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5 Questions to Ask Before Calling the Doctor

5 Questions to Ask Before Calling the Doctor

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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.

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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:

Welcome!

Will Kelly, MSN, FNP-C
Thank you for visiting my site! I help nurses and nurse practitioners improve their clinical knowledge by providing high-quality content to turn their nursing education into practical application!  Read More

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Calling the Doctor – Giving Nurse to Provider report

Calling the Doctor – Giving Nurse to Provider report

*This post may contain affiliate links. Please see my affiliate disclosure for more information*

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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.

Welcome!

Will Kelly, MSN, FNP-C
Thank you for visiting my site! I help nurses and nurse practitioners improve their clinical knowledge by providing high-quality content to turn their nursing education into practical application!  Read More

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Six Steps for Sepsis Management

Six Steps for Sepsis Management

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Sepsis is not a specific disease but rather a clinical syndromewhich represents the body’s response to severe bacterial infection. Sepsis is very common. In fact, within the hospital, you will take care of patients with sepsis in any department. Sepsis is a very serious condition with a poor prognosis. As the medical team suspecting and treating sepsis – there are important management steps that need to be taken in order to maximize patient outcomes and save lives!

Early sepsis– while not clearly defined – is the presence of infection and bacteremia – which can and likely will progress to sepsis without intervention. Sepsis used to be identified using SIRS criteriaSystemic Inflammatory Response syndrome. This syndrome is defined as the presence of at least 2 of the following 4 clinical indicators: Fever >38C or <36C, HR >90bpm, RR > 22/min or PaCO2 <32 mmHg, or WBC >12,000/mm3, <4,000/mm3, OR 10% BANDS. Once SIRS is identified with suspected source of infection – sepsis diagnosis was met. However, the definition of sepsis has changed with 2016. Sepsis is now is defined as life-threatening organ dysfunction in response to infection. Organ dysfunction, usually from hypoperfusion, can be evidenced by hypotension, altered mental status, tachypnea, or increased sofa score by 2 points (see below).  Septic shockis defined as those patients who have received fluid resuscitation and still have a MAP <65 mmHg and a lactic >2.0 mmol/L. These patients require vasopressors and should be monitored in the ICU.

Sepsis can be very serious and even fatal. Because of this – it is important to kn ow the steps to take in sepsis management. Performing these correct steps can literally mean the difference between life and death.

  1. Recognition and Early Intervention

    The most important aspect of sepsis management is recognizing it’s presence and acting quickly. Common symptoms of sepsis include fever, chills, sweats, and confusion. Common signs include altered mental status, elevated temperature, tachypnea, tachycardia, and hypotension.

    Initial management should include investigating the extensiveness of their infection, and applying initial measures to help them. After vital signs are taken an IV should be established and lab work drawn. If the patient’s blood pressure is low – consider starting 2 large-bore IVs. Be sure to draw at least 1 set of blood cultures per IV site (up to 2) as this will need ordered in all sepsis patients. Make sure the blood cultures get drawn before antibiotics are started.

    Diagnostics should investigate the source of the infection – sometimes it is not obvious. If unsure – it is a good idea to obtain a urinalysis with culture to r/o UTI and a Chest x-ray to r/o pneumonia should be ordered. A wound culture, sputum culture, or abdominal imaging may be ordered if clinically indicated. Blood work will usually include blood cultures x 2, CBC with differential, CMP, and a lactic acid level. Sometimes in severe cases, an ABG can be ordered to evaluate acid-base status.

    Lactic acid levels are very important in sepsis. Lactate is released from cells when they are forced to utilize glycolysis instead of the Kreb’s cycle (throwback to Cell Biology!). This means that there is decreased tissue perfusion due to decreased volume, increased oxygen demand, and decreased oxygen delivery. Lactic levels correlate with severity of sepsis.

    Apply oxygen at 2 L/min unless contraindicated – titrate if SPO2 <92%. During sepsis, oxygen demand increases and delivery diminishes. Supplemental oxygen will help put less stress on the body and may help diminish lactic acidosis.

    The qSOFA (Quick Sequential Organ Failure Assessment) score is now starting to be used as a clinical tool for sepsis. This is usually used within the hospital to stratify the mortality of patients with sepsis (see infographic for more details).

  2. Fluid Resuscitation!

    Fluid resuscitation during sepsis is the staple of sepsis management. Evidence shows early fluid intervention decreases mortality. There is such a massive need for fluid because during sepsis there is poor tissue perfusion and often hypovolemia. To correct this – large amounts of fluids are needed.

    Typically, 0.9% normal saline is used 9 times out of 10. The recommended standard volume is a 30 ml/kg bolus. So if a patient was 70 Kg, they would receive 2100 ml total. This should be given as quickly as possible – as tolerated. This amount is typically given to anybody recognized as possibly having sepsis, but is especially indicated in those with sever sepsis, fast heart rate, or low blood pressure. Traditionally even larger amounts of fluids were given (5-6 Liters), but several randomized control trials showed no difference in mortality compared with the now-recommended 2-3 Liters.

    Exceptions to receiving this bolus includes those with active pulmonary edema. Those with a history of Heart Failure, end-stage renal disease, or severe liver disease should still receive fluids. However – it is recommended to give fluids in 500mL bolus increments and to reassess lung sounds and breathing status after each bolus. If pulmonary edema ensues – the bolus should be stopped and the patient may need diuretics.

  3. Timely Antibiotic Administration

    Another very important aspect of sepsis management is early antibiotics. The term empiric simply means antibiotics based on the best “clinical guess”.

    The choice of empiric antibiotics will be selected based off of the patient’s signs or symptoms and where the likely source – since certain organisms are more likely from one source as opposed to another. This means the antibiotic regimen should be geared towards covering all likely gram-positive and gram-negative organisms. For sepsis – usually a broad spectrum antibiotic like Zosyn or a Carbapenem is combined with another antibiotic of a different lass – such as Vancomycin. Vanco is often added when the patient has risk factors for MRSA.

    Correct regimen of antibiotics are important – however timely administration of those antibiotics are just as important. Antibiotics should be initiated within the first hour after suspecting sepsis – especially during severe sepsis or septic shock. This is because several observational studies have shown poorer outcomes with delayed antibiotic initiation. Once again, try to be sure you obtain both sets of blood cultures before you start the antibiotics!

    As nurses, it is often up to you to choose which antibiotic to start first as both are often ordered concurrently. If you have both Zosyn and Vancomycin ordered – start with the broad-spectrum antibiotic first. But what exactly is broad-spectrum? This means heavy-hitter antibiotics that cover most pathogens – both gram positive and negative. Contrary to popular belief – vancomycin is NOT broad-spectrum. In fact, it has a very narrow spectrum specific for gram positive organisms such as Staph or Strep. Most cases of sepsis are from gram negative sources. This means starting the Zosyn first should be your priority. Additionally – Zosyn runs much quicker as a loading dose (4.5 grams over 30 minutes) – whereas vancomycin usually runs over 1.5 hours.

  4. Hemodynamic Management

    Sometimes when sepsis becomes severe – distributive shock can occur. This is termed septic shock. When this occurs – hemodynamic compromise is present.  If blood pressure remains low, the patient’s tissue perfusion continues to suffer and steps need to be taken to improve outcomes.

    The patient may require more fluid if they are still hypovolemic after the initial bolus and can tolerate more fluids. However, the mainstay of treatment of septic shock is intravenous Vasopressors. For the most part – Norepinephrine (Levophed) is the go-to pressor for sepsis. However, other choices can be chosen based on clinician discretion (i.e. If very tachycardic consider Vasopressin which has no beta stimulation). Sometimes, multiple vasopressors may need to run concurrently to manage septic shock.

    When a patient is in septic shock with hemodynamic compromise – they should have a central venous catheter inserted and/or an arterial line. Vasopressors can be started in a peripheral line, but a central line should be ordered as vasopressors can be caustic and damaging to the peripheral vasculature. Additionally, these catheters can monitor CVP and continuous blood pressures. If a patient is in cardiogenic shock and has inadequate cardiac output – cardiac inotropes can be added such as dobutamine or epinephrine.

    Sometimes during severe septic shock, IV glucocorticoids may or may not help. Usually this is ordered if fluid resuscitation and vasopressors have failed.

  5. Monitoring

    Monitoring is the essential last step to sepsis management. Patient’s with sepsis can respond well to the regimen – or they can decompensate unexpectedly. Sepsis has a high mortality and the patient’s should be monitored very closely.

    If the patient has any hemodynamic compromise and are on pressors – they should be monitored in the ICU for a few days until they become stable. Patient’s with mild to moderate sepsis should be closely monitored on a med-surg or telemetry floor. Continuous cardiac monitoring is essential during sepsis. The increased tissue demand for oxygen places the heart at a greater risk for having cardiac events secondary to the sepsis. It is not uncommon for someone with sepsis and cardiac comorbidities to have secondary myocardial ischemia and/or infarctions.

    Blood pressure should be monitored closely – especially initially. Normotensive blood pressure should be maintained (SBP >100). However – maybe even more importantly the MAP (mean arterial pressure) should be monitored closely. The goal of MAP should be >65mmHg – this ensures adequate tissue perfusion (i.e. brain). Heart rate is also an important metric to monitor. Tachycardia is usually present – often in the 120s-130s during fever and sepsis – sometimes higher. While giving fluids – heart rate should improve. This can be somewhat helpful in monitoring the response of fluid therapy. Fever should be monitored as well – as sometimes it can become very high and increases insensible water losses and further propitiates hypovolemia. Remember a rectal temperature is preferred in those with suspected sepsis – especially the elderly. Urine output is also often monitored during severe sepsis – as secondary hypoperfusion of the kidneys can cause acute kidney injury and decreased urine output.

    Nursing assessments should include skin color and perfusion, mucous membranes (i.e. dry vs moist), mental status, and heart/lung sounds. Nurses should be vigilant in recognizing flash pulmonary edema or cariogenic shock which may develop after rapid administration of fluids with underlying comorbidities (i.e heart failure, ESRD, etc). 

    If the initial lactic acid level is elevated > 2 mmol/L, then a repeat level should be drawn in 4 – 6 hours. The lactic acid level should respond quickly to changes in tissue perfusion. CBC should be trended each day to monitor for resolution of the leukocytosis, bandemia, and/or thrombocytopenia. Electrolytes and kidney/liver function should also be monitored closely dpeneding on which abnormalities are present.

  6. Patient Disposition and Follow-Up

    Last but certainly not least – the patient needs to be sent to the correct unit, needs the correct consults, and needs adequate follow-up. Almost all patients admitted to the hospital with sepsis will warrant an Infectious Disease consultation. Additionally, if they have any pre-existing comorbidities these consults should be made as well (i.e. cardiology for heart failure, nephrology for kidney disease).

    Patients should have frequent nursing assessments and daily physician assessments, with close follow-up of labs. Blood cultures can start showing growth at about 24 hours. The pathologist will gram-stain the growth and give a report of “gram positive cocci” a similar description. This tells the clinician if they are on the right track and can guess at the offending organism. At about 48 hours, most clinically significant bacteria will be identified and a sensitivity is done to detect the bacteria’s sensitivity vs resistance to various antibiotics. Urine, wound, and sputum cultures have similar timelines. Antibiotics may be changed depending on the results. Remember, Infectious Disease should likely be involved in this decision.

And those are the six steps to sepsis management. Knowing the general steps to sepsis can help you as the nurse provide high quality care to your septic patients and help improve outcomes. As always, it is a collaborative team effort in offering you patients the best possible care.

Do you have any other sepsis tips? leave them in the comments below!

 

Welcome!

Will Kelly, MSN, FNP-C
Thank you for visiting my site! I help nurses and nurse practitioners improve their clinical knowledge by providing high-quality content to turn their nursing education into practical application!  Read More

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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. While IVs are very useful, sometimes IV insertion can be difficult,  especially for the new 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.

    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, starting an IV in a forearm vein does 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 can usually only fit 20g – 22g. 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 an order needs to be placed by the Physician/APP.

  3. IV Insertion with Fragile Veins

    Change your Selecton

    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 and it appears to be engorged enough to thread the catheter – 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 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 you will know which patients you probably shouldn’t go digging.

    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 – larger gauges are better in an emergency, are more durable, and tend to cause less irritation to the veins.

    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 IV’s 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 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 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’ve found that this is often from having too much of an angle with the skin. 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 by chance 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: “Top 5 Apps for ER Nurses”

  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 decreases 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!

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 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 appropriately? 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 kindof know if its 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. Patient’s are often going to be bed-bound, on bedrest, or perhaps sleeping when you go to take their vital signs. 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 learn when a low reading is actually dangerous.

    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 dinamap 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 pulses? 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 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 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 happen 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”.

  1. 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 5 Apps for ER Nurses

Top 5 Apps for ER Nurses

*This post may contain affiliate links. Please see my affiliate disclosure for more information*

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 To work as a nurse in emergency medicine, you have to be quick on your feet, efficient, and knowledgeable. Drawing on information in life and death situations can be daunting. Sometimes, it can be difficult to think when you are stressed, overworked, and underfed. Using smartphone apps specific to emergency nursing can save you some brain power and offer a quick reference to ensure patient safety. Sure – googling is an option, but using smartphone apps specific to nursing or medical information can greatly improve the accuracy and utility of the information.

  1. WikEM

    WikEM is an “online wiki and database of emergency medicine knowledge”, primarily intended for clinicians such as physicians or advanced practice providers. However, WikEM offers great information to those nurses who need to look up a new disease, refresh an old disease, or update their knowledge on various procedures, labs, or medications.

    All information on this database is specific to emergency medicine and will help you draw the need-to-know information. Just like a Wikipedia article, a convenient table of contents is offered to assist you to navigate to the desired information. Topics are not too wordy and are easy-to-read synthesized information specific to the emergency clinician.

    The best part about this app is that it is completely FREE to use. All you need to do is first create an account on their website. Afterward, you can use the website database or download the app and use your login information. You can choose to subscribe to get access to personalized lists and favorites, but this is only $5 dollars per year and helps them maintain free information for everyone.

    Information is continuously updated from their online database and ensures accurate and up-to-date information.

  2. Critical – Medical Guide

    Critical – Medical Guide is a one-stop shop for all things critical care. This app can be used for really any nurse in the hospital setting but seems to specifically cater to the ED or ICU.

    This app “aims to assist by providing crucial medical guidelines, emergency medical references & materials” to use on-the-fly. Within it, there is information on ACLS algorithms, EKG interpretation, fluid and blood products, laboratory values, hemodynamics, ventilator management, and various assessments.

    In my opinion, one of the most useful features is the critical drips function, which gives you all the critical drips you may entail within the critical setting. Each drug offers a calculator, in which you enter the patient’s weight (in kg), the total dose and dilution amount, and the infusion rate. The app will give you a mg/hr and mL/hr rate. It offers a small slider which lets you adjust the mg/hr and titrate the medication effectively.

    Another helpful feature is the RSI tab, which gives you dosing calculators for common medications used in rapid sequence intubation. The app also offers many other features including a pediatrics critical tab, which overviews each Braslow weight including medication dosages and ET tube sizes. The app also has a “pharmacology” section which overviews the pharmacology, indications, and adverse effects of commonly used emergency drugs.

    Unfortunately, this app is not free. It comes with a one-time payment of $9.99. However, I have personally used this app in the ED and find it to be very helpful with my management of a critical patient.

  3. Intravenous Medications: Gahart

    IV Meds boasts itself as “the #1 IV drug reference for 40 years”. Basically, this is your go-to resource for IV medications and drips. It provides comprehensive information regarding every type of IV drug.

    This includes comprehensive information on dosing, dose adjustments that may need to be made, dilution, compatibility, the rate of administration, drug actions, indications, contraindications, precautions, interactions, side effects, and antidotes.

    The app also offers calculators and charts for dilution and rate administration, although I find these to be a bit difficult to use and unsightly. There is an option to mark your favorites for quick-access in the critical setting.

    You can download the app for free, but unfortunately, to use the app you must pay $50. You can likely find all the information you need on google or other medication reference apps, but this app is specific to IV medications and offers convenience in the critical setting.

  4. Eye Chart HD

    Eye Chart HD is a great app to utilize within the emergency setting. Any patient who presents with an eye complaint usually needs visual acuity tested. Unfortunately, most exam rooms do not have a Handy Snellen chart available. This means that you have to take the patient out to a common area and have them perform the visual acuity assessment in a less-than-ideal setting.

    The app will detect which phone you are using, and recommend an appropriate distance (such as 4 feet). This is ideal for testing at the end of the stretcher with the patient in high Fowler’s position. Assess the visual acuity as you normally would.

    The app also offers a “randomize” option, which randomizes the letters. You can also click “mirror” and test yourself in the mirror!
    The app also offers other visual acuity charts including Tumbling E, Sloan Chart, and a Landolt Chart.

    This app is FREE, but you can choose to pay $2.99 per month to get access to a randomized near-vision chart, Amsler grid, line isolation, and other specific eye chart features. However, this seems excessive for use in the emergency department, and I don’t recommend it.

  5. Lab Values Medical Reference

    Lab Values + offers comprehensive information regarding lab values. The app separates the labs by system, but also has a search function.

    Within each lab, the app lists common “normal” values for the lab in both SI and US units. Additionally, it offers a description of the lab and the pathophysiologic significance. It also offers a differential for abnormal levels, as well as which lab vial color to draw. Please note that not every hospital utilizes the same colors. For example, a lab that may be run off of a gold tube at one facility may be run off of a mint tube at another.

    While not free, you can utilize this app with a one-time payment of $2.99, which is very affordable. You can likely find the information within this app elsewhere, but this app offers convenience and a pleasing aesthetic.

So there you have it – my Top 5 apps for ER Nurses. Have you used any of these apps in your ED? Are there any other apps that you use in the ER setting that you recommend? Comment below!

Welcome!

Will Kelly, MSN, FNP-C
Thank you for visiting my site! I help nurses and nurse practitioners improve their clinical knowledge by providing high-quality content to turn their nursing education into practical application!  Read More

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