10 Clinical Calculators for Inpatient Providers

Aug 11, 2019 | 0 comments

10 Clinical Calculators for Inpatient Providers

Working in a hospital as a provider can be unexpected and stressful. There are so many factors to consider when managing a patient’s acute and chronic diseases. Luckily, there has been a great amount of research involving management of patients within the hospital. There are many different systems and calculations which can help with risk stratification, prevention, diagnosis, and management. These inpatient clinical calculators are sure to be useful to you during your shift in the hospital!

1

Padua Predictive Score for Risk of VTE

Inpatient medicine constantly involves predicting, preventing, diagnosing, and treating blood clots. Venous Thromboembolism (VTE) is the general term used to describe blood clots (thrombi) in the body which may have moved (embolized) to the lungs (pulmonary embolism).

VTE are an important cause of morbidity and mortality – especially with patient’s who have many comorbidities. Approximately 900,000 patients in the US are affected by VTE each year, and 60,000-100,00 American’s die. The first symptom of a PE is sudden cardiac death in 25% of people! You can see why it is SO important to prevent this from occurring within the hospital. Those admitted to the hospital are at higher risk for developing health-care associated VTE due to decreased mobility and recent surgery and/or procedures.

The Padua Predictive Score is a useful tool which separates patients into high and low risk groups for developing VTE. Those who score < 4 points are considered low-risk, and those >/= 4 are considered high risk. This calculator takes into account 11 factors which increase risk for VTE including age, mobility, history of cancer, heart disease, or respiratory disease, obesity, among others. If scores less than 4, consider non-pharmacologic measures such as SCDs or early ambulation. With scores greater than 4, pharmacologic measures are indicated including unfractionated heparin (UFH) or Lovenox (Enoxaparin).

Check out the Calculator!

2

Wells’ Criteria for DVT

The Wells’ criteria score system is a method to quantify the diagnostic probability for a patient presenting with a DVT/PE, however the calculators are different depending on which you are assessing for.

The Wells’ score for DVT involves specific risk factors for developing a DVT including the presence of symptoms such as calf/leg edema, recent immobility or surgery, leg tenderness, etc. The modified Wells’ score factors in a previous history of DVT.

Low Probability

Scores of 0 or less have a low-probability of needing further workout to rule out a DVT.

Moderate Probability

Scores of 1-2 points have a moderate probability and should get a high-sensitive D-dimer result. If <500 ng/ml, this effectively rules out a DVT. However, since the D-dimer test is nonspecific, a score >500 ng/ml warrants further investigation (i.e. a venous duplex).

High Probability

Scores of 3-8 have a high probability of a DVT and should get a venous duplex to rule out a clot regardless.

https://www.mdcalc.com/wells-criteria-dvt

3

Wells’ Criteria for PE

Just like the Wells’ score for DVT, there is a calculator for the pretest probability of a PE. The calculator assesses for PE risk factors including s/s of DVT, clinical suspicion of PE, HR >100, immobility/recent surgery, previous VTE, the presence of hemoptysis, and malignancy.

Low Probability

Scores <2 indicate a low probability of a PE. However, if s/s of PE are present (pleuritic chest pain, SOB, tachycardia, etc) then clinicians are encourages to use the PERC rule. The PERC rule is a list of 8 criteria which effectively rule out a PE in those with low-probability of having a PE. The patient must meet all of the following criteria:

Age < 50 years
Heart rate < 100 bpm
Oxyhemoglobin saturation ≥ 95% on RA
No hymoptysis
No estrogen use
No prior DVT/PE
No unilateral leg swelling
No surgery/trauma requiring hospitalization within the prior 4 weeks

If the patient meets any of the above, a D-dimer should be performed. In those already admitted to the hospital or critically ill patients, a D-dimer should be obtained regardless. As above, levels < 500 ng/ml do not require further workup, but levels > 500 ng/ml need further workup (i.e. CT Pulmonary Angiography).

Moderate Probability

Scores 2-6 indicate moderate probability for having a PE. This is handled with a high-sensitivity D-dimer score as above – the PERC rule is not used. If less than the cut-off, PE is ruled out. Otherwise, further testing must be performed.

High Probability

Scores >6 indicate high probability for having a PE. Those with high-risk should NOT have a D-dimer level checked. Instead, they should have diagnostic imaging to rule out PE regardless. The preferred test is a CTPA, but if this cannot be obtained than a V/Q scan should be ordered.

https://www.mdcalc.com/wells-criteria-pulmonary-embolism

4

CHA₂DS₂-VASc Score for AFIB Stroke Risk

Some medical conditions predispose patients to blood clot formation. One of those conditions is Atrial fibrillation, which increases the chance of clot formation within the atria of the heart. Clots formed in the right atria may embolize to the lungs, and clots formed in the left atria may embolize to the brain and cause a embolic stroke.

The CHA₂DS₂-VASc Score is a scoring system which helps clinicians to determine the need for oral anticoagulation to prevent clot formation and subsequent embolization. The score includes their age, sex, and their medical history including CHF, HTN, CVA, VTE, Vascular dz, or Diabetes.

Low Risk

Scores of 0 indicate a low-risk for stroke in those with Afib. No oral anticoagulation is recommended. Sometimes these patients are placed on low-dose aspirin.

Low-Moderate Risk

Scores of 1 indicate a low-moderate risk of stroke in those with Afib. In this category, clinical judgement must be used. If you are a generalist, remember that cardiology will often be the one to make this decision. Many choose not to anticoagulate those who’s only score is that they are a woman.

Moderate-High Risk

Scores ≥ 2 points indicate a moderate-high risk of stroke in those with Afib. Anticoagulation in this group is highly recommended. All studies have shown the benefit of anticoagulation significantly exceeds the risk for almost all patients with afib and a score ≥ 2. Typically the cardiologists specialists will be determining which anticoagulation that will be used.

https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism

5

HAS-BLED Score for Major Bleeding Risk

HAS-BLED is a system which scores the risk for major bleeding for those with Afib who are on oral anticoagulation. The system is scored by the following:

Hypertension – 1 point
Abnormal renal and/or hepatic function – 1 point each
Stroke – 1 point
Bleeding tendency/predisposition – 1 point
Labile INR on warfarin – 1 point
Elderly (age >65) – 1 point
Drugs (asa or NSAIDs) and/or alcohol – 1 point each

https://www.mdcalc.com/has-bled-score-major-bleeding-risk

Results are not separated into probability categories. Instead, clinical judgement must weight the benefits vs risks. However, the following risk can be estimated:

0 points – 1.13 bleeds per 100 patient-years
1 point – 1.02 bleeds per 100 patient-years
2 points – 1.88 bleeds per 100 patient-years
3 points – 3.74 bleeds per 100 patient-years
4 points – 8.70 bleeds per 100 patient-years
5-9 points – insufficient data (but high risk)

Remember this decision should be made with specialty consultation to cardiology.

6

Serum Osmolality

Other than blood clots and anticoagulation, inpatient providers often have to manage electrolyte abnormalities. One important electrolyte which often is low is sodium – called hyponatremia. The treatment of hyponatremia depends on the etiology. In order to determine the cause, an important calculation is the serum osmolality.

The calculator uses the serum sodium, BUN, Glucose, and ETOH to estimate the osmolality.

HypoOsmolar

Calculated osmolality <275 mOsm/kg is considered hypoosmolar (and usually hypotonic). This is the most common type of hyponatremia and fluid status must then be considered to determine etiology:

Euvolemic

Often caused by SIADH (from many causes) or thiazide diuretics.

Hypovolemic

Often caused by decreased PO intake, diuretics, GI losses, 3rd spacing, or adrenal insufficiency. This is treated with careful fluid resuscitation as replacing sodium too quickly can lead to deleterious effects such as osmotic demyelination syndrome (previously referred to as central pontine myelinosis).

Hypervolemic

Often caused by heart failure, liver cirrhosis, nephrotic syndrome, and severe AKI/CKD. Treatment in this case involves restricting water, loop diuretics (i.e. IV Lasix), and sometimes medications.

IsoOsmolar

Calculated osmolality 275-290 mOsm/kg is considered IsoOsmolar (and usually isotonic). This used to be caused by lab errors secondary to high lipid or protein levels. However, Ion-specific electrodes are now used in the lab, so this error does not really happen anymore.

HyperOsmolar

Calculated osmolality >290 mOsm/kg is considered hyperOsmolary (and usually hypertonic). This is usually caused from solutes which cause osmotoic shifts of water out of cells into the extracellular fluid (i.e. glucose, mannitol, sorbitol, etc).

https://www.mdcalc.com/serum-osmolality-osmolarity

7

Sodium Correction for Hyperglycemia

Due to the osmotic shifts caused by hyperglycemia, hyponatremia should be corrected when glucose levels are elevated. The serum sodium concentration will fall by ~2. mEq/L for every 100 mg/dL of glucose elevation. For example, if the blood sugar is 400 and the sodium level is 124, the corrected sodium level is ~130 mEq/L. But you don’t have to do math, just use the calculator! It’s recommended to base your treatment plan on the calculated sodium level, as once the glucose is corrected the osmotic shifts will resolve.

https://www.mdcalc.com/sodium-correction-hyperglycemia

8

Fractional Excretion of Sodium (FENa)

The Fractional Excretion of Sodium (FENa) is calculated to determine the cause of acute kidney injury (AKI), and is a useful tool that many nephrologists utilize. This can help determine the difference between prerenal AKI from Acute tubular necrosis (ATN). This is calculated from the serum sodium creatinine, and the urine sodium and creatinine.

FENa levels < 1% generally indicate prerenal disease (i.e. decreased bloodflow to kidneys). Levels >2% usually indicates ATN. Levels between 1-2% can indicate both.

Remember that the FENa will not be accurate if the patient is on a diuretic. In general FENa is utilized by Nephrology, but can be useful to calculate if the etiology is unclear.

https://www.mdcalc.com/fractional-excretion-sodium-fena

9

Fractional Excretion of Urea (FEUrea)

The Fractional Excretion of Urea (FEUrea) can be used to differentiate between prerenal AKI and ATN in patients who are on diuretics as FENa will not be accurate. Levels 50-65% generally indicate ATN , and levels <35% indicate prerenal disease.

Again, many factors can determine these tests and they should be interpreted with the consultation of specialists (nephrologists).

https://www.mdcalc.com/fractional-excretion-urea-feurea

10

Calcium Correction for Hypoalbuminemia

Unrelated to sodium and fluid status, calcium levels can be falsely altered in the presence of hypoalbuminemia. Calcium ions have two forms – ionized and protein-bound. About 40% of calcium in the blood is bound to protein (i.e. albumin), and about 50% circulates as free ionized calcium. The ionized calcium is what is truly clinically significant because this is what is physiologically active. If a patient is symptomatic from hypocalcemia – their ionized calcium will be low.

Since almost half of the calcium in the bloodstream attached to albumin, abnormal albumin levels will affect serum calcium levels. To correct this, you need to know the patients serum calcium and their albumin level. The calculator will give you a good idea of what their corrected calcium level actually is. So if you see a malnourished patient with an Albumin of 2.0 and a serum calcium of 7.0, the corrected calcium is 8.6 mg/dl.

This is not an exact science and many factors (i.e. acid-base disturbance) will alter calcium binding to protein and may cause ionized calcium levels to fluctuate. This is why most clinicians will order an ionized calcium level when serum calcium levels are significantly low (even in the presence of low albumin).

https://www.mdcalc.com/calcium-correction-hypoalbuminemia

1

Padua Predictive Score for Risk of VTE

VTE are an important cause of morbidity and mortality – especially with patient’s who have many comorbidities. Approximately 900,000 patients in the US are affected by VTE each year, and of those 60,000-100,00 die. The first symptom of a PE is sudden cardiac death in 25% of people! You can see why it is SO important to prevent this from occurring within the hospital. Those admitted to the hospital are at higher risk for developing health-care associated VTE due to decreased mobility and recent surgery and/or procedures.

The Padua Predictive Score is a useful tool which separates patients into high and low risk groups for developing VTE. Those who score < 4 points are considered low-risk, and those ≥ 4 are considered high risk. This calculator takes into account 11 factors which increase risk for VTE including age, mobility, history of cancer, heart disease, or respiratory disease, obesity, among others. If scores less than 4, consider non-pharmacologic measures such as SCDs or early ambulation. With scores 4 or greater, pharmacologic measures are indicated including unfractionated heparin (UFH) or Lovenox (Enoxaparin).

Check out the Calculator!

2

Wells’ Criteria for DVT

The Wells’ score for DVT involves specific risk factors for developing a DVT including the presence of symptoms such as calf/leg edema, recent immobility or surgery, leg tenderness, etc. The modified Wells’ score factors in a previous history of DVT, as these patients are more likely to develop another one.

Low Probability

Scores of 0 or less have a low-probability of DVT, and thus usually do not warrant further workup to rule out a DVT.

Moderate Probability

Scores of 1-2 points have a moderate probability and should get a high-sensitive D-dimer. If <500 ng/ml, this effectively rules out a DVT. However, since the D-dimer test is nonspecific, a score >500 ng/ml warrants further investigation (i.e. a venous duplex).

High Probability

Scores of 3-8 have a high probability of a DVT and should get a venous duplex to rule out a clot regardless. This means that a D-dimer test is not indicated since a Venous Duplex will be obtained regardless.

Check out the Calculator!

3

Wells’ Criteria for PE

Just like the Wells’ score for DVT, there is a calculator for the pretest probability of a PE. This calculator assesses for PE risk factors including s/s of DVT, clinical suspicion of PE, HR >100, immobility/recent surgery, previous VTE, the presence of hemoptysis, or malignancy.

Low Probability

Scores <2 indicate a low probability of a PE. However, if s/s of PE are present (pleuritic chest pain, SOB, tachycardia, etc) then clinicians are encourages to use the PERC rule. The PERC rule is a list of 8 criteria which effectively rules out a PE in those with low-probability of having a PE. The patient must meet all of the following criteria:

Age < 50 years
Heart rate < 100 bpm
Oxyhemoglobin saturation ≥ 95% on RA
No hymoptysis
No estrogen use
No prior DVT/PE
No unilateral leg swelling
No surgery/trauma requiring hospitalization within the prior 4 weeks

If the patient meets any of the above, a D-dimer should be performed. In those already admitted to the hospital or critically ill patients, a D-dimer should be obtained regardless. As above, levels < 500 ng/ml do not require further workup, but levels > 500 ng/ml do (i.e. CT Pulmonary Angiography).

Moderate Probability

Scores 2-6 indicate moderate probability for having a PE. This is handled with a high-sensitivity D-dimer score as above – the PERC rule is not used. If less than the cut-off, PE is ruled out. Otherwise, further testing must be performed.

High Probability

Scores >6 indicate high probability for having a PE. Those with high-risk should NOT have a D-dimer level checked. Instead, they should have diagnostic imaging to rule out PE regardless. The preferred test is a CT Pulmonary Angiography (CTPA) – but if this cannot be obtained, a V/Q scan should be ordered.

Check out the Calculator!

4

CHA₂DS₂-VASc Score for AFIB Stroke Risk

Some medical conditions predispose patients to blood clot formation. One of those conditions is Atrial fibrillation, which increases the chance of clot formation within the atria of the heart. Clots formed in the right atria may embolize to the lungs and cause a pulmonary embolism, and clots formed in the left atria may embolize to the brain and cause an embolic stroke.

The CHA₂DS₂-VASc Score is a scoring system which helps clinicians to determine the need for oral anticoagulation to prevent clot formation and subsequent embolization. The score includes their age, sex, and their medical history including CHF, HTN, CVA, VTE, Vascular dz, or Diabetes.

Low Risk

Scores of 0 indicate a low-risk for stroke in those with Afib. No oral anticoagulation is recommended. Sometimes these patients are placed on low-dose aspirin.

Low-Moderate Risk

Scores of 1 indicate a low-moderate risk of stroke in those with Afib. In this category, clinical judgement must be used. If you are a generalist, remember that cardiology will often be the one to make this decision. Many choose not to anticoagulate those who’s only score is that they are a woman.

Moderate-High Risk

Scores ≥ 2 points indicate a moderate-high risk of stroke in those with Afib. Anticoagulation in this group is highly recommended. All studies have shown the benefit of anticoagulation significantly exceeds the risk for almost all patients with afib and a score ≥ 2. Typically the cardiologists specialists will be determining which anticoagulation that will be used.

Remember to always take into account the patient’s risk of major bleeding (see below!)

Check out the Calculator!

5

HAS-BLED Score for Major Bleeding Risk

HAS-BLED is a system which quantifies the risk for major bleeding for those with Afib who are on oral anticoagulation. The system is scored by the following:

Hypertension – 1 point
Abnormal renal and/or hepatic function – 1 point each
Stroke – 1 point
Bleeding tendency/predisposition – 1 point
Labile INR on warfarin – 1 point
Elderly (age >65) – 1 point
Drugs (asa or NSAIDs) and/or alcohol – 1 point each

Results are not separated into probability categories. Instead, clinical judgement must weight the benefits vs risks. However, the following risk can be estimated:

0 points – 1.13 bleeds per 100 patient-years
1 point – 1.02 bleeds per 100 patient-years
2 points – 1.88 bleeds per 100 patient-years
3 points – 3.74 bleeds per 100 patient-years
4 points – 8.70 bleeds per 100 patient-years
5-9 points – insufficient data (but high risk)

Remember the decision for a patient with Afib to not be on oral anticoagulation should be made with specialty consultation.

Check out the Calculator!

6

Serum Osmolality

Other than blood clots and anticoagulation, inpatient providers often have to manage electrolyte abnormalities. One important electrolyte which often is low is sodium – called hyponatremia. The management of hyponatremia depends on the etiology. In order to determine the cause, an important calculation is the serum osmolality.

The calculator uses the serum sodium, BUN, Glucose, and ETOH to estimate the osmolality.

HypoOsmolar

Calculated osmolality <275 mOsm/kg is considered hypoosmolar (and usually hypotonic). This is the most common type of hyponatremia and fluid status must then be considered to determine etiology:

Euvolemic

Often caused by SIADH (from many causes) or thiazide diuretics.

Hypovolemic

Often caused by decreased PO intake, diuretics, GI losses, 3rd spacing, or adrenal insufficiency. This is treated with careful fluid resuscitation as replacing sodium too quickly can lead to deleterious effects such as osmotic demyelination syndrome (previously referred to as central pontine myelinosis).

Hypervolemic

Often caused by heart failure, liver cirrhosis, nephrotic syndrome, or severe AKI/CKD. Treatment in this case involves restricting water, administering loop diuretics (i.e. IV Lasix), and sometimes other medications.

IsoOsmolar

Calculated osmolality 275-290 mOsm/kg is considered IsoOsmolar (and usually isotonic). This used to be caused by lab errors secondary to high lipid or protein levels. However, ion-specific electrodes are now used in the lab, so this error does not really happen anymore.

HyperOsmolar

Calculated osmolality >290 mOsm/kg is considered hyperOsmolary (and usually hypertonic). This is usually caused from solutes which cause osmotoic shifts of water out of cells into the extracellular fluid (i.e. glucose, mannitol, sorbitol, etc).

Check out the Calculator!

7

Sodium Correction for Hyperglycemia

Due to the osmotic shifts caused by hyperglycemia, hyponatremia should be corrected when glucose levels are elevated. The serum sodium concentration will fall by ~2. mEq/L for every 100 mg/dL of glucose elevation. For example, if the blood sugar is 400 and the sodium level is 124, the corrected sodium level is ~130 mEq/L. But you don’t have to do math, just use the calculator! It’s recommended to base your treatment plan on the corrected sodium level, as once the glucose is corrected the osmotic shifts will resolve.

Check out the Calculator!

8

Maintenance Fluid Rate

As inpatient providers, we have to order IV fluids on many patients. Maintenance fluids may need ordered if the patient is NPO, or if they have fluid losses/dehydration. In order to determine the best rate at which to run the IV fluids, there is a simple calculation. Take their weight in Kg, subtract 20 Kg and add 60mL. Then for every over Kg left, add 1mL. So a 60Kg patient gets 100ml/hr. If this is confusing – you can just use the calculator below!

Keep in mind this rate is a general estimation, and the patient’s own medical history should be taken into account. If they are fluid overloaded (i.e. CHF, Liver cirrhosis, etc), then a slower rate may be more appropriate. Always use your physical examination to guide your management. If the patient is elderly, consider slowing the rate as well. If the patient is having continuous fluid losses (i.e. diarrhea), then consider increasing the rate to 1.5x the maintenance rate – or using your best judgement.

(The calculator also lists the 20ml/kg bolus amount for sepsis patients)

Check out the Calculator!

9

Calcium Correction for Hypoalbuminemia

Unrelated to sodium and fluid status, calcium levels can be falsely altered in the presence of hypoalbuminemia. Calcium ions have two forms – ionized and protein-bound. About 40% of calcium in the blood is bound to protein (i.e. albumin), and about 50% circulates as free ionized calcium. The ionized calcium is what is truly clinically significant because this is what is physiologically active. If a patient is symptomatic from hypocalcemia – their ionized calcium will be low.

This is not an exact science and many factors (i.e. acid-base disturbance) will alter calcium binding to protein and may cause ionized calcium levels to fluctuate. This is why most clinicians will order an ionized calcium level when serum calcium levels are significantly low (even in the presence of low albumin).

Check out the Calculator!

10

Arterial Blood Gas (ABG) Analyzer

Arterial Blood Gases (ABGs) are commonly ordered in patients with respiratory failure in the hospital. This helps clinicians determine etiology and guides management of many respiratory conditions. If you struggle with analyzing ABGs, this calculator can help. Simply input the pH, PaCO2, Bicarb, Sodium, Chloride, and Albumin. This will help you determine whether the ABG abnormality is respiratory, metabolic, and which type with compensation (if any).

It is important for clinicians to be able to analyze blood gases on their own as well. You can read more about ABG interpretation in my ABG guide!

Check out the Calculator!

If you’re a practicing NP or NP student and need access to my free NP Resource library – sign up here! It has both inpatient and outpatient SOAP note templates, History and physical sheets, death pronouncement notes, and more to come!

References:

Barbar, S., Noventa, F., Rossetto, V., Ferrari, A., Brandolin, B., Perlati, M., … Prandoni, P. (2010). A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. Journal of Thrombosis and Haemostasis, 8(11), 2450-2457. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20738765

Bauer, K. A., & Lip, G. Y. (2019). Overview of the causes of venous thrombosis. In UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-causes-of-venous-thrombosis

Data and Statistics on Venous Thromboembolism. (2019, August 9). Retrieved August 11, 2019, from https://www.cdc.gov/ncbddd/dvt/data.html

Garcia, D. A., & Crowther, M. (2019). Risks and prevention of bleeding with oral anticoagulants. In UpToDate. Retrieved from https://www.uptodate.com/contents/risks-and-prevention-of-bleeding-with-oral-anticoagulants

Goltzman, D. (2019). Diagnostic approach to hypocalcemia. In UpToDate. Retrieved from https://www.uptodate.com/contents/diagnostic-approach-to-hypocalcemia

Higgins, C. (2007, July). Ionized calcium. Retrieved from https://acutecaretesting.org/en/articles/ionized-calcium

Hoorn, E. J., & Sterns, R. H. (2019). Causes of hyponatremia without hypotonicity (including pseudohyponatremia). In UpToDate. Retrieved from https://www.uptodate.com/contents/causes-of-hyponatremia-without-hypotonicity-including-pseudohyponatremia

Kearon, C., & Bauer, K. A. (2019). Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity. In UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-deep-vein-thrombosis-of-the-lower-extremity

Lip, G. Y. (2011). Implications of the CHA2DS2-VASc and HAS-BLED Scores for Thromboprophylaxis in Atrial Fibrillation. The American Journal of Medicine, 124(2), 111-114. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20887966

Manning, W. J., Singer, D. E., & Lip, G. Y. (2019). Atrial fibrillation: Anticoagulant therapy to prevent thromboembolism. In UpToDate. Retrieved from https://www.uptodate.com/contents/atrial-fibrillation-anticoagulant-therapy-to-prevent-thromboembolism

Sterns, R. H. (2019). Causes of hypotonic hyponatremia in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/causes-of-hypotonic-hyponatremia-in-adults

Sterns, R. H. (2019). Overview of the treatment of hyponatremia in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-treatment-of-hyponatremia-in-adults

Sterns, R. H. (2019). General principles of disorders of water balance (hyponatremia and hypernatremia) and sodium balance (hypovolemia and edema). In UpToDate. Retrieved from https://www.uptodate.com/contents/general-principles-of-disorders-of-water-balance-hyponatremia-and-hypernatremia-and-sodium-balance-hypovolemia-and-edema

Sterns, R. H. (n.d.). Diagnostic evaluation of adults with hyponatremia. In UpToDate. Retrieved from https://www.uptodate.com/contents/diagnostic-evaluation-of-adults-with-hyponatremia

Thompson, B. T., Kabrhel, C., & Pena, C. (2019). Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism. In UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism

Wells, P. S., Anderson, D. R., Bormanis, J., Guy, F., Mitchell, M., Gray, L., … Lewandowski, B. (1997). Value of assessment of pretest probability of deep-vein thrombosis in clinical management. The Lancet, 350(9094), 1795-1798. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed?term=9428249

Yu, A. S., & Stubbs, J. R. (2019). Relation between total and ionized serum calcium concentrations. In UpToDate. Retrieved from https://www.uptodate.com/contents/relation-between-total-and-ionized-serum-calcium-concentrations

10 IV Insertion Tips for Nurses

Aug 15, 2018

10 IV Insertion Tips for Nurses

Published: August 15, 2018

Last Updated: October 27, 2022

William Kelly, MSN, FNP-C

Author | Nurse Practitioner

Procedures

Emergency Nursing

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.

IV Insertion: Location, Location, Location!

Cubital Fossa (AC)

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

AC lines are when IVs are placed in the Cubital Fossa, or the elbow pit triangular area. 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.

Anterior-arm-veins-IV-insertion-website-min

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!

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!

Don't Give Up during the 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”

IV Quick Start Guide

Learn how to start an IV, Step-by-Step, with all the best tips and tricks!

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”

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.

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.

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”

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!

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:

Want to learn more?

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

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

This course includes:

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

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

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

Check out more about the course here.

Top 6 Charting Tips for Newbie Nurses

Apr 20, 2018 | 11 comments

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!

Patient Care Organization Sheets

Great for bedside RNs!

Use these FREE patient care organization sheets to keep your patient information nice and organized. What do you have to lose - it's absolutely FREE!

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Nurse Charting Nurse Documentation Abbreviations

10 ER Nursing Hacks You Need to Know

Mar 8, 2018 | 17 comments

10 ER Nursing Hacks You Need to Know

William J. Kelly, MSN, FNP-C

Author | Nurse Practitioner

ER nursing hacks can be just what you need to make your shift go from terrible to not-as-terrible. As nurses, we aren’t afraid to get our hands dirty. We take charge, do what needs to be done, and then find a way to laugh about it in the end.

Working in the Emergency Department can be especially draining – physically, mentally, and emotionally. However, just because nursing is HARD doesn’t mean we can’t utilize tips and tricks to make that 12-hour shift a little bit more bearable. Use these “10 Nursing Hacks Every ER Nurse Should Know” to save time, save your senses, and save your sanity!

Please keep in mind the following hacks are anecdotally based. You must use these within your own judgment and within your facility’s protocols. You can read more about this on my disclaimer page.

1 ER Nursing Hacks: Double-Glovin’ in the Oven

As you know, personal protection equipment including clean gloves and gowns are absolutely necessary in a hospital environment. For some procedures, clean gloves are “good enough”. However, for high-risk infection procedures, sterile gloves are necessary.

Foley catheter insertion is one of those procedures, as catheter-associated infections are very common. While putting in a Foley catheter can become like second-nature rather quickly, there can be some difficulties with the sterile procedure.

For one – those cheap sterile gloves that come with the foley kit are typically a size 5.0. So unless you have baby-hands, I’d recommend grabbing an appropriately sized package of latex-free rubber gloves. You might want to go a half-size above your normal for this method.

After grabbing your foley kit and sterile gloves, position the patient, and then wash your hands (duh). Afterward, put on a pair of clean gloves FIRST, then proceed to open your kit and apply your sterile gloves, and continue the insertion per normal.

Using this nursing hack, once you insert the foley and blow up the balloon, you can take off your previously sterile gloves which are now likely dripping with Betadine and other fluids. Luckily – you still have a pair of gloves underneath to secure the cath-secure, position the foley bag, and clean up your pile of trash! Once that’s done, slip off the gloves, wash your hands, and you’re done! Easy-peasy-Kegel-Squeezy.

2 Burp that Bolus

This concept is a little more confusing, but it can save time! In the ER, we hang A LOT of boluses and every ER nurse knows that pumps are harder to find than a rectal thermometer. So naturally, ER nurses are resourceful and use gravity. Patients often require multiple boluses, and Lord knows you are ~~almost always~~ sometimes just too busy to switch out bags before the bag runs out and half of the tubing is now air.

In this predicament, you could flush out the rest of the line in a trash can, then unspike and re-spike your new bag, and THEN re-prime the line. Or you could get a whole new tubing set and just throw out the old bag/tubing. As you can see – this wastes either valuable time or equipment/money!

But what if I told you there was an ER nursing hack to solve this? When you go to prime the original bolus, clamp your tubing and spike your bag. Do NOT squeeze fluid into the drip chamber yet. Now, turn the bag upside down. Unclamp the tubing, and “burp” out the excess air at the top of the upside-down bag.

Once the air is gone and some fluid is forced into the drip chamber, turn the bag right-side-up. Now prime the tubing as normal and hook the patient up. You’ve essentially created a vacuum so that the fluid will stop flowing before it empties the drip chamber – ready for your second bolus when you are.

3 Juice cup? Change it up!

Unless you work at an adult-only ER, you are likely seeing patients that span the clinical spectrum – this includes pediatric patients. One thing about pediatric patients is that they HATE taking their medications.

One particularly difficult medication to give a child PO is Dexamethasone oral solution. Unfortunately, it’s usually made with a good portion of alcohol content, and it smells and tastes like…vodka?

After forcing it down, kids often vomit it up – all your hard work for nothing. One ER nursing hack to avoid having to give an IM shot is swapping oral Dexamethasone for the IV solution.

IV medications cannot always be used orally, but sometimes they can! IV Dexamethasone has successfully been administered mixed with cherry-syrup, juice, or followed by a popsicle – and children take the medicine MUCH easier! Don’t forget though, you must run this by the provider before trying it, as studies are somewhat mixed on the efficacy (pharmacokinetic info here).

4 Septic Sock

Now I KNOW you have smelt some SMELLS in the ER (or anywhere in the hospital for that matter). There is nothing stronger than a nurse’s nose. C-diff, fungi, and bodily secretions aside – sometimes the worst smell comes from down under (the feet – ya nasty).

Unfortunately, working 12-hour shifts where you are constantly on your feet and running around, you might find yourself with some STANKY feet. The good news is, even if you don’t have stinky feet, this ER nursing hack can help you deal with a patient’s particularly putrid piggy-toes. But first, a quick science lesson.

While sweat is the main cause of foot odor, sweat doesn’t actually smell. Instead, it creates a perfect medium for bacteria. These bacteria include Brevibacteria and S. epidermidis (known for their cheese-like smell), as well as propionibacteria (known for its vinegar-like smell).

Regardless of which bacteria are causing the odor, they are all highly acidic. So here’s the hack: If you or one of your patients has particularly powerful foot odor – use an antacid! Lather Maalox or Mylanta on the feet, put surgical booties over top, and you won’t believe how fast it can help! Another option is to scrub the feet with Hibiclens or betadine for antibacterial action. Better yet – do both!

Fair warning though, if there is any fungi growing – these methods might not work as well. To prevent foot odor, it’s recommended to wear breathable shoes, breathable socks (cotton or wool), and wash and exfoliate your feet frequently. A little dab of foot-powder in your shoes every few days never hurt anyone either (Gold Bond anyone? #NotSponsored)

Related Article: Six Steps for Sepsis Management

Get my Free Nursing Report Sheets!

Use these sheets to write up on your patients and stay organized!

5 Thinking Outside the Vial

Every nurse knows that lidocaine is extremely helpful as a topical anesthetic for suturing , regional blocks, and even intra-articular injections to numb pain. However, lidocaine is not limited to only these uses. While not quite a “nursing hack”, these alternative uses of lidocaine are important to know so you can offer suggestions to the attending when indicated.

Gastritis

OK, you probably knew this one – viscous lidocaine is often mixed with an antacid and sometimes an antispasmodic to create a “GI cocktail” to help with the pain of gastric or esophageal etiology. This is always a good suggestion for those young chest pain when GI etiology is suspected.

NG Tube Insertion

They have done research to see if lidocaine gel, nebulized lidocaine, and anesthetic spray have been useful for NG tube insertion. Not too surprisingly, patients who get lidocaine gel or spray administered intranasally/orally had significantly less pain with insertion – but can have a more difficult NG experience. Additionally, nebulized lidocaine has proven to decrease pain and increase comfort during NG tube insertions, but can increase the chances of nosebleeds.

Cough

Sometimes with persistent laryngospasm, nebulized lidocaine can be used effectively to help with a cough. However, there isn’t a significant amount of research on this, so you likely won’t see it ordered often and will depend on the Provider.

Oral Pain

Those experiencing pain in their mouth from a painful lesion such as an aphthous or herpetic ulcers can benefit from viscous lidocaine “swished” and either swallowed or spit afterward.

Foley Insertion (males)

This is also more common, but the provider may order 5-10ml viscous lidocaine to inject into the urethra before a difficult-anticipated foley insertion in males. Luckily, this usually comes pre-packaged in a syringe called a Uro-Jet. This should be injected directly into the urethra a few minutes before attempting the foley insertion. This can help reduce pain and be especially helpful in patients with a small meatus, anatomical abnormalities, or prostate enlargement.

Renal Colic ER

While meds like morphine and Dilaudid are used frequently in the ER and hospital, sometimes there are effective alternatives to opioids that actually work really well. Slow infusion of low-dose IV lidocaine can be used effectively for kidney pain. It’s recommended for use if NSAIDs and Opioids are contraindicated or risky. One study even indicates that IV lidocaine at appropriate doses safely lowered the patient’s pain more than morphine.

Related Article: Opioid Alternative Analgesics in the ER

6 Alcohol Swab Nursing Hacks

There are a few things we nurses usually load up our pockets with. Usually, these consist of tape, band-aids, paper, pens, and alcohol pads. But did you know how versatile alcohol pads can truly be?

Blood Cleanup

This is more of a no-brainer, but when you accidentally make a mess with blood while putting in an IV, patients appreciate it if you help clean up your mess. Busting out an alcohol swab can easily clean up dried blood on their skin. If alcohol doesn’t do the trick, sometimes using KY jelly lube works even better. Alternatively, you could use hydrogen peroxide.

Nausea Nursing Hack

Did you know that a few whiffs of alcohol pad can relieve nausea almost immediately? Sure – Zofran is still our bread and butter, but this nursing hack works pretty quickly!

When your patient is nauseous, break open an alcohol swab and place it right under their nose. Tell them to take 3-4 deep slow breaths. Before you know it – they should start feeling somewhat better. In fact, clinical research suggests that alcohol may even be more effective than oral zofran, or at least a useful adjuct.

Scientists don’t exactly know why this works. Some think it’s purely due to “olfactory distraction” – distraction while following the instructions, taking deep breaths, and relaxing the body.

Pseudoseizure Nursing Hack

In the ER, the nurses frequently experience patients who have not-so-believable “seizures”. These “fake” seizures are termed pseudoseizures, and the patient might not even know that they are “faking”. Typically when this happens, we bust out an ammonia salt and place it underneath the patient’s nose. This tends to stop their “seizures” pretty much immediately. But what do you do if you don’t have an ammonia inhalant on hand?

Not every ER utilizes ammonia salts, and sometimes they can be hard to find. If you experience a patient with what you believe to be a pseudoseizure, try opening an alcohol pad and placing it directly beneath their nose. This may distract them and bring them out of their “seizure”. Please note this is anecdotal and is not in the literature.

Save your Senses (ER Nursing Hack)

Clostridium Difficile (C-Diff) is a common diarrheal infection which can make people pretty sick. We often see these patients in the ER and hospitals. Unfortunately, C-diff is very contagious and tends to run rampant in nursing homes and hospitals. As we all know, C-Diff has a pretty distinct and powerful smell which can be hard to erase from our noses!

Before going into a C-diff patient’s room, add a mask to your PPE. Break open an alcohol swab and place it inside the mask. This way, the isopropyl alcohol overpowers the C-diff smell and you save your senses – or at least make it more tolerable.

If alcohol swabs are too strong for you, you can try rubbing toothpaste or Vix rub inside a double-layered mask. This nursing hack works well for C-diff, but also for other smelly situations including I&Ds, rotting flesh, nasty wounds, and fungal infections.

7 IV Stick Trick

Putting in IVs is super common in hospitals, especially within the emergency department. If one thing is sure – patients hate getting stuck! Some tense up, others look away, and then there’s those who shake, cry, and even syncopize. Ironically, the latter is usually buffed up guys with tattoos all over their bodies! People don’t like needle sticks because the needles hurt. But what if I were to tell you that there’s a way you can decrease pain, without any medication or extra equipment?

This ER nursing hack will help your IV insertions go more smoothly! After you clean the IV site, place the needle flush with the skin right where you are going to poke. Press the needle into the cleansed skin with the bevel up for 3-5 seconds before you puncture the skin. The longer you wait – the more desensitized their pain receptors will become – this should decrease the pain felt.

With less perceived pain, the patient may tell you “is that it?!” or “I could barely feel it!”. It also takes away the “shock” factor, making the patient less likely to jump! For most patients, this technique will be effective, however, some patients still will have a high amount of perceived pain, especially if you dig.

Related Article:

8 BP not Enough? Use the Bedside Cuff

Vital signs are an important aspect of nursing care and patient monitoring. Blood pressures have a tendency in the ER to be very high or very low. When very low, we give large amounts of fluids as fast as we can. While pressure-bags are a great option and ensure fast infusion, they are not always available.

Many ER rooms have bedside manual blood pressure sphygmomanometers. In place of a pressure-bag, use the blood pressure cuff around the middle to top of the bolus and pump it up until it flows nicely. Like the pressure bag – you will have to occasionally pump in more air as the bag empties.

Related Articles: “5 Vital Sign Errors to Avoid”

9 Neb-wick Air Freshener

After a particularly smelly patient leaves, sometimes the aroma sticks around in the air. Unfortunately, Lysol sprays don’t always cut it. Now I personally am not a huge believer in the essential oil craze, but this nursing hack requires someone on staff to have essential oils or strong smelling lotion.

Take a used nebulizer adapter and squirt some water or saline in the medication chamber. Next, add a few drops of an essential oil of your choice. Turn the oxygen on high and viola. This nursing hack will have the room smelling Glade-scented fresh in no time. Talk about Oxy-Clean!

10 The Dependable Bedpan Nursing Hack

Many patients cannot or should not ambulate while they are in the ED. This is fine until they have to use the bathroom. Bedpans can be successfully used for both #1 and #2, but unfortunately, they have a tendency to cause messes. Whether you are using a fracture pan or a regular bedpan, line the pan with an adult diaper or absorbable pad. Secure it with tape or rubber bands. You can also use a large pull-up inverted inside-out and secure it over the bedpan. Place the bedpan underneath the patient as normal.

This way, any urine or liquid stools are absorbed in the material and do not splash, spill, or cause messes. It also allows for easy cleanup! If you need to collect a urine or liquid stool sample – this method should not be used.

Related Articles: “Comprehensive Urinalysis Interpretation”

Hopefully, you found these 10 ER nursing hacks to be useful. Implementing them in our everyday shifts should help save our senses and our sanity, not to mention our time! As a nurse, we are pulled in so many different directions at once and expected to always be on top of our patient care. Utilizing these hacks will hopefully help.

What are your personal nursing hacks which help save you time and make you a more efficient nurse? Let me know in the comments below, and share this article with your nursing friends!

Check out more general nursing hacks over at FRESHRN here!

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