whether our patients are bleeding, we are drawing their blood, or a procedure causes bleeding – it will inevitably get all over.

Of course, nurses should be using universal precautions and hopefully, the bleeding is controlled. However, sometimes it can get messy and be difficult to clean up.

Dried blood can be very difficult to clean, and there are a few nursing hacks that can help!

17. Alcohol Swab

A well-prepared nurse always has alcohol swabs in their pocket.

If you have trouble getting a small amount of dried blood off of a patient’s skin, bust out the swab and start scrubbing.

This is somewhat effective, although soap and water or cleaning wipes will likely do just as well. So this is especially useful for small amounts of blood.

18. Hydrogen peroxide

Hydrogen peroxide can be used to get dried blood out of clothing and off of skin.

When hydrogen peroxide meets your blood, oxygen is created and bubbling/foaming is seen. This breaks down the blood and allows for it to get out of your clothing and off of dry skin.

Following up with soap and water or cleaning wipes is beneficial.

19. KY Lubricant

Lube is useful for so many activities (both in and out of the hospital), but did you know it can also help with blood?

Specifically, it helps get rid of dried blood on the patient’s skin.

Leave the lube in place for a few minutes and then come back and wipe it up. This will usually make the removal of the blood a piece of cake. Ultrasound Gel works too!

ArtiFACTS of Life

Many patients on a Med-Surg nursing floor will have telemetry / cardiac monitoring ordered. This is a great tool we can use to monitor a patient’s heart rate and rhythm, but sometimes there can be difficulties obtaining a good tracing.

Poor tracing of a cardiac rhythm is termed “artifact” and there are many different potential causes.

Artifact can be from excessive patient movement, tremors, or shaking; but it can also be from improper application of the electrodes.

If your patient’s monitor has excessive artifact despite not moving or shaking, try these ECG nursing hacks:

20. Replace the Electrodes

The electrodes could be old and dry, decreasing the conduction and quality of the ECG tracing.

Electrodes should typically be replaced every day.

21. Clean the Skin

Dead skin cells, dirt, and grime can all interfere with the conduction of the ECG.

Before applying the electrodes, try washing the patient’s chest with soap and water or a cleaning wipe.

In a pinch, using an alcohol wipe over the areas in which you are placing the electrodes can help exfoliate the skin.

Allow to dry before applying the new electrodes.

22. Shave it Off

Hair can be a big interference when conducting cardiac activity.

If the patient is excessively hairy in the areas where you need to place the electrodes, you may need to shave them to get good conduction.

23. Change the Equipment

Sometimes the wires or equipment is the problem. Switch out the equipment or wires and see if you get a better result.

24. Remove interference

Electrical signals from other equipment can interfere with the telemetry monitor and cause artifact.

Make sure the wires and telemetry box are not in close contact with any other equipment such as an IV pump.

Make sure the patient’s electrodes are not overtop of a pacemaker or ICD!

25. Make Due

Sometimes no matter what you try, there still may be some artifact. Try adjusting the amplitude and changing the lead view to obtain the best view with the least amount of artifact.

I also have a video course all about how to read ECG rhythm strips, which you should check out if you’re interested!

IV HACKS

Now this is a section that deserves it’s own post, and lucky for you I have one here!

On a Med-Surg nursing unit, you won’t have to put in IVs as much as the ER, but it is still a skill that you will have to use and improve on. Patient’s IVs go bad all the time and they may need replacement.

I will outline some basic hacks here, but be sure to read the full article as well if this interests you!

26. Try Defying Gravity

Use gravity to your advantage! Hang the extremity below the level of the heart (off the bed).

This will cause vasodilation of the veins and increase your target vein! This will make it easier to see, feel, and cannulate!

27. Heat it Up

If Gravity isn’t enough, you can try a nice warm compress or hot pack! This will also cause vasodilation and increase your chance of success

28. Nitroglycerin

You can obtain an order for a small amount of 2% Nitroglycerin ointment to be applied to the area in which you plan to cannulate. This will also cause vasodilation.

29. Blood Pressure Cuff

Using a bedside blood pressure cuff can help you from blowing a vein. Pump the pressure cuff just above the patient’s systolic pressure.

This will prevent excess pressure from the tourniquet, but still enough to engorge the veins.

30. Start Digging

If you don’t see a flash of blood on your first advancement, don’t give up just yet.

Pull the needle and catheter back, re-palpate the vein, and attempt to insert in the direction of the vein again. If the patient can tolerate this, it will prevent extra pokes.

Also check out:

Want to Learn More?

If you want to learn more about how to read an ECG and cardiac arrhythmia – check out my ECG Rhythm online video course out now!

It’s specifically designed for nurses, and not only teaches you how to identify each arrhythmia, but also why and how they occur, and what to do about it!

If you’re not ready to take that leap yet but still want to learn more about ECG rhythms – be sure to download my free ECG Cheat Sheet below!

You may also like:

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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

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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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Covid Nursing Tips Featured Image

Nursing Do’s and DONT’s of 2021

This post contains 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

The field of medicine is always changing and there is always so much more to learn. As time passes and nurses gain more experience, we should always be updating our practices!

Check out these nursing Do’s and Don’ts for 2021!

Nursing Do's and Don'ts of 2021

Don’t: Assume a Respiratory Rate

You laugh – but I’m serious! It has become WAY too common for nurses and nursing assistants / PCTs to just “make up” the patient’s respiratory rate. It’s easy to do, and does the respiration rate even matter? Well… YES!

With COVID, the respiratory rate matters now more than ever. The pulse ox shows us a patient’s oxygenation, whereas the respiratory rate shows us their work of breathing.

A normal respiratory rate is 12-20 rpm. A patient with a pulse ox of 98% could have a respiratory rate of 34. Without realizing or counting, this can lead to improper treatment until the patient fatigues and the SPO2 actually drops.

We are seeing TONS of COVID patients come through the ER. We always check their pulse ox and their respiratory rate. If they are hypoxic or too tachypneic – these patients will likely need to stay within the hospital on oxygen.

Respiratory rate is also super important in people with potential cardiac or pulmonary disorders like asthma, COPD, or an active CHF exacerbation.

The respiratory rate is also important for accidental or intentional overdoses, as many medications like opioids can cause respiratory depression.

An increased respiratory rate can also be secondary to metabolic acidosis! The patient may be trying to breathe off extra CO2 to compensate for the acidosis – termed respiratory compensation.

Long story short – the respiratory rate is an important vital sign, and just assuming it is normal can be detrimental to the patient. This is dangerous, let alone illegal to fraudulently chart a vital sign that you did not actually obtain.

Related Articles:

Do: Learn to Give Great Report

Part of what makes a nurse a great nurse is their ability to communicate effectively. Nurses constantly need to communicate to their patients, but maybe more importantly to their fellow nurses, ancillary staff, resident and attending physicians, and APPs.

Learning to give a good hand-off report takes practice, and it can be difficult because nursing school doesn’t really teach you how to do it, at least not well. Sure – they talk about SBAR, but I never found it super helpful, especially when giving hand-off report to fellow nurses.

Something that I use myself I call IMSBAR. This is what I use for my phone report to physicians, but it can work well with modifications to giving patient hand-off as well!

IMSBAR essentially adds some important patient information before launching into the meat of the reason for calling. For use over the phone, this includes:

  • Introduction: Introduce your name, title, where you’re calling from, and who you’re calling about including their name and room number
  • Medical History: Relevant and “big” past medical history including diabetes, hypertension CAD with stents, Afib (on Xarelto), etc. Include history relevant to the current admission.
  • Situation: Why are you calling? Does the patient need a medication? Is there a change in their status? Is there a critical lab result?
  • Background: Elaborate on the background information regarding the situation. If you’re asking for pain medication, where is their pain, is it new or changed, when was their last pain medication, and did it help? Do the preliminary investigation work to help the Provider make a decision on the management of the patient.
  • Assessment: Give a quick focused assessment of the patient. If they’re short of breath, what do their lung sounds like? What are their current vital signs?
  • Recommendations: Do you have any recommendations that you think might help the patient?

This can also be modified to give a clear and concise patient hand-off report. This will obviously be different depending on which unit you are in, but as a basic guide:

  • Introduction: List the patient and room number you are reporting on
  • Medical History: List relevant medical history – can be more detailed if inpatient with a full list of history
  • Situation: Why was the patient admitted and what are they being treated for?
  • Background: What has occurred since their admission? Are they waiting on any tests?
  • Assessment: Any physical assessment abnormalities? Vital sign trends? Lab result trends?
  • Recommendations: Give any recommendations or anticipations that you may have regarding the patient, and include any other info that you find pertinent.

Related Articles:

Do: Update Your Patients!

And speaking of communication, start communicating with your patient and their families!

Some nurses are great at this, and others need some work.

At least within the ER, keeping your patient updated can make a HUGE difference in their satisfaction. Most patients become impatient when waiting for hours for any type of update.

And let’s be real – most physicians and APPs are not the best at keeping their patients updated either! This can be frustrating for patients and their family members.

Try to let the patient know what the holdup is for. Are they waiting for CT because there’s a line? Do they have to wait for a 3-hour troponin before they can be discharged?

I always try to explain from the get-go what the workup is going to be, and even how long it may take. But never speak in absolutes because as you know – things almost never work out like they’re supposed to in the hospital!

Do: Update Your iPhone!

Or Android… if you’re into that.

What I mean is – there are some GREAT apps out there to use as medical resources.

We are medical professionals – we should not be resorting to google or WebMD to help us take care of patients! There are so many evidence-based resources that we can actually use!

My all-time favorite is UpToDate. This is perfect for physicians and APPs, but I would argue that reading on UpToDate can help make you an excellent nurse.

You can look up specific information on drugs or medical conditions like clinical manifestations or treatments. UpToDate isn’t free though, but many institutions offer it free to their staff! You just need to login on your institution’s internet every 3 months or so!

WIKEM is a great quick reference for all things emergency medicine.

FP Notebook offers quick and comprehensive information as well, in bullet-style notes!

Another non-medical resource app that I LOVE is Nurse Grid! It helps me keep my schedule organized, is color-coded, and lets me see who else I am working with!

Related Articles:

Do: Update Your Knowledge!

As I always say – medicine is always changing, so we always need to stay updated! There is so much to learn.

Nursing school teaches you the basics, but it’s on YOU to take the initiative and keep learning!

I recommend taking digital courses online to help you with knowledge and skills that you want to be comfortable with!

Some of my favorite online courses are:

FYI: I have an ECG Rhythm course for nurses coming out in February! Be sure to sign up for the interest form so you can be notified when it drops!

Don’t: Neglect Yourself!

As nurses, it is TOO easy to neglect our own health and well-being as we are so focused on the health of our patients, and then on our families once we finally get home!

The nursing field is TOUGH – it’s stressful with long hours, high-stress environments, and you are constantly blamed for things that seem out of your control. AND add the pandemic to it all!

Nursing Burnout is a HUGE deal and happens to so many of us – myself included.

In 2021, make yourself a priority! Focus on your own health. Here are some ways you can focus on yourself:

  • Diet + Exercise: Make lifestyle modifications to your diet or exercise patterns (or lack thereof!). I’m doing KETO because it’s worked for me in the past, but do any diet or lifestyle change that you can stick to and is healthy!
  • Take Time Off: Use your PTO to relax and focus on yourself and your relationships! Take that trip to Disney (I’m obsessed), travel Europe, relax on the beach in the Bahamas, cruise the open sea!
  • Change your Mentality: Realize that money isn’t everything. Your quality of life is more important than any amount of money you can make. If you are breaking your back picking up overtime left and right – you will burn out! Sure, money is important and we all have bills (and giant amounts of student loans), but if you are miserable – make a change! I started working Part-time this month to focus on myself and so far – so SO good!
  • Pick up a new Hobby: Dive into an old hobby, or pick up a new one! There is so much more to the world than work, money, and medicine! Exercise the other side of the brain and get your creative juices flowing! No – drinking alcohol doesn’t count!
  • Stay off Facebook: Yeah… self-explanatory. Besides… all the cool kids are on TikTok nowadays 🙂

It’s not easy to admit, but at the end of the day, we’re all replaceable in the eyes of our employers. You need to put yourself first so that you can help your patients!

As Rupaul says “If you can’t love yourself, how in the heck are you going to love somebody else?” Now can I get an amen!? That love starts with self-care!

And those are the “insert title here” for 2021! Do you have any New Years Nursing resolutions? Drop them below in a comment!

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Adverse Drug Reactions Nurses NEED to know

Medications are a huge part of modern medicine and how we treat disease, but there are many adverse drug reactions that can occur.

As nurses, it is important to educate our patients about these adverse drug reactions, what to expect, and what to do if they are experienced by our patients.

Some of these medication reactions are ingrained in us, but others are less commonly taught.

Make sure you remember to educate your patients who are being prescribed these medications!

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Antibiotics and Adverse Drug Reactions

Antibiotics are essential in treating bacterial disease, but they don’t come without their own side effects!

There are many different classes of antibiotics. Because of this, some adverse drug reactions apply to only certain antibiotics, and some apply to antibiotics as a whole.

1. Diarrhea and Antibiotics

All antibiotics can cause diarrhea. This is due to normal “good” bacteria in your intestines being killed by the antibiotic, leading to imbalances digestion.

While all antibiotics can cause diarrhea, there are certain antibiotics that are more likely to cause diarrhea.

These include amoxicillin, cephalosporins, clindamycin. When mixed with clavulanic acid, diarrhea tends to be more pronounced (i.e. Augmentin).

Clostridium Difficicile (CDIFF) is an opportunistic diarrheal infection that can lead to profuse diarrhea and can be difficult to treat.

Antibiotics increase the risk of CDIFF – especially broad-spectrum antibiotics like cephalosporins, fluoroquinolones, and clindamycin.

Patient Education Example: “Some watery diarrhea and mild cramping can be expected while on antibiotics. Make sure to stay hydrated if this occurs. If you have excessive diarrhea, severe abdominal pain, abdominal swelling, fever, or blood or pus in your diarrhea – you should contact your doctor or return to the emergency department”. 

adverse Drug Reactions - Abx and diarrhea

2. Allergic Reactions

All medications and antibiotics can cause allergic reactions.

True allergic reactions cause itchy hives and potentially swelling of the face, eyes, lips, or mouth. It can even cause swelling of the airways and lead to wheezing and stridor.

When giving any prescribed medications, the patient should always be educated on the potential signs of an allergic reaction.

Patient Education Example: “All new medications can cause allergic reactions, and mild-moderate allergic reactions are common with antibiotics. If you develop a red, raised, itchy rash, immediately stop taking the antibiotic and call your doctor. If you develop swelling of the face, eyes, lips, tongue, or shortness of breath – this is potentially a life-threatening severe allergic reaction called anaphylaxis, and you should seek immediate medical care or call 911.”

Adverse Drug Reaction - Allergic

3. Rifampin and Birth Control

Antibiotics were frequently thought to interact with birth control… but this is somewhat of a myth.

There is no convincing evidence that any antibiotic other than Rifampin interacts with birth control.

Rifampin is not a commonly prescribed antibiotic but is the recommended treatment for tuberculosis.

There is a concern that antibiotics as a whole can affect the gut microbiome which may alter estrogen levels, but this has not been proven and is likely untrue.

If patients are prescribed rifampin, they should be educated to use backup protection for up to 1 month after they finish the rifampin.

Patient Education Example: “While commonly believed to interact with birth control, there’s no evidence that most antibiotics do. If you want to be safe, you can use a backup method like condoms while taking the antibiotic, and up to a few days to a month after you finish.”

Adverse Drug Reaction - Rifampin and OCP

4. Doxycycline and GI Upset

Doxycycline is commonly given for infections including cellulitis, URIs, tick-borne illnesses, pneumonia, STDS, and more.

Doxycycline works great, but it does have some significant adverse drug reactions that we need to educate our patients about.

Doxycycline can cause some significant GI upset, including nausea, vomiting, and diarrhea.

Educating the patient to take this pill with food or milk can help, although it may inhibit some absorption of the drug.

Doxycycline (and clindamycin) can cause drug-induced esophagitis which can lead to significant inflammation and pain within the esophagus.

To prevent this, educate the patient to take Doxycycline with a full glass of water, milk, or eat food afterward, and stay upright for 30 minutes after taking it.

Patient Education Example: “Doxycycline can cause significant nausea and vomiting, and drinking milk or eating food directly after taking it can help minimize this. If not, drink with a full glass of water and remain upright for 30 minutes afterwards to prevent any damage to your esophagus.”

Adverse Drug Reaction - Doxycyline pill esophagitis

5. Flagyl and ETOH

Metronidazole, or Flagyl, or is commonly given for intestinal infections like colitis or diverticulitis, and for vaginal infections like trichomoniasis.

Flagyl is traditionally taught to NEVER be taken with alcohol as this can cause a “disulfiram-like reaction”.

Flagyl + ETOHDisulfiram causes excessive nausea, vomiting, and other unpleasant symptoms when mixed with alcohol.

Evidence of this severe reaction occurring with Flagyl is somewhat lacking, but it can sometimes occur. Educate the patient on this potential reaction, but if they do drink they may be fine.

It is never a bad idea to recommend against taking medications with alcohol.

Patient Education Example: “Flagyl can potentially cause nausea and vomiting if taken with alcohol. Avoid any alcohol consumption while taking it”. 

6. Fluoroquinolones and Tendon Rupture

Fluoroquinolones are a powerful class of antibiotic which kill a broad-spectrum of bacteria.

These are commonly utilized to treat UTIs, Abdominal infections, and Pneumonia.

Fluoroquinolones have fallen out of favor recently due to their large number of potential side effects, even if rare.

These side effects include:

  • Hyper/hypoglycemia
  • Peripheral neuropathy
  • CNS effects (seizures, increased ICP, tremors)
  • Psych reactions (psychosis, hallucinations, deririum, etc)
  • Aortic aneurysm and dissection
  • Tendonitis and tendon rupture.

Sometimes these antibiotics are still needed, so be sure to educate the patient on these possible side effects.

The tendinopathy can occur hours or days after starting the antibiotic or sometimes delayed for months.

This is more likely to occur in those >60 years old, those on steroids, with diabetes or kidney failure, or with extended therapy.

Patient Education Example: “Cipro can rarely cause significant side effects like inflammation and even rupture of your tendons, most commonly the Achilles tendon above your heel. If you feel any swelling or pain in this area or near another joint, immediately stop taking and contact your doctor”.

Adverse Drug Reaction - Tendon rupture

Non-Antibiotics and Adverse Drug Reactions

Antibiotics are not the only cause for adverse drug reactions, and every medication has expected side effects.

While there are many potential adverse effects for every single medication, there are a few common or interesting side effects you should know to educate your patients on!

7. Dexamethasone and the Burning Crusade

Dexamethasone is a steroid given for various reasons, including sore throats, cerebral edema, migraines, and various other conditions in and out of the hospital.

Dexamethasone is commonly ordered IV in the ED and hospital. One interesting side effect that you need to warn your patients about perineal discomfort when given IV.

When given rapidly, perineal discomfort (burning or tingling) can occur.

I’ve personally heard “MY CROTCH IS ON FIRE!”.

This is usually short-lived but can cause significant discomfort and be shocking for the patient if not warned.

Dilute the dexamethasone in NS and infuse over 15-30 minutes to help minimize this side effect.

Patient Education Example: “I’m going to give you some IV Dexamethasone to help with your condition. Sometimes it can cause brief burning or discomfort in your groin, but we are giving it slowly to try and prevent that. It can still happen though, so if it does I just want you to be aware.” 

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8. Adverse Drug Reactions with Opioids

Opioids like Oxycodone or Hydrocodone are commonly given for pain and can be a great tool we can use to offer relief to our patients.

Unfortunately, opioids do have significant side effects that need to be taught to our patients.

Opioids cause respiratory depression and this is how opioid overdoses kill people.

But appropriate doses, it shouldn’t cause significant respiratory depression unless mixed with other medications or alcohol.

Opioids also cause drowsiness and even stupor, so anything that requires a high level of mental alertness needs to be avoided.

This includes driving or operating heavy machinery.

Patient Education Example: “Oxycodone helps your pain but can cause drowsiness, so you shouldn’t drive or operate any heavy machinery. It can increase your risk of falls, so be careful on the stairs. You should never take this medication with alcohol, other opiates, or benzodiazepines like Xanax or Ativan.”

Related Content: Opioid Alternative Analgesics in the ER

9. Anticoagulants and Bleeding

Adverse Drug Reaction - Brain bleedAnticoagulants are often necessary to prevent blood clots in those with a history of DVT, PE, or Atrial Fibrillation.

Unfortunately, they also hinder the body’s natural ability to clot when injured.

This can lead to ineffective clotting and an increased risk of bleeding. Patients on blood thinners should take extra precautions to prevent trauma like falls.

If there is a head injury, these patients should be evaluated by a medical professional, preferably within the ED where a CT scan can be obtained to rule out an intracranial bleed.

Patient Education Example: “Eliquis helps prevent blood clots, but it also increases your chance of bleeding. If you fall or sustain any injury, you should be evaluated by a doctor. If you hit your head, you should call your doctor or come to the ER.”

Every medication has adverse drug reactions, but we should be knowledgeable about these common or potentially serious reactions, and educate our patients!

Is there any other drug reaction that you are sure to educate your patients about? Let us know in the comments!

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