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Advanced Physical Exam Maneuvers

Advanced Physical Exam Maneuvers

When becoming a nurse, we are taught how to assess our patients and perform a physical exam. We talk with them and make sure they are alert and oriented, we listen to their lungs and heart, check for leg swelling or redness, and are making sure there are no significant changes every shift. However, there are many advanced physical exam maneuvers that are not taught to us in nursing school.

This may be because these advanced physical exam maneuvers tend to guide diagnosis and “nurses don’t diagnose”. However, performing advanced physical exam techniques can help you recognize serious conditions in your patient, which you can notify the Provider about and improve patient outcomes.

Physical Exam

1. Extraocular Muscles

Extraocular Muscles (EOMs) are responsible for eye movement and are largely innervated by the third cranial nerve – the oculomotor cranial nerve, as well as the 4th and 6th cranial nerves. Intact EOMs suggests that those three cranial nerves are intact, but also is important in ruling out a central lesion such as a stroke or a mass – although a more thorough cranial nerve assessment is required.

When looking at the extremes of vision, sometimes nystagmus can occur. Nystagmus is defined as a fine rhythmic oscillation of the eyes. A few beats at the lateral gaze extremes can be normal,  but any excessive nystagmus, especially when the eyes or more centered, can suggest vertigo, seizure activity, Chiari malformation, stroke, or a mass.

Additionally, testing EOMs in your physical exam can be useful to test when evaluating for orbital cellulitis. Orbital cellulitis is an infection of the orbital structures and muscles. As you might expect, when the extraocular muscles are infected, they are inflamed and painful. This means testing of the EOMs often is painful, especially when looking in a certain direction. Painful EOMs in association with swelling or redness of the eye or surrounding area should prompt a CT of the orbits with contrast to rule out any orbital cellulitis. Orbital cellulitis often requires IV antibiotics, whereas periorbital cellulitis can usually be discharged home with PO antibiotics and close ophthalmology follow-up.

EOMs should be tested whenever there is any neurologic complaint (possible strokes, vertigo, seizures), or when you suspect periorbital or orbital cellulitis.

To test EOMs – hold out a finger or a pen approximately 2 feet away from the patient’s eyes. Ask them to follow your finger or object with their eyes only. Now move your finger/object in the six cardinal directions, making a large “H” in the air. To the right, upper right, lower right, then to the left, upper left, and lower left (see illustration).

An abnormal exam is when these movements are painful, when they cause dizziness, or when one or both eyes are unable to gaze in a specific direction. The latter can indicate a brain lesion such as a stroke, so this is a major physical exam finding that you don’t want to miss and is part of your NIH scale!

Be sure to check out my advanced cranial nerve assessment for more information on proper neurological assessments! Keep reading for more advanced physical assessments!

 

    2. Jugular Vein Distention

    Jugular vein distention, or JVD, is just that – when the jugular veins are bulging or distended. Pressure in the jugular veins indicates right atrial pressure, which can be helpful when evaluating patients with known or suspected heart failure, volume overload, or even pulmonary embolisms.

    Testing the Jugular venous pressure isn’t exactly easy, and sometimes a “gestalt” JVD is noted by healthcare providers. This can usually be noticed when the patients are in clear volume overload.

    JVD can be tested whenever you suspect a patient to have volume overload or increased right atrial pressures. This means whenever you suspect heart failure, volume overload in renal failure patients, or a pulmonary embolism.

    JVD can be “noticed” with a bulging external jugular vein when the patient is between 30 and 45 degrees semi-fowlers, with their head turned toward their left. You should be evaluating their right side as this is the most accurate indication of right atrial pressures. The higher they are sitting up while maintaining jugular venous distention, the higher the pressure is.

    If you want to get technical, you can also measure – but most of us don’t carry around a measuring device. I have never seen a non-specialty clinician actually perform this in real life. However, to officially test the jugular venous pressure, you want to elevate the head of the bed to approximately 30-45 degrees. Have the patient turn their head to the left. Identify the top of the venous pulsations of the external jugular vein, or preferably the internal jugular vein. You can not directly visualize the internal jugular vein, but should be able to see the pulsations. Use a pen to “draw” or visualize a horizontal line from the top of the pulsations to above the sternal angle. This is the notch where the sternum begins. Now measure how high this horizontal line is above the skin. Then add 5cm because the right atrium is approximately 5cm deep. The total is the patient’s estimated central venous pressure (CVP).

    Remember that normal CVP are 0-8 cm H2O. Anything higher is considered abnormal and could indicate the increased right atrial pressures.

    Hepatojugular Reflux

    The hepatojugular reflux (HJR) is an additional physical exam maneuver to help determine possible heart failure exacerbation or other conditions which could increase venous pressures. This is often performed if JVD is not obvious but clinical suspicion remains.

    To test the HJR, position the patient the same as JVD. Apply gentle pressure over the RUQ or mid-abdomen for 10-60 seconds, and watch for increased JVD. Normal patients should have a decrease in JVP (less distention) with this physical exam maneuver since it should decrease venous return. Those with fluid overload and heart failure will have an increase >3cm in measured JVP.

    Related article: “Interpreting Cardiac Labs”

     

      3. Murphy’s Sign

      Murphy’s sign is a physical maneuver to determine the possibility of cholecystitis or inflammation of the gallbladder. This can be a great physical exam test to aid in the clinical suspicion of acute cholecystitis (inflammation of the gallbladder).

      Murphy’s sign is tested when a patient presents with abdominal symptoms such as abdominal pain, nausea, or vomiting. You can also perform this physical exam maneuver if the patient has a fever of unknown etiology – especially in the elderly or those who may not be able to verbally express pain.

      To check for Murphy’s sign, place your fingers firmly in the patient’s right upper quadrant underneath the patient’s ribs, and ask the patient to take a deep breath. This is considered deep subcostal palpation, and on inspiration, the diaphragm pushes the gallbladder towards your palpating fingers, which should be painful if the gallbladder is inflamed.

      A positive’s Murphy sign is indicated when during inspiration, the patient has an acute increase in pain that will often cause them to stop inspiring mid-way through their breath. In true acute cholecystitis – this is often positive as Murphy’s sign as high sensitivity (97%) for acute cholecystitis, however, it is much less specific (48%) – this means that it could indicate other pathology within the liver or surrounding area.

       

        4. Costovertebral Angle Tenderness (CVAT)

        Costovertebral angle tenderess (CVAT or CVA tenderness) is a physical exam maneuver that is often used when evaluated potential kidney stones or other inflammatory renal pathology. The costovertebral angle is the angle “formed by the lower border of the 12th rib and the transverse process of the upper lumbar vertebrae.” Basically – On the back when the ribs end on each side – approximately where the kidneys lie. If there is a condition which has your kidney’s or surrounding structures inflamed and irritable, percussion over this area often causes acute worsening of pain.

        CVA tenderness should be checked whenever the clinician suspects a kidney stone or pyelonephritis. Often, this means the patient is presenting with flank pain, back pain, or some form of dysuria – whether painful urination, difficulty going, or even hematuria.

        To check for CVA tenderness – place one hand over their costovertebral angle on their back, and percuss with your other fist. You don’t want to be too forceful because if they do have a kidney stone – this can be very painful. However, you also want to make sure you are not percussing too lightly. Percuss a few times on each side.

        Positive CVA tenderness is when the patient reports pain with percussion. From my own experience – this is often very painful for those with acute kidney stones. However, I have also had plenty of patient’s with negative CVA tenderness who ended up having acute renal pathology including kidney stones.

         

          5. McBurney’s Sign

          Not to be confused with Murphy’s sign above, McBurney’s sign is an advanced physical exam maneuver to help raise suspicion for acute appendicitis.

          Mcburney’s point tenderness is when the patient’s most tender area is 1.5-2 inches from the anterior superior iliac spine in the direction of the umbilicus. Draw an imaginary line from the anterior superior iliac spine to the naval, and approximately 1/3 down the line closest to the the iliac spine is the “sweet spot”.

          If a patient has abdominal pain with this being their most tender spot, they should undergo further testing to rule out acute appendicitis. Mcburney’s sign is 50-94% sensitive, and 75-86% specific.

            McBurney's Sign for acute appendicitis

            As always, these advanced physical exam maneuvers should always be used with clinical judgment as part of a full history and physical exam. Hopefully these advanced physical maneuvers can help aid in your diagnosis. Nurses are constantly at the bedside, and knowing these physical exam maneuvers can help strengthen your physical assessment skills.

            Let me know if you found these helpful below in the comments!

            Be sure to also check out:

            Opioid Alternative Analgesics in the ER

            Opioid Alternative Analgesics in the ER

            Opioids are necessary in medicine – they provide essential pain relief for those experiencing both acute and chronic pain. From kidney stones to chronic back pain, opioids are often necessary to increase quality of life for those suffering from debilitating pain. However, opioid alternative analgesics should not be ignored, and there are often many valid reasons for starting with these non-opioid analgesics first, or even using them as adjuncts to minimize side effects and provide better overall relief.

            Why even consider opioid alternative analgesics in the first place?

            It’s no surprise to anyone working in healthcare that there are indeed those people who are classified as “drug seekers”, lying to medical providers so they can continue to score narcotics. Regardless, nurses and Providers should still provide pain relief as best they can without bias or judgment. We can only do our best to provide the best pain relief while still being cognizant of the potential for those to take advantage. However, healthcare workers should consider opioid alternatives in many more individuals than just potential “drug-seekers”.

            Opioids can provide great pain relief but also come with quite a few side effects. These include nausea and vomiting, sedation, respiratory depression, and even hypotension. These side effects tend to be more profound in the elderly, and delirium or confusion is common within the hospital. For chronic opioids, constipation can be a troublesome adverse effect. Oftentimes opioids may still be necessary, especially in acute conditions, but limiting the dose and frequency while supplementing non-opioid analgesics is a great way to reduce side effects while still providing adequate pain relief.

            OFIRMEV (IV TYLENOL)

            Ofirmev, or Acetaminophen, is your standard Tylenol but in IV form. Tylenol is one of the safest pain medications you can take – as long as you don’t overdose (trust me – Tylenol overdoses are NOT pretty). While Tylenol pills work decently, IV Tylenol anecdotally seems to work great for some people. The IV route ensures rapid action and onset of pain control. However, studies seem to be mixed on whether or not IV Tylenol provides superior pain control to PO Tylenol, and this systematic review suggests no clear indication for prescribing IV over PO – at least when the patient is able to tolerate oral. But even oral Tylenol is also a valid opioid alternative and has been shown to be effective for many types of pain – especially as an adjunct.

            Ofirmev does not have a generic brand as of yet, so it tends to be expensive. However, this is cheaper than it used to be. The cost of 1gm of Ofirmev (standard dose) is $57, while 1gm of PO Acetaminophen is less than $1 – so cost is still something to consider. For repeated dosing, if the patient can tolerate PO Tylenol – you should probably try that (or risk getting yelled at by your hospital pharmacist).

            KETOROLAC (IV/IM TORADOL)

            Ketorolac (Toradol) is a staple in the Emergency department. We often give it when we suspect musculoskeletal causes of pain, when the patient has an orthopedic injury or surgery, or if the patient has renal colic. Toradol can be given in both IM and IV routes. Common dosages are 60mg for IM, and 15-30mg for IV. This is an NSAID – basically the equivalent of IV ibuprofen, so those who are allergic to NSAIDs or those with GI bleeds or significant cardiac disease should probably get something else to be on the safe side. A common misunderstanding is that IV Toradol is safe to give for those with upper GI bleeds or Gastritis since its IV, but the action of Toradol still inhibits prostaglandin synthesis and can lead to stomach irritation and decreased renal perfusion.

            Interestingly enough, it’s possible IM Toradol hasn’t been shown to be more effective for pain control over PO ibuprofen in ER patients [6]. The IV route, however, does offer a more rapid onset of action. I personally think patients seem to think that IV or IM routes offer better relief, and if an IV is already being ordered why not try an IV dose. When used at appropriate doses, side effects from a one-time dose are rare. If present, they can cause dizziness, nausea, or headaches.

            Traditionally 30mg was used for IV dosing, however, this Randomized control trial indicates that IV doses at 10, 15, and 30mg all offered similar pain relief. I usually just order 15mg IV when using this med IV, especially to geriatric patients.

            LIDOCAINE

            Similar to Toradol, Lidocaine can be useful for both musculoskeletal and renal colic – just in different forms. Lidocaine topical patches are often used for musculoskeletal pain from a muscle strain or chronic back pain. A Cochrane meta-analysis indicated that there was “some indication that topical lidocaine offered benefit”, specifically for neuropathic pain, but the trials were poor. Even so, it is often used because of the high safety profile and the limited adverse reactions due to lack of significant systemic absorption.

            5% lidocaine patches should be placed on the most painful area and left for 12 hours. Up to 3 patches can be used at the same time if needed for a large area. When prescribing, brand Lidoderm patches can be expensive at approximately $24 per patch. Without insurance – this is clearly an issue as a 30 count is > $600. A cheaper option is to prescribe 4% lidocaine cream which is about $30 for a month’s supply.

            IV Lidocaine has traditionally been used as an antiarrhythmic for dangerous ventricular cardiac arrhythmias like VTACH or VFIB. However, IV lidocaine has also been shown to offer significant pain relief for various types of pain including neuropathic pain and renal colic [7],[2]. The normal dose is 1.5mg/kg (max 200mg) given slowly over 10 minutes. Cardiac monitoring should be applied during and for 30-60 minutes after the infusion. If given, it should probably be combined with IV Toradol for adjuvant therapy if able to tolerate it. Contraindications include:

            • Allergy to Lidocaine
            • History of seizures
            • Actively Pregnant
            • Hepatic or Renal Failure
            • Severe CAD, heart block, or arrhythmia

            If any serious reaction like seizures or cardiac arrhythmia does occur – intralipid emulsion therapy is the treatment, and this should be readily available in case it is needed – although side effects at the normal dose are rare, with mild transient dizziness being the most common.

            FLEXERIL

            Cyclobenzaprine (Flexeril) is another opioid alternative for musculoskeletal pain, specifically involving the muscles. If there is any type of muscle strain – Flexeril can help relax the muscles and offer some pain relief. This is usually not used alone, but in conjunction with Tylenol, or an NSAID like Ibuprofen/Naproxen. Flexeril should usually be used as a short-term treatment for muscle strains or back pain. Although overall safe, they do have some side effects including sedation, so the patient needs to be able to tolerate this effect and be sure not to drive or work under the influence of Flexeril. Be wary when combining with opioids as they can compound the sedation and risk respiratory depression (Narcan anyone?)

            Other Opioid Alternatives

            There are multiple other specific treatments for pain depending on the source. Reglan works directly on migraine-pain, Pyridium works for bladder pain from UTIs, and even low-dose Ketamine can be used for chronic and perioperative pain. There is also a multitude of non-pharmacologic pain management techniques including heat or cryotherapy, massage, acupuncture, or even guided imagery (never have I ever seen this be a valid option within the hospital).

            These opioid alternatives are not a reason not to give appropriate analgesia to patients in pain. Patients experience real and debilitating pain every day, and opioids are one of our tools to provide them with some relief and aid in their healing. Oftentimes non-narcotic analgesics can be great adjuncts to supplement opioids, or at least a reasonable first step prior to “stepping up” to meds like morphine, Dilaudid, or fentanyl. As always, use your clinical judgment and always advocate for your patients.

            References:

            1. Derry, S., & Moore, R. A. (2014). Topical lidocaine for neuropathic pain in adults. Cochrane Database of Systematic Reviewshttps://www.ncbi.nlm.nih.gov/pubmed/25058164
            2. Firouzian, A., Alipour, A., Rashidian Dezfouli, H., Zamani Kiasari, A., Gholipour Baradari, A., Emami Zeydi, A., Amini Ahidashti, H., Montazami, M., Hosseininejad, S. M., & Yazdani Kochuei, F. (2016). Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial. The American Journal of Emergency Medicine, 34(3), 443-448. https://www.ncbi.nlm.nih.gov/pubmed/26704774
            3. Jibril, F., Sharaby, S., Mohamed, A., & Wilby, K. J. (2015). Intravenous versus oral acetaminophen for pain: Systematic review of current evidence to support clinical decision-making. The Canadian Journal of Hospital Pharmacy, 68(3). https://www.ncbi.nlm.nih.gov/pubmed/26157186
            4. Knight, C. L., Deyo, R. A., Staiger, T. O., & Wipf, J. E. (2020). UpToDate. T. W. Post (Ed.). UpToDate. https://www.uptodate.com/contents/treatment-of-acute-low-back-pain
            5. Motov, S., Yasavolian, M., Likourezos, A., Pushkar, I., Hossain, R., Drapkin, J., Cohen, V., Filk, N., Smith, A., Huang, F., Rockoff, B., Homel, P., & Fromm, C. (2017). Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: A randomized controlled trial. Annals of Emergency Medicine, 70(2), 177-184. https://www.ncbi.nlm.nih.gov/pubmed/27993418
            6. Neighbor, M. L., & Puntillo, K. A. (1998). Intramuscular ketorolac vs oral ibuprofen in emergency department patients with acute pain. Academic Emergency Medicine5(2), 118-122. https://www.ncbi.nlm.nih.gov/pubmed/9492131
            7. Soleimanpour, H., Hassanzadeh, K., Vaezi, H., EJ Golzari, S., Esfanjani, R. M., & Soleimanpour, M. (2012). Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urology, 12(1). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3508963/

            UpToDate Drugs: Acetaminophen | Ketorolac | Lidocaine (systemic) | Flexeril

            How to Find Nursing Jobs

            How to Find Nursing Jobs

            [social_warfare]

            Finding nursing jobs can be stressful – especially finding the right nursing job. You’ve spent hours of effort and time in learning how to be in the nursing profession, but now you need to actually start working and making some money! Let’s be real – those loan payments are coming in 6 months! While finding nursing jobs is easier than other fields, it can still be difficult, especially in certain oversaturated areas. Below you’ll find 5 tips for finding nursing jobs.

            1. Job Search Engines

              Back in the day, they had to look at newspapers and rely on word-of-mouth to find job offers. Nowadays, thanks to the internet, there are multiple sites and apps to help you find nursing job offers in your area! Job search engines are an easy and quick way to scout your area of interest to see what kind of nursing jobs are available.

              Glassdoor and Indeed are two common job search engines where you can find nursing jobs pretty easily. My personal favorite is Glassdoor as it offers great information about the companies including employee reviews, interview information, benefits, and salary insights. However, it seems as though Indeed and Glassdoor share much of the same info regardless. Personally, I recommend using both sites while searching for prospective jobs.

              Search your desired job role “Registered Nurse”, “Nurse”, or “Nurse Practitioner”, and input your desired location. There are filters you can set up to narrow down your search including salary, distance radius, etc. However, I recommend NOT using the salary filter as Glassdoor’s salary estimator isn’t always accurate. You can favorite or save jobs which you are interested in.

              These sights also offer great insight into the company including employee reviews. Previous interview candidates can also say how the interview is structured, what types of questions were asked, and how their overall experience went.

              Additionally, you can get a good idea of what type of salary you can expect at the current role. To do a bit more research, you can go into the company and search for how much they pay other people who perform the same job as you in your specific location.

              There are also great apps for Glassdoor and Indeed for both Android and iOS.

              Related Content: “How Much Do Nurse Practitioners Make?”

            2. Website Job Postings

              One great way to find nursing jobs that weren’t posted to job search engines is to go to the hospital or health system’s website directly. Not every hospital or network will post their jobs on job search engines, so this is a great way to make sure you aren’t missing any great nursing job opportunities.

              You can find both inpatient and outpatient jobs using this format. In fact, this method is how I found my current job as an inpatient Nurse Practitioner.

              Go to the hospital or health networks website. Somewhere on the homepage, you should see a link that says “careers” or “jobs”. This may be at the top of the web page or in the footer at the bottom. It can sometimes be hard to find but 99% of the time it is there.

              If they are a small network, they may list all available jobs. Most sites will have some type of job search function where you can pick your role (i.e. RN or NP), and it will give all available jobs within their network. Click on the jobs you are qualified for and apply using the link provided.

              If you do not see any jobs for you, sometimes you can find the nursing recruiters email. If so, send a professional email letting them know your interest in working for their system, and attach an updated resume to the email.

            3. Nursing Jobs on LinkedIn

              If you didn’t know, LinkedIn is a social media for professionals to grow their professional network and even find jobs. LinkedIn is overall underutilized by the healthcare industry, especially by nurses. However, healthcare recruiters definitely use this platform, and if you are searching for nursing jobs this may be just the route for you!

              LinkedIn lets you create a professional profile that essentially functions as your digital resume. Once your profile is top-notch, LinkedIn has a job search function that lets you search for jobs much like Indeed or Glassdoor. You might find some nursing jobs on LinkedIn that aren’t posted elsewhere. For most of the jobs, you can apply directly using your LinkedIn profile alone. This makes the application process super easy and is why it is so imperative for you to start your LinkedIn now and start creating a great profile.

              Make sure you go into your settings and set “open to job opportunities”. Healthcare recruiters will literally find you and message you details of nursing jobs that they want you to fill.

              Overall LinkedIn is a great way to professionally connect with other healthcare providers as well. As with many things in life – landing your dream job may be all about who you know within your professional network.

              Follow me on LinkedIn here!

            4. Word of Mouth

              With the internet being so easy to use, sometimes we forget about the good ole faithful methods of finding a job. Word of mouth and can be a great way of finding nursing jobs that may not be posted online. Ask your professional connections within the healthcare industry if they know of any nursing job needs. Sometimes they may know of internal employment issues or upcoming vacancies. They may be a hiring manager or know a hiring manager, and can put in a good word for you. This can have a huge impact on your nursing job search process.

              Sometimes if no full-time positions are available, companies are willing to accept new per-diem applicants which helps them “test” your work before actually committing to hiring you full-time.

            5. Find Nursing Jobs In-Person

              Once again – don’t forget about non-internet methods of finding jobs. Going in-person to a hospital or clinic can help you secure a nursing job. Don’t underestimate the value of face-to-face interaction with a potential employer. Presenting yourself professionally and handing in your resume can help give them a great first impression of you that an internet application could never do. While this method is definitely not the norm nowadays, it can definitely be effective.

              Again, make sure you look professional, are best-dressed, are polite, and smile! You never know who you will be making an impression on or who will go to bat for you. Try to make connections with people at your desired working location and see what comes of it.

              This method may work better for smaller places of employment such as outpatient clinics or urgent care centers.

             

            Hopefully, you found these tips useful in your nursing job search. If you like professional development articles like this – let me know in the comments below. If there are other useful methods of finding nursing jobs – let us know!

             

            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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            The Cranial Nerve Assessment for Nurses

            The Cranial Nerve Assessment for Nurses

            The cranial nerve assessment is an important part of the neurologic exam, as cranial nerves can often correlate with serious neurologic pathology. This is important for nurses, nurse practitioners, and other medical professionals to know how to test cranial nerves and what cranial nerve assessment abnormalities may indicate. This becomes especially important when evaluating potential new strokes.

            In school, cranial nerves tend to be something you memorize and then forget the day after the test. But they are important in testing a patient’s neurologic status, as an abnormality in a cranial nerve can indicate a central lesion (stroke, tumor, bleed, etc).

            Every nurse should at the least know how to do a basic cranial nerve assessment, specifically the visual acuity and pupillary light reflex. When evaluating a stroke, The NIH scale is a method to evaluate the severity of a stroke. This scale walks you through evaluating many of the cranial nerves, but not all of them. If you want to feel confident when you chart “Cranial nerves II-XII grossly intact”, then keep reading!

            1. The Olfactory Nerve (CNI)

            The olfactory nerve is responsible for the sense of smell. Although rarely tested in practice, alterations in smell can be caused by serious intracranial pathology (brain tumors, strokes, TBI), neurodegenerative diseases like Alzheimer’s, Parkinson’s, or MS, or benign and transient causes such as the common cold.

            If both branches of the olfactory nerve are damaged, this can lead to permanent anosmia (loss of smell) and can lead to food tasting bland and decreased appetite. In most individuals, the sense of smell decreases over time, with up to 75% of individuals older than 80 have some degree of anosmia.

             How to test the Olfactory Nerve

            The olfactory nerve is almost never tested within an acute care setting such as in the hospital. However, this is sometimes tested in outpatient neurology offices. To test the olfactory nerve, blindfold the patient and have them smell and identify common scents such as vanilla, cinnamon, coffee, or peppermint while covering up one nostril at a time. Do not use ammonia or alcohol as these can trigger intranasal trigeminal nerve receptors and bypass the olfactory nerve.

            2. The Optic Nerve (CNII)

            The optic nerve is the second of the cranial nerves and is responsible for vision. This nerve transmits signals perceived in the retina and cones of the retina to the occipital lobe. This is commonly tested within the clinical setting and for a variety of presentations.

            Partial or complete loss of vision can be caused by conditions such as:

            • Diabetes
            • Intracranial pathology (ischemia, stroke, tumors)
            • Inflammation or infection of the eye
            • Toxicity

            How to test the Optic Nerve

            When testing the optic nerve, you need to examine the visual fields, the visual acuity, and the pupillary light reflex. All three are an important part of the cranial nerve assessment, although the pupillary light reflex involves cranial nerve 3 as well.

            Testing the Visual Fields (II)

            If the patient loses part of their vision on one side, it is termed partial hemianopia, and if they lose complete vision on one side it is complete hemianopia. There are a few different ways to test visual fields, but here is an easy way. Stand one arm length away from the patient and ask them to cover up one eye or do it for them if they are unable. Close your own eye on the same side. Now hold up numbers with your fingers at each of the four corners of their vision. Once satisfied, test the other eye.

            Testing the Visual Acuity (II)

            Nurses often assess visual acuity, and most emergency departments will have a Snellen eye chart to use. The distance the patient stands depends on the visual acuity chart (it should say). If you do not have easy access to this, there is an app you can get on your phone which is super helpful!

            Have the patient stand the appropriate distance away and have them cover up one eye. Do not have them forcibly close the eye as this can somewhat inhibit their ability to see out of their open eye. Ask the patient to read the 20/20 line on the chart. On a standard Snellen eye chart, this would be 20 feet away. If the patient gets more than half wrong, move onto the line above. Stop once the patient gets over 50% right. Mark this down and test the other eye. If they wear glasses – have them wear their glasses for this as well!

            Pupillary Light Reflex (II, III)

            The pupillary light reflex tests both cranial nerves II and III. First, inspect both pupils and make sure they are equal in size and shape. Then dim the lights if possible and shine a penlight directly into the right eye. Both pupils should constrict and maintain symmetry. Note if they are brisk or sluggish and if they are symmetric. Remove the light source and watch both eyes dilate equally as well. Do the same for the left eye.

            3. The Oculomotor Nerve (CNIII)

            The oculomotor nerve controls the majority of the extraocular muscles. It is primarily responsible for eye movement, eyelid movement, and pupillary constriction. If there is any oculomotor nerve impairment, there will be a pupillary dilation, ptosis (drooping eyelid), and outward deviation of the eye – termed abduction. When a patient has diplopia (double vision), it is often due to a unilateral lesion on this cranial nerve. In most cases, third nerve palsy resolves over weeks to months.

            Causes of oculomotor nerve palsy include:

            • Intracranial aneurysm
            • Microvascular ischemia (in diabetics especially)
            • Trauma: Severe blows to head with skull fracture

            Testing Extraocular Muscles (III, IV, VI)

            To test the oculomotor nerve, you need to assess the EOMs. Testing the EOMs also tests cranial nerves IV and VI, as all three nerves are responsible for eye movement.

            Hold your finger or a pen 2 feet in front of the patient’s eyes midline and have the patient focus on it with both eyes. Ask the patient to follow your finger or pen with only their eyes, moving the pen to the right, back to the midline, and then to the left and back again. Do this again for up and down. Lastly, do this again to the down-left diagonal angle, and then the down-right diagonal angle. You should have tested a total of 6 different directions – termed the “6 cardinal directions”.

            Eye movement should be symmetric, smooth, and moving in all directions. At each extremity of vision, you should be observing excessive nystagmus. Nystagmus is repetitive uncontrolled eye movement.

            Conjugate nerve palsy is when both eyes are unable to look in a specific direction during your testing. This most commonly occurs in the horizontal directions. This is usually due to a stroke within or near the brain stem.

            The pupillary light reflex listed above is also used to assess the oculomotor nerve.

            4. CN IV: The Trochlear Nerve

            The fourth cranial nerve, the trochlear nerve, innervates the superior oblique muscle of the eyes. This means it controls the downward movement of the eyeball and prevents it from rolling upward. When there is a fourth nerve palsy, patients will often complain of vertical diplopia and/or tilting of objects. This may be most noticeable when in a downward gaze such as when going down the stairs. They may also have a head tilt, as the visual changes improve with tilting of the head. On exam, the eye will with deviated upward and rotated outward.

            Testing the trochlear nerve involves evaluating the patient’s extra-ocular movements as described above.

            5. CN V: The Trigeminal Nerve

            The Trigeminal nerve is the 5th cranial nerve and responsible for facial sensation, as well as moving the muscles involved with biting and chewing. This has three branches including the ophthalmic V1, maxillary V2, and Mandibular V3. Compression of this nerve root can cause trigeminal neuralgia – a rare but painful condition.

            How to test the Trigeminal Nerve

            To test the trigeminal nerve, you are testing their facial sensation. Lightly touch both sides of the forehead and ask if they felt the same. Do this on the cheek, and then the chin. If the patient is uncooperative, you can test their corneal reflex. Do this by having the patient look right, then touch their left cornea with a whisp of cotton. They should blink. Do this on both sides.

            6. CN VI: The Abducens Nerve

            The sixth cranial nerve, the abducents nerve innervates the lateral rectus muscle of the eye. This means its responsible for outward movement of the eyes. Patients with dysfunction of this nerve will be unable to outwardly move their eyes. This causes horizontal diplopia, where the double images are side-by-side, which is worse at far distances.

            This nerve is often the first nerve compressed when there is any increased intracranial pressure (ICP). However, more common causes include vascular disease (diabetes, hypertension, atherosclerosis) or trauma.

            To test the abducents nerve, test the EOMs as described above.

            7. CN VII: The Facial Nerve

            Cranial nerve VII is the facial nerve, which controls the muscles of facial expression, as well as the sensation of taste of the front of the tongue. Facial nerve palsy can occur for various reasons, the most common being Bell’s palsy. Some other common causes include stroke, Lymes disease, trauma, or even diabetes.

            How to test the Facial Nerve

            To test the facial nerve, you must assess the patient’s facial expressions. Have the patient close their eyes tightly, then have them open their eyes. Ask them to frown, looking for symmetry in the forehead muscles. Have them smile and look for any drooping or asymmetry.

            Clinical Tip: To differentiate Bell’s palsy from stroke, assess the patient’s use of their forehead muscles. Peripheral nerve lesions (such as with Bell’s palsy) cause paresis of the entire side of the face. Central lesions tend to only effect the lower portion of the face. This is not always the case though, so you must use clinical judgement. Bell’s palsy should have no other associated neuro deficits. Check out my Infographic for more information!

            8. CN VIII: The Vestibulocochlear Nerve

            The vestibulocochlear nerve, also called the auditory vestibular nerve, is responsible for hearing and balance. Vestibular neuritis is when the nerve becomes inflamed and can cause vertigo, dizziness, and balancing difficulties – most likely from a viral infection.

            How to test the Vestibulocochlear Nerve

            While not routinely tested within the hospital, the vestibulocochlear nerve involves testing both hearing and balance. Hearing is tested by holding your fingers a few inches away from their ears and rubbing them together. If they can hear, then that is a pass. Test their balance by assessing their gait while walking. The presence of nystagmus can also indicate vestibular dysfunction.

            9. CN IX: The Glossopharyngeal Nerve

            The glossopharyngeal nerve is partially responsible for the sensation of taste, pharyngeal sensation, as well as for the gag reflex. A damaged glossopharyngeal nerve can cause a loss of taste in part of the tongue and cause trouble swallowing.

            How to test the Glossopharyngeal Nerve

            Palatal Movement (IX, X)

            Instead of doing the gag reflex which can be very uncomfortable for patients, you can instead assess palatal movement. Do this by having the patient yawn or say “ahh”, and observe their palate movement for symmetry. If this is abnormal, consider testing the gag reflex.

            Gag Reflex (IX, X)

            When performing the cranial nerve assessment, the easiest way to test the glossopharyngeal nerve is to test their gag reflex, however, this is usually not necessary in the clinical setting. Remember that approximately 20% of people will not have a gag reflex at baseline. Check both sides of the pharyngeal wall by gently poking the pharynx with a cotton swab.

            Dysarthria (IX, X, XII)

            There is no specific test for this but listen to the patient’s speech. Assess for any slurred speech or abnormality of the voice. Ask the patient or the family if it sounds different than normal.

            10. CN X: The Vagus Nerve

            The Vagus nerve innervates the hearts, lungs, and digestive tract, along with a few muscles. Most noticeably, it controls the heart rate, GI motility, sweating, and speech. It is also partially responsible for the gag reflex (along with cranial nerve IX).

            Overstimulation of the vagal nerve can drop the heart rate and cause syncope, termed vasovagal syncope. Activities that stimulate the vagal nerve include bearing down, holding breath, carotid massage, or extreme fear or stress.

            There are even implantable vagus nerve stimulators that can help slow down the firing of neurons within the brain and thus help manage seizures.

            How to test the Vagus Nerve

            The only real way to test the vagus nerve is via the gag reflex as described above.

            11. CN XI: The Accessory Nerve

            The accessory nerve innervates the sternocleidomastoid and trapezius muscles. This means it is responsible for tilting/rotating the head as well as shrugging the shoulders. This nerve can be damaged after neck surgery or blunt force trauma.

            How to test the Accessory Nerve

            To test the trapezius muscle, ask the patient to shrug both of their shoulders at the same time. Then apply some downward pressure with both hands and ask them to shrug both shoulders against the resistance.

            To test the sternocleidomastoid, place a hand against their cheek and ask them to rotate their head against resistance in each direction. If you notice weakness, this indicates the opposite side is the weaker muscle.

            12. CN XII: The Hypoglossal Nerve

            The hypoglossal nerve controls most of the movement of the tongue. This means it is highly responsible for speech and swallowing. Damage to the hypoglossal nerve is rare, but if so are likely to be caused by tumors or gunshot wounds. Other causes include stroke or neurodegenerative disease.

            How to test the Hypoglossal Nerve

            To test the hypoglossal nerve, ask the patient to stick out their tongue. If the tongue deviates to one side, this indicates hypoglossal nerve dysfunction on the side of deviation. Then ask them to move their tongue from side to side rapidly. Additionally, listen for dysarthria when the patient is speaking as described above.

            Cranial Nerve Assessment Cheat sheetCranial Nerve Assessment Cheat Sheet

            How’s that for a refresher?  Although we may have forgotten some of the in’s and out’s of the cranial nerve assessment, this should serve as a reminder for how to examine cranial nerves. Hopefully, after reading this, you can feel more confident in your neurologic assessment!

            If you need an easy cranial nerve assessment handout, you can download my handout here! This is the perfect cheat-sheet that you can refer to in practice when assessing cranial nerves!

            References:

            Gelb, D. (2019). The detailed neurologic examination in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/the-detailed-neurologic-examination-in-adults

            Lee, A. G. (2019). Third cranial nerve (oculomotor nerve) palsy in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/third-cranial-nerve-oculomotor-nerve-palsy-in-adults

            Lee, A. G. (2019). Fourth cranial nerve (trochlear nerve) palsy. In UpToDate. Retrieved from https://www.uptodate.com/contents/fourth-cranial-nerve-trochlear-nerve-palsy

            Mullen, M. T. (2014). Differentiating Facial Weakness Caused by Bell’s Palsy vs. Acute Stroke. Journal of Emergency Medical Services39(5). Retrieved from https://www.jems.com/2014/05/07/differentiating-facial-weakness-caused-b

            Oculomotor Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/neuroscience/oculomotor-nerve

            Olfactory Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/neuroscience/olfactory-nerve

            Rea, P. (2014). Clinical Anatomy of the Cranial Nerves. Cambridge, MA: Academic Press.

            Trigeminal Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/trigeminal-nerve

            9 Nursing Medication Errors that KILL

            9 Nursing Medication Errors that KILL

            Did you know that Medication errors are the 3rd leading cause of death in the United States – right behind heart disease and cancer? Med errors account for more than 250,000 US deaths every year. Medications save lives every day, but unfortunately, these same medications can also hurt our patients if given inappropriately. Now, most nursing medication errors don’t actually kill our patients, but they do increase morbidity, increase hospital admissions and length of stay, as well as decrease the quality of life of our patients. As nurses administer almost all of the medications within the hospital, this means that nurses are on the front lines and will be responsible for causing or preventing these nursing medication errors from occurring. While nurses are not the ordering physician, it takes a team of nurses, doctors, pharmacists, and patients to decrease these med errors from occurring.

            1. Nitro Paste

            There’s a reason that Nitropaste only seems to be good for one thing… causing headaches! I’ve found that Nitropaste doesn’t work well oftentimes due to medication errors in administration! If you’re anything like I was as a new grad – you may have been taught to squirt put a thin line of nitro-paste to the ½ inch or 1-inch mark (whichever was ordered by the physician). This usually leaves a good amount of paste leftover in the Nitrobid individual packet. What some nurses fail to realize is that this is incorrect dosing! Each individual packet of nitrobid 2% is usually preloaded (pun intended) with 1 gram or about 1 square inch of ointment. So if the provider orders ½ inch, squirt out half the packet on the application paper, or squirt the whole thing out if 1 inch is ordered.

             

            Now you might be saying “OK, but underdosing of Nitropaste isn’t exactly killing my patient”. But you see – it can! Nitroglycerin is a SUPER important medication when treating acute coronary syndrome. If the patient has an acute coronary artery blockage (or similar pathology), nitroglycerin can quite literally dilate those arteries, improve blood flow around the obstruction, and can lead to saved cardiac tissue and potentially also saving a patient’s life! It is also very helpful for decreasing preload and afterload in your acute decompensated heart failure patients – so it is important to make sure the patient is receiving the correct dose!

            2. Ceftriaxone and Lactated Ringer’s

            Intravenous medication drips are very common within the hospital – especially IV fluids, antibiotics, and even critical drips within the ICU. Oftentimes our patients will have IV fluids running as primary, and they may also have secondary IV pushes or IV antibiotics. This really isn’t an issue with Normal Saline, as just about every drug is compatible with NSS. However, sometimes Lactated Ringer’s (LR) or another fluid is ordered instead. With LR, you want to avoid giving IV Ceftriaxone (Rocephin), as this may cause precipitates from forming which can harm the patient. This is because there is calcium within the LR, and Ceftriaxone + Calcium = bad! These precipitates can theoretically cause damage to your kidneys, lungs, or gallbladder.

             

            This may not be a HUGE issue on the floors, since pharmacy often sends IV antibiotics to the floor and may caution the nurse not to run the ceftriaxone secondary to the LR. However, in the ED – they sometimes mix their own antibiotics and hang it secondary to whatever fluid is running. If this is LR – this can lead to issues as above. This is just another example of how ER nurses need to be hypervigilant about preventing medication errors like this from occurring – while simultaneously managing life-threatening emergencies of their patients.

            3. Paralytic Before Sedation

            Rapid Sequence Intubation (RSI) is the term used to define the methods taken to intubate a patient who is not unresponsive (yet!). Considering we’re about to stick a tube down their trachea and breathe for them – this requires sedation! To prevent the body from fighting against the intubation, this requires medication to paralyze them – a paralytic. During RSI, there is a specific sequence that must be followed.
            In the ER or wherever the patient is being intubated, you must ALWAYS GIVE SEDATION BEFORE THE PARALYTIC. Why you ask? Well.. isn’t it obvious? If you paralyze someone before knocking them out – they are going to be TERRIFIED. They won’t be able to breathe or move, and will be cognizant of it… So no – this won’t kill the patient, but this nursing medication error will make the whole process much more traumatic, and the patient may remember the whole thing when they wake up.
            Common IV sedatives (Induction agents) include: etomidate, midazolam, ketamine, fentanyl, propofol, thiopental
            Common IV paralytics include: succinylcholine, rocuronium, vecuronium

            4. IV Insulin

            It doesn’t take long working as a nurse to realize how COMMON diabetes is in hospitalized patients. This is because uncontrolled diabetes eats away at basically every body system that you have. Your kidneys fail, your nerves are destroyed, your eyes go bad, and your arteries clog up! Diabetics often come in for Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycemic State (HHS), or a patient may just need IV insulin for hyperkalemia (to push the K+ back into the cells). IV insulin may be ordered for your patients with these conditions.
             
            Insulin is usually given in a subcutaneous manner, so some nurses may not be used to giving it IV. Those SubQ insulin needles don’t hook up to a needleless IV system – so what do you do? Some facilities have special adapters, but honestly, the EASIEST way to do this is to draw the insulin up in your normal Subcutaneous syringe anyway. This will usually be 5-10 units. VERIFY this dose with other nurses – most facilities will require this. Then take a sterile NS flush, squirt half out, pull back on the syringe to make room, and squirt the insulin into the syringe. Essentially you’ve just diluted the insulin with ~5mL of saline. Now don’t set down the syringe – label it per facility protocol and give it to the patient the same way as any other IV push medication.
            This may seem simple to some, but many nurses draw up the insulin in a regular 3mL syringe. I’ve seen nursing medication errors occur, and sometimes the patients are given up to 10x the ordered dose. This obviously leads to hypoglycemia and a need for close monitoring. Worst case – this med error can lead to death, and there have been accidental deaths due to insulin overdoses.
             
            As a side note, when verifying ANY high-risk medication, make sure you look at the syringe AND the vial. I once had a nurse ask me to verify their 1mL (5,000u) subQ heparin dose. Turns out she had actually drawn up 1mL of INSULIN LISPRO! That’s 100 units! MUCH higher than most can tolerate. This med error was avoided by being diligent about verifying both the syringe amount and the vial.

            5. Sound Alike – Look Alike

            You may have heard about this in the news, but a nurse in Tennessee had accidentally killed a patient when she administered VECURONIUM instead of VERSED. This was apparently ordered to calm the patient down at MRI, so the nurse grabbed it out of the accu-dose, had overridden the medication, and administered the paralytic to the patient at CT. Now – there are MANY nursing errors in this scenario, so let’s talk about them.

            Overriding the Accudose system

            This is usually a major no-no on the floors, but I can tell you from firsthand experience, working in the ED, it is often done for many medications like Pain meds, Zofran, etc. In the ED, they don’t always have the luxury of waiting for the pharmacy to verify medications, and some systems won’t even have the pharmacist verify ED physician orders. If you absolutely HAVE to override, make sure you are hypervigilant about which medication you are pulling out, reconstituting, etc. If you are unsure of a medication – ASK for help! You shouldn’t be giving a medication that you don’t know about anyway. Always know the intended use, appropriate dosing, and potential side effects to monitor for! There are many sound-alike-look-alike drugs, and it can be common to make these nursing med errors if you aren’t careful!

            Appropriate Monitoring

            Monitoring the patient is an essential aspect of appropriate nursing management. As nurses, you are at the bedside and will be the first ones to notice a change in a patient’s status. Monitoring is especially important after the administration of ANY IV medication, but especially high-risk meds like IV narcotics or sedatives. The nurse, in this case, was going to give IV versed to a patient at MRI. This patient was NOT hooked up to the monitor, the nurse had injected the medication and reportedly left back to the ER. If you are giving IV versed, you should always have your patient on a monitor – at the least a pulse ox machine. Because she had given VECURONIUM instead of versed, her patient was paralyzed and couldn’t breathe – causing her suffocation in the MRI machine. Appropriate monitoring of the patient, even after administering the wrong medication, would have saved their life.

            6. IV Haldol

            Speaking of monitoring, it is also necessary to have cardiac monitor during and after administration of certain medications. This is because some medications can cause arrhythmias, and you want to be able to immediately identify them and recognize the need for rapid action.

             

            Haldol is a medication that I often see being administered IV due to agitation or dementia. Unfortunately, this medication is high-risk for cardiac arrhythmias by increasing QT, predisposing the patient to PVCs, VTACH, Torsades, and even VFIB. It also is worth noting that Haldol is technically to be avoided in cases of dementia-related agitation due to an increased risk of sudden death. While our options are limited and Haldol may still need to be given, appropriate measures including cardiac monitoring should be used – at least when given IV.

            7. IV Push Not IV Slam

            Giving IV push medications is commonplace within the hospital. Usually, these are medications like Zofran, IV narcotics, Toradol, and Lasix (among many others). Nurses can be busy, so this can tempt us to quickly give the medication and move on to the next task. However, sometimes medications that are given too fast can cause unpleasant side effects for the patient, some even disastrous.

            Dilaudid

            Dilaudid (hydromorphone) is a common IV narcotic given for pain. This is the “heavy hitter” that providers can order for pain, and is approximately 7 times stronger than morphine. Ideally, Dilaudid should be given over 2-3 minutes, as administering Dilaudid more rapidly has been associated with increased side effects, specifically respiratory depression and hypotension. This is true for other IV narcotics as well (morphine and fentanyl). As a quick tip, many nurses will dilute the Dilaudid in a 50ml bag and run it over 15 minutes. Just be aware that a small amount of this medication will be wasted within the tubing itself.

            Reglan

            IV Reglan (metoclopramide) can be given IVP in doses ≤ 10mg undiluted over 1-2 minutes. If pushed too fast, this can cause an intense but short-lived feeling of anxiety and restlessness, followed by a period of drowsiness. A small dose of Benadryl is often ordered to treat the restlessness, but note this will increase the drowsiness experienced afterward. Be on the lookout for true dystonic reactions, characterized by involuntary contractions of the muscle of the body.

            Cardiac Meds

            Cardiac medications like Lopressor (metoprolol) and Cardizem (diltiazem) should be pushed slowly in order to prevent adverse events from occurring. Typically these include bradycardia and/or hypotension. Lopressor should be pushed over 2-5 minutes and Cardizem over 2 minutes.

            Dexamethasone

            Doses 4-10mg are often given undiluted over <1 minute. However, rapid administration is associated with perineal irritation. Patients will tell you “my crotch is on fire!”. This can even happen with slow administration, so warn the patient that this is a possible side effect, is short-lived, and will go away on its own. Its recommended to dilute it in a 50ml bag and run it over 5-15 minutes to minimize this occurrence.

            8. Proper IM Location

            OK – so not quite a medication error, but hear me out. When I was a nurse I was taught to inject most IM medications >1mL in the butt. However, where I was injecting in the butt wasn’t really specified. Many nurses just shoot for the middle of the buttock (dorsogluteal), but this can actually cause all sorts of injury to the patient. This can lead to skin and tissue trauma, muscle fibrosis and contracture, hematoma, nerve palsy, paralysis, and infection. Instead, these medications should be given in the ventrogluteal site (google it!).

            The Deltoid muscle is an easy location for all injections 1-2mL in most adults. However, even 1 mL can be very painful in the deltoid depending on the patient. This is also not a recommended site if giving repeat injections, as the surface area of the muscle is not very high.

            An important fact to know about intramuscular injections is that the vastus lateralis (the side of the thigh) actually offers the quickest absorption. This means that if you have a patient come in for a severe anaphylactic reaction – your best bet is to inject the epinephrine in the thigh as opposed to the arm.

            9. Broad Before Narrow

            Again – not really a medication error, but more of a nursing administration error. Antibiotics are given ALL the time within the hospital. Many times, patients are septic and need immediate treatment including multiple IV antibiotics. Some antibiotics have a very broad spectrum – meaning they kill all sorts of bacteria. Others have a narrow spectrum, meaning they kill fewer bugs. You always want to make sure to hang the broad-spectrum antibiotic first. This ensures that the antibiotic most-likely to help will be given first.

            One common mistake is nurses think Vancomycin is broad-spectrum because it is a “heavy hitter”, but Vancomycin is actually narrow! Vancomycin only covers gram-positive organisms! This means unless the bacteria is actually MRSA or another Gram-positive infection, Vancomycin is less likely to help. PLUS it takes a while to infuse anyway. The best decision in sepsis is to hang the broad-spectrum antibiotic first. Common examples of broad-spectrum antibiotics include:

            • Ceftriaxone (Rocephin)
            • Cefepime
            • Pipericillin-Tazobactam (Zosyn)
            • Imipenem
            • Ampicillin

            And there you have it! With great power comes great responsibility. Nurses are responsible for administering life-saving medications, but these medications can also hurt if given inappropriately. We must be vigilant in avoiding nursing medication errors and improve our patient-outcomes.

            Do you have any other nursing medication errors to avoid? Let me know in the comments below!

            5 Questions to Ask Before Calling the Doctor

            5 Questions to Ask Before Calling the Doctor

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

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

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

            1. Is the Patient Stable?

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

            Physical Assessment

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

            Vital Signs

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

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

            Related content:

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

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

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

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

            3. Are there any PRN orders?

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

            Some frequent PRN medications are as follows:

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

            Other Frequent PRN orders include:

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

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

            Also check out my Nursing Medical Abbreviations graphic!

            4. Can I phone a friend?

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

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

            5. Am I calling the right person?

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

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

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

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

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