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5 Questions to Ask Before Calling the Doctor

5 Questions to Ask Before Calling the Doctor

Communication is an essential element in coordinating patient care in every clinical setting. Communication within the hospital is especially important due to the fact that there are often critical patients, and a patient’s status can change at any second. In order to convey this change of status accurately and provide the patient with the best care possible, it is imperative for the nurse and the provider to have great communication.

As a nurse, sometimes it can be difficult to know just what your patient needs. When you don’t know – it can be nerve-wracking trying to decide your next action. Do you call the doctor immediately, do you just ignore it and hope for the best, or do you have to call an RRT?

When you’re unsure – it’s common to call the doctor or provider because that is a frequent solution as they often know what to do. However, not every patient issue needs to be called to the provider. Decreasing these unnecessary calls can increase your efficiency and problem-solving skills, but additionally will allow the providers to be more efficient as well. To help you with the decision-making process – these are 5 questions to ask yourself before you call the doctor.

1. Is the Patient Stable?

Learning to be a great nurse involves learning how to prioritize. Whenever there is a change in patient status or a reason to call the provider, always ask yourself – “Is the patient stable?”. This will oftentimes seem obvious but calling a Rapid Response can be nerve-wracking. What if you call one and everyone thinks you’re dumb because it wasn’t necessary? This is a common worry as a new graduate RN. As you gain experience in nursing – you will be able to more easily be able to identify the need for an RRT when it presents itself. However, in order to assess your patient’s stability – you really must do two things first (in this order!):

Physical Assessment

You must lay eyes on your patient. Let me repeat that – YOU MUST LAY EYES ON YOUR PATIENT. You may not even need to touch the patient and already acknowledge the need for immediate emergent intervention. If they are unresponsive and not breathing and/or don’t have a pulse – you can immediately activate an emergency response (CODE BLUE). However, it won’t always be so black and white – so the next step is to assess their vital signs.

Vital Signs

Obtaining a new set of vital signs is imperative in order to assess the stability of a patient. “Is the patient stable” really just means “are their vital signs stable”. A patient who doesn’t have a pulse has a HR of 0 – so you don’t need to grab the Dynamap and grab a full set of vitals (spoiler – they won’t have any!). But it’s usually less clear. The patient may have increased lethargy, increased SOB (but not in acute respiratory failure), new chest pain, or any other changes of status. Getting these patient’s vital signs will determine whether or not they are stable. A patient who is SOB, in the tripod position, has an SPO2 of 80% on 4L NC, and RR of 48 – this patient needs an RRT or whatever emergency response team activated immediately. A patient with COPD who is moderately SOB, is 88% on 2L NC, and RR of 28 and mildly labored – this patient can likely be handled over the phone with changes in respiratory treatments and oxygen therapy.

If the patient has been deemed stable – you can move onto the next question.

Related content:

2. Is there more information I need to know first?

This will obviously depend on the situation and will require some investigation. If the patient is SOB – what is their history? Do they have any related diseases such as Asthma, COPD, or CHF? If they have back pain – have they had this before? What do they usually take for it? It’s possible the same complaint or situation may have happened earlier in their hospital stay – what was done about it and how did the patient respond?

Investigating trends in their labs or vital signs is also important. If a patient’s blood pressure is 180/90 – what has their BP been running? The same holds true for hypotension. A patient whose BP is 90/40 but who’s baseline is 90s/40s is important to know. If you get a call for an elevated troponin or lactic acid level – what were their previous levels? Note all of this information for when you have to call the provider – so you can anticipate what they will ask and assist them in making the appropriate clinical decision.

The next important step is to check the orders that already exist.

3. Are there any PRN orders?

Many times patient’s will have “PRNs” or medications “as needed” that are already ordered by the provider. This means they have a medication or order which can be used for pre-established reasons that the provider must list. Look at their MAR and see if they have any PRN medications.

Some frequent PRN medications are as follows:

  • Melatonin 3-9mg PRN for sleeping difficulty
  • Acetaminophen 650mg Q4H PRN for Fever > 101.4 F
  • Ondansetron 4mg IV PRN for nausea or vomiting
  • Morphine 2mg IV Q4H PRN for severe pain
  • Hydromorphone 0.5mg IV Q4H PRN for severe pain
  • Ketorolac 15mg IV Q6H PRN for moderate pain
  • Hydralazine 10mg IV Q6H PRN for SBP >160
  • Ipratropium-Albuterol Inhl Q4H PRN for SOB or wheezing

Other Frequent PRN orders include:

  • Oxygen via NC PRN – titrate SPO2 > 94%
  • Heating pad PRN for back pain
  • The patient may shower PRN

No matter the PRN order – it is your job as the nurse to look for which PRNs are available to you, and if you can utilize them accordingly. If your patient above who is mildly SOB and wheezing with a history of COPD – give them one of their Duonebs if it is appropriate. If they just received a treatment and still have not improved – then calling the provider is likely necessary.

Also check out my Nursing Medical Abbreviations graphic!

4. Can I phone a friend?

Sometimes we may not know what to do with our patients, but we may also be unsure if we need to call the doctor for it. Asking a fellow nurse’s opinion on what needs to be done for your patient can improve your problem-solving and clinical judgment. Your nursing colleagues, especially those with more experience or even just more skill in a particular area – may be the perfect person to ask of their nursing opinion. Do they feel like its necessary to call the doctor – or is there a nursing intervention that can be tried first instead? Are you unsure of what EKG rhythm you are reading and think you might see a run of VTACH but aren’t sure – ask a nurse who is good at rhythm interpretation.

Now I am NOT saying that asking a fellow nurse is a replacement for calling the provider. However, sometimes bouncing ideas off of our colleagues can save us from having to make an unnecessary call. Even calling the nursing supervisor may be a resource which you can utilize if appropriate. However – for a new significant change in patient status or vital signs – the provider will need to be called regardless.

5. Am I calling the right person?

OK – so you know that you’ve exhausted your other options, you have the background information you need… now you just need to actually call the provider. But make sure you are calling the right provider. First – check to see who the attending physician is on record. Is there an in-house medical team such as a hospitalist group, house coverage, or medical resident team that covers that attending? If not – you may need to reach out directly to the attending physician’s service to speak with whoever is on call. This will be facility-specific, so you may not always know if you are new. This is where asking your colleagues for assistance can benefit you.

Reaching out to the medical team (listed above) is common and usually, they can help! However, sometimes they are not the right person to be notified in certain instances. Are there any specialists on board? If Infectious Disease is seeing a patient and there is a positive blood culture – it would be better to put a call out to them instead. If a patient who is on dialysis has uncontrolled high BP, placing a call to nephrology would be a better choice as well. You can reach out to the general medical team – but don’t be surprised if they ask you to place another call to the specialists instead.

Now you are fully prepared to make the phone call and accurately communicate what is going on with your patient, you will have investigated the background information, you will have obtained vital signs and done a quick assessment, and you will have recommendations for medications or orders at the ready (thanks to the other nurses you’ve asked!). As you can see – this perfectly sets you up to provide a great phone report to the provider! To learn more about giving a great phone report to a provider and steps to calling the doctor – you can read all about it here!

Calling the doctor doesn’t have to be scary. If you critically think your way through these important steps, and utilize my IMSBAR communication style – you WILL succeed and you will be amazed at how far a little preparation can go.

You may also want to read:

Calling the Doctor – Giving Nurse to Provider report

Calling the Doctor – Giving Nurse to Provider report

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

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

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

Step 1: Introduce yourself and the patient

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

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

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

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

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

Step 2: Brief Medical History

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

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

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

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

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

Step 3: Why You’re Calling (SITUATION)

“The patient is complaining of increased SOB”

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

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

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

Step 4: Situation Background

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

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

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

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

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

Step 5: Assessment

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

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

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

Step 6: Recommendations

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

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

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

Related Content: Tips for New Nurse Practitioners

– – – – – –

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

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

Tips for New Nurse Practitioners

Tips for New Nurse Practitioners

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

While I’m no expert NP, I do know what its like to be a new one! After all – that was just a little over a year ago! Being so fresh in my mind – I have some valuable tips to share with new NPs or NPs to be. No matter what setting you start in, utilize the resources you have available to you, work your butt off, and constantly be open to learning – and you will succeed! But to help you on your journey – here are 6 of my best tips for clinical practice!

1. Use UpToDate Religiously

If you haven’t heard of UpToDate – I don’t know how you made it through NP school! This medical reference database is the GOLD STANDARD of medical information for Providers. While I’m working, I often use this to quickly reference drug dosing information and renal dosing considerations. On the spot, the algorithms are SUPER useful. You can just scroll down to the bottom, check out the algorithm section, and viola – suddenly you know just what to do for your patient with hyponatremia of unknown etiology. No but really – there is SO much useful information. If you have a bit more time on your hands – you can read through articles more in-depth related to literally whatever medical topic that is relevant to your clinical practice. Keep a list throughout the day of symptoms and diagnosis that you don’t feel 100% comfortable with, and make a habit of reading up on those topics on UpToDate at the end of the day.

Unfortunately, UpToDate is expensive, but most hospitals provide free access for it’s providers. If you create an account, you just have to login once every 3 months on the hospital’s network to maintain access – and you can download the easy-to-use app for your smartphone.

There are other reference apps out there – but UpToDate is by far my favorite and the gold standard. Check out my top 5 medical reference apps for more information!

2. Templates, Templates, Templates

When you’re a new NP – you are going to be overwhelmed – especially in a new hospital or office environment. You are going to forget to ask basic questions to the patients, and you are going to feel dumb plenty of times. You likely won’t have the most confidence when conducting you’re history and physical. That’s why templates are SUPER important in being your back-up. Find templates such as History/Physical or SOAP note templates, and use them with every patient. This will ensure that you don’t forget to ask about surgical history, family history, smoking status, even something as easy as allergies. If you can’t find a template that works for you – make one yourself! Get a system down, write down information in the same place when you’re doing your chart reviews, and this will help you know where to always find the information you need on your patient – especially in high-stress situations.

Since working as an inpatient hospitalist NP, I’ve been using the same H&P template since I started. I’ve made some small tweaks along the way, but this ensures I don’t forget to ask about anything important, and I always know where to look for the information on my patient. (You can get access to my templates here)

3. Master Verbal Report

As an NP – you will be communicating with physicians and other colleagues much more frequently, and mastering verbal report is essential. Sure – you might have been a nurse for years and know how to give a good NURSING report, but NP-to-Physician report is much different. Physicians are trained specifically to give and get report in a certain way, and unfortunately they can get a bit… testy if we take too long to get to the point or leave out crucial information. The idea it to be concise, but also include the relevant clinical information.

In general – start with their Age, Sex, relevant PMHx, Admission diagnosis, relevant findings, physical assessment, and any recommendations.

Since I work in the hospital, an example of this would be the following:

“86yo Female with a PMHx of HTN, HLD, T2DM, and COPD presenting with cellulitis of right lower extremity calcaneal wound. Initial XR does not indicate Osteomyelitis, MRI is pending, WBC  13, Lactic normal, Blood cultures pending. Patient was started on Zosyn and and vancomycin in the ED.”

After you present the initial basic information, you can specify exactly why you are calling and tailor it to their specific specialty – so obviously if you are calling a nephrologist you would focus on their renal function, blood pressure, electrolytes – etc.

I’m planning on doing a more detailed blog about presenting a patient to another provider whether or as NP or as an RN, so be on the lookout next week!

4. When in Doubt – Cheat!

When I began as a new NP in the hospital setting, I brainstormed the top 20 common diagnosis in my specific specialty. I sat down and made cheat sheets for each diagnosis including information on the etiology, pathophysiology, clinical manifestations, diagnostic findings, and clinical management. You can use textbooks and online resources to find uptodate information – as I said before I recommend UpToDate!

Making these cheat sheets can really help you narrow down specific need-to-know information for your exact clinical role. Making them yourself can help you retain the information. However, if you can’t find the time, the following books have some pretty solid cheat sheets:

These cheat sheets are going to help you look up relevant need-to-know information on the spot while you are at work. Personally, my sheets that I made on Acute kidney injury and hyponatremia have been especially handy in the inpatient setting.

5. Follow the Paper Trail

Whether you work inpatient or outpatient, there will be specialist consultation notes for you to read. You can learn a TON from these notes. These guys are literally specialists, and if you’re a generalist –  you’re kind of the jack of all trades and the master of none. Simply following the paper trail and reading up on your patient’s after you have seen them can help expand your knowledge tremendously.

But don’t only read specialist notes. Working inpatient, theres often medical students and medical resident notes which are very detailed and provide rationale – which Attending physician’s notes often do not have. Don’t write them off simply because they are not attendings. They learn so much in school that unfortunately, we as NPs do not. Reading these notes can be invaluable!

6. Have the Right Attitude

As a new NP, you are the new kid on the block. You need to be humble, ready to learn, confident in yourself but willingly admit when you don’t know. Trust your insticts, but check your ego at the door. We are dealing with patient’s lives here and nothing is more important than hard work, communication, and collaboration with our patients and our knowledgeable colleagues.

There are so many more tips to help new NPs, but I wanted to keep this list short and practical – things that will help you succeed in the clinical setting.

Something that I know will help you guys out as new NPs is signing up for my email list and getting access to my free NP resource library! You’ll be sent a folder with my templates for History and physicals (both inpatient and outpatient), Soap notes, and pronouncement notes. I plan on adding more useful information as time passes, so be sure to check back often!

10 IV Insertion Tips for Nurses

10 IV Insertion Tips for Nurses

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

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

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

1. IV Insertion: Location Location Location

AC

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

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

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

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

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

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

Forearm

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

However, not everyone has great forearm options.

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

Hand

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

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

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

2. Small veins? Make them Larger

Heat

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

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

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

Gravity

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

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

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

Nitroglycerin Ointment 2%

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

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

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

3. IV Insertion with Fragile Veins

Change your Selection

Sometimes, elderly patients tend to have crappy veins.

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

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

Forget the Tourniquet

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

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

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

4. Don’t Give Up during IV Insertion

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

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

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

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

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

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

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

Related content: “How to Start an IV”

    5. Go Big or Go Home

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

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

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

    Related content: “5 Vital Signs Error to Avoid”

    6. Arterial Stick

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

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

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

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

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

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

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

    Remove the catheter and try again in an actual vein.

    7. Inserting the IV Outside the Box

    Or rather – think outside the lower arm.

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

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

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

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

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

    8. Angle Danger

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

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

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

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

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

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

    Related content: “How to Start an IV”

    9. Rollie Pollie Ollie

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

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

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

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

    10. Patient Comfort

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

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

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

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

    You might want to also read:

    5 Vital Sign Errors to Avoid

    5 Vital Sign Errors to Avoid

    Vital signs are essential in every aspect and setting of medicine – whether that be inpatient such as in the emergency department, the Intensive Care Unit (ICU), the medical/surgical floors, or pediatrics – as well as virtually every outpatient office setting.

    Vital signs are objective measures of a patient’s health and can tell A LOT of information about the patient.

    This can give great indications of their health status and prognosis, as well as aid in the differential of many different medical conditions.

    When a patient can’t speak, sometimes all the medical team has to go on is their vital signs. Vital signs, matched with a thorough history and physical assessment, can mean the difference between life and death.

    To sum it up – vital signs are SUPER important. While ignored by many, the slightest changes in vital signs can clue the nurses and Providers into acute changes in the patient’s status, and diligence with early correction can avoid prolonged hospitalizations and improve patient outcomes.

    Vital signs are frequently obtained by nursing assistants, patient care technicians, medical assistants, nurses, and sometimes even physicians or advanced practice providers. All are important to the healthcare team. We ALL know how to take vital signs, but it is up to the Provider (often notified by the nurse) to interpret those vital signs and make patient interventions accordingly.

    It is because of this crucial importance that it is absolutely necessary that vital signs are taken correctly to give the most accurate readings. There are many errors that novices and even some experts can make when taking vital signs, but these 5 errors will help any member of the medical team to provide accurate measurements.

    1. Incorrect Cuff Size and Location

    Blood pressure is a key vital sign to obtain, and it seems everyone is worried about their blood pressure. This is because high and low blood pressure are indications of underlying diseases.

    A very high blood pressure could indicate uncontrolled hypertension, a stroke, a medication reaction, etc. Low blood pressure could indicate internal bleeding, systemic infection (sepsis), an adrenal crisis, etc. The lists go on. So many different diseases affecting various body systems can affect the blood pressure, and this is why it is so important to obtain the right measurement.

    Blood pressure cuffs should be sized appropriately to fit the patient’s arm. But what is appropriate?

    The correct answer is that the bladder (the part that inflates with air) should encompass 80% of the person’s arm circumference. That means it should just about fall short of wrapping around their entire arm.

    In reality, though, you just kind of know if it’s too big or too small after some experience. Most adults with regular-sized arms will fit the regular adult size, and larger individuals or gym-rats will benefit from the larger size. It should fit nice and snug, but not too snug.

    Place the middle of the bladder (usually marked with some type of marking such as “Artery Here”) over their brachial artery. This is usually on the medial aspect of their antecubital fossa. Place the cuff 2-3cm above the crease, or about an inch.

    So why does it matter so much? Incorrect cuff sizes will lead to incorrect blood pressure measurements. If you place a cuff too small on an individual, the blood pressure will likely be falsely elevated. If you place a cuff to big on an individual – you guessed it – the reading could be falsely decreased.

    This becomes very important when blood pressures begin to push the boundaries of normal.Top 5 Vital Sign Errors from medical providers - Chalkboard Style

    2. Incorrect Positioning

    Patient positioning, which is also important in blood pressure, should not be overlooked.

    In the office-setting, patients should be seated with uncrossed legs for 5 minutes before getting their blood pressure checked. This usually does not lead to many issues due to the routine and setting of the office.

    However, in the hospital, this error occurs very frequently. While patients do not need to be sitting in a chair for 5 minutes prior to a blood pressure reading within the hospital, it is important to maintain proper positioning.

    Patients are often going to be bed-bound, on bedrest, or perhaps sleeping when you go to take their vital signs.

    Placing the patient in Semi or high fowler’s positioning for at least 5 minutes before checking the blood pressure is ideal, but supine is often accepted as well.

    The MOST IMPORTANT thing to remember is that the blood pressure cuff is at the level of the heart (more specifically the right atrium) when the reading is taken.

    Patients who are on their sides will give you inaccurate readings. The arm above their heart will read falsely lowered readings, and the arm below may render falsely elevated readings.

    This is common, especially within the units that have constant blood pressure monitoring with frequent intervals (ER and ICUs).

    3. Incorrect Waveform

    Blood oxygen saturation is monitored with a pulse-oximetry sensor usually on a finger, and this is another important vital sign which we need correct measurements.

    While of great value, sometimes oxygen sensors read incorrectly low, and with a little practice, it can be easy to learn when a low reading is actually dangerous vs when it is just artifact.

    The important thing to check with a pulse-ox reading is whether or not there is a good wave-form.

    This is usually within the hospital where a bedside monitor or dynamap displays the “pleth” – that is, the waveform that “beats” in congruence with the heartbeat.

    Peripheral pulse ox’s can measure how much blood is passing with each beat through the device sensor. This should look equal, symmetric, and have adequate amplitude.

    If all you see is a straight line with occasional movements, this is NOT a good pleth, and likely an inaccurate reading.

    The waveform or pleth may look poor due to poor circulation (cold fingers, peripheral artery disease, hypotension, etc), or the patient may be shaking or moving their finger too much.

    Try changing to a different finger or hand. With cold fingers with poor circulation, try using an earlobe (infant probes are often easy to use in this location).

    If the patient has nail polish on, you may be able to get a reading but it is possible that this is interfering with the spectrum of light for the sensor. If you are getting a bad reading – it may be wise to remove the nail polish on one finger and try again.

    Another important fact to remember is to ALWAYS CHECK THE HEART RATE from the pulse-ox. Does this match their HR on the heart monitor? If they are not hooked up to the heart monitor, does this match their peripheral pulse? If your heart monitor reads a HR of 82, and your Pulse-ox is reading 78% and a HR of 30 – this is likely not a good reading as the heart rates do not match up. The exception is an arrhythmia, so make sure they are in a Sinus Rhythm before assuming it is an error.

    4. Incorrect Temperature Method

    Infections often present with fevers, and severe infections can have either really high temperatures or really low temperatures.

    It is important to use the correct temperature method for the correct situation, as using the wrong method can lead you to not picking up on a fever.

    Oral Method

    In most settings and for most patients, the oral thermometer is adequate. As long as the patient can follow instructions and leave it under their tongue for 10 seconds or so, you will likely get an accurate reading.

    However, if the patient recently drank something, this can lead to a falsely lower reading. The colder and more recently they drank it, the more likely it is to interfere with the reading.

    Cold beverages can decrease the temperature for up to 30 minutes, and hot beverages can falsely elevate the temperature for up to 5 minutes or so. Interestingly enough, if the patient is chewing gum this can also slightly increase the temperature reading.

    Additionally, if the patient has a high respiration rate (greater than 20 breaths per minute), this can lead to falsely low readings. In these instances, it may be prudent to check the temperature with another method.

    Rectal Method

    The rectal thermometer is the “gold standard” because it is the closest to the core body temperature, but it is not always practical.

    Studies have shown that a significant amount of fevers are missed in triage due to less invasive methods. Rectal temperatures should be obtained on anyone with whom there is suspicion of fever when other methods are afebrile.

    A basic summary is that a rectal temperature should be performed on those suspected of serious infection or sepsis, those with hypothermia from the field, and those who are critical or unresponsive.

    Rectal temperatures are also frequently obtained in children under a certain age. It depends on facility protocol, but obtaining rectal temperatures in infants and young children (often under 2 years) is common, especially if they present with complaints of fever.

    Rectal temperatures tend to be 0.5-1.0°F HIGHER than the “normal” oral temperatures – 98.6°F.

    Temporal Method

    The temporal method is dependent on the facility and available equipment but does offer quick and fairly accurate temperature readings.

    If the patient is not very acute, has no symptoms, and simply needs a quick screening temp – the temporal thermometer can be your best friend.

    However, the diagnostic accuracy of the temporal thermometer is iffy, and if there is concern for altered temperature, another method should likely be used.

    Forehead sweat is a common cause for false low readings. 

    Tympanic Method

    The tympanic method is commonly used in and out of the hospital setting but often can yield lower-than-accurate readings.

    This is often due to the fact that the end of the probe needs to be pointed directly at the tympanic membrane. Improper technique can lead to inaccurately low readings.

    If done properly, tympanic readings actually tend to run hotter than oral readings, similar to rectal readings at 0.5-1.0°F higher than 98.6°F.

    The tympanic thermometer has shown to be useful, comfortable, and generally tolerable. It is generally appropriate to use 6 months and older, depending on the device.

    Axillary Method

    Axillary temperatures tend to be unreliable and are not often recommended in the hospital setting.

    They can be used for screening purposes in the office-setting if the patient is not complaining of fever. Additionally, they can be used for screening in an infant or young child, but some settings will accept an axillary temperature for children above 2 years old.

    This method often yields results about 0.5-1°F lower than 98.6°F. If there is any doubt, use another method.

    These readings will be inaccurate in very sick patients who have compensatory peripheral constriction or dilation, so this method should generally be avoided within the hospital.

    Long story short – do a rectal when the patient is severely sick or unresponsive, in those very young (generally under 2), and in various specific circumstances when asked or ordered by the provider.

    In all other scenarios, use the most appropriate, comfortable, least-invasive method which is likely to yield accurate results.

    5. Respiration Rate

    The respiration rate is crucial in evaluating those with respiratory complaints.

    It can clue the clinician into impending respiratory failure, indicate acid-base balance, and guide patient interventions. However, it seems as though most hospital workers (nurses, techs) don’t actually count respirations.

    It happens very often when someone just puts “16”, “18”, or “20” – without even thinking twice. I can’t even tell you how many times another medical professional put in a normal respiration rate and the patient actually had a rate greater than 30, sometimes above even 50.

    I get it – do you REALLY want me to stand here and count their respirations for 30-60 seconds?! AINT NOBODY GOT TIME FOR THAT, and we are BUSY. However, accurate respirations can lead to quick and timely recognition of a change in patient status.

    All in all, you should be counting. But if the patient appears to be breathing fast, having respiratory difficulty, is an infant, or came in with a respiratory complaint – this becomes a necessity and there really is no excuse for “just putting 16”.

    Hopefully you found these errors illuminating and helpful. Remember to always try to obtain accurate results in the least-invasive, most respectful manner possible.

    When in doubt, consult with the nurse, physician, or advanced practice provider.Let me know in the comments if you’ve seen these errors occur, and any other errors that might be helpful to other readers!

    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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