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These 8 COVID Nursing Tips could save your life

These 8 COVID Nursing Tips could save your life

This post may contain affiliate links, which means I get a commission if you decide to purchase through my links, at no cost to you. Please read affiliate disclosure for more information

Whether we want to admit it or not, the COVID19 pandemic is not ending anytime soon. Even with the vaccines coming soon, there is still be months of hard work ahead of us. Using these COVID nursing tips might be able to help!

As nurses, COVID can be exhausting and even somewhat demoralizing. I have felt plenty of burn-out since this all began, and nurses across the nation can relate.

In this article, I will list some COVID nursing tips for ER and inpatient nurses – to help you get through your shift safely!

Covid Nursing Tips Featured Image

1. Minimize Contact

This is easier said than done – but minimize your contact with patients who have symptoms consistent with COVID. If you need a refresher, common symptoms of COVID include:

  • Fevers
  • Cough
  • SOB
  • Body aches and Headache
  • Nausea and Vomiting
  • Loss of taste/smell

As an NP, this is actually fairly doable. I can conduct my history at 3-6 feet away, and perform a very limited physical assessment, often without even touching the patient. Sounds terrible, but the safety of healthcare workers is essential.

Bedside nurses are much more hands-on. What I’m going to say might be controversial, but you do not need to listen to every patient with lung sounds. We are going to get a chest X-ray anyway. Minimize contact, minimize exposure, and minimize your risk as best possible.

Patients with COVID often have normal or somewhat diminished lung sounds. Knowing this does not change management. When I do listen to lung sounds, they are patients with asthma, COPD, or CHF, because I’m specifically looking for wheezes or rales.

Make sure you get everything you need before garbing up and entering the room. Bring with your IV equipment and blood tubes, vital sign hookups if not already in the room, any medications already ordered, a COVID nasopharyngeal swab, etc.

If the patient may be discharged and an ambulatory pulse ox might be ordered – might as well get them up and walk them around the room while recording their SPO2. This is using your nursing judgment to anticipate orders. Let’s face it – not all Providers are great about putting in every order at the same time (guilty!).

2. Reduce, Reuse, Recycle (Your N95)

Don’t take your N95 for granted, because they’re running out! At least, that was the worry when this pandemic started and is definitely a possibility if infections and hospitalizations continue as they have been in the US.

However, we can’t afford to be wasteful. Before COVID, we would use an N95 like a surgical mask – apply it when taking airborne precautions, and removing it upon leaving the room. This life of luxury is no more.

Many hospitals have decontamination protocols for N95s – where they decontaminate them in some capacity. However, not every hospital will do this. If needed, there are multiple ways that you can decontaminate your N95 yourself using the following COVID nursing tips.

Bake It

Covid Nursing Tips bake itNo, really – throw that N95 in the oven! Baking with dry heat at 75° C (167° F) for 30 minutes effectively kills Sars-COV-2. Researchers at Stanford found that this can be done for 20 cycles without significantly reducing the filtration efficiency. Other studies indicated that only 2 cycles proved safe.

Hang the N95 from the oven rack with a wooden paperclip, or place an oven-safe fabric on a metal sheet. Do not place the N95 directly on the metal as this can overheat the mask.

Rotation Schedule

COVID has been found to survive on hard surfaces for 48 hours, plastic for 72 hours, and cardboard for 24 hours. While scientists aren’t 100% sure on the specifics of covid spread via surfaces, they do know that COVID doesn’t spread much through touch.

An alternative method to decontaminating your N95 is to leave it in a safe, warm, dry area and allow it to “air-dry” for 3-4 days. Placing it in a paper bag may be useful for this. This will kill the coronavirus without degrading the filter.

If you have three or four N95s, you can start a rotation cycle and effectively never run out of N95s.

Please note this does not appear to be a well-studied decontamination procedure and is solely based on theory.

Covid Nursing Tips recycle n95

Other methods

There are other methods to decontaminate your N95, including moist heat, UV radiation exposure, boiling, and even steaming. These all kill COVID but degrade the N95 at varying rates, and are likely more difficult to perform while at home.

If the idea of having to decontaminate and then reuse your N95 does not fit your desires – you can always skip this COVID nursing tip and buy a reusable N95 Device.

3. Buy a Reusable N95 device

They do make reusable N95 devices which are somewhat affordable and probably worth it.

Using a reusable N95 is more comfortable, less of a hassle, and can leave you feeling more protected.

Envo Mask is all the rage in my ER, and for good reason. This reusable N95 is comfortable and won’t fog your goggles. There are replaceable filters that you use, making this usable forever (but hopefully COVID won’t last forever too).

You can also buy a respirator, which can be cheaper depending on which one you get. If you do, you need to make sure you buy the appropriate filter though, as many of these respirators were intended to be used for occupational exposure. The 2091 filter is recommended by the CDC.

Please be aware it can be somewhat difficult to speak to people with a respirator on, as they can have a hard time hearing. This can be especially difficult over the phone.

Covid Nursing Tips Different Masks

4. Protego Skin!

Covid Nursing Tips skin breakdown exampleWe’ve all seen those horrid photos of nurses who worked 12+ hours in an n95 mask, with deep facial markings to prove it. Many of us have experienced this firsthand.

You shouldn’t only worry about your patient’s skin breakdown. Wearing an N95 for 12 hours straight can cause your own skin-breakdown, and it can be very irritating, painful, and eventually lead to open wounds. There are a few different COVID nursing tips regarding your skin protection that can help!

Take Breaks

To minimize skin breakdown, frequent removal of the N95 is recommended. However, with the COVID pandemic among us – that is not always feasible.

If able to safely remove your N95, the recommendation is to take a 15-minute break every 2 hours. For the vast majority of us, this just won’t work.

Skin Protectant

Probably one of the safest options, you can apply a liquid skin protectant onto your skin. Once applied and allowed to dry, this creates a protective barrier that minimizes moisture and friction.

Any skin protectant should work, and skin repair creams with dimethicone can also be effective. Apply it over the areas where the N95 will cause the most skin breakdown (nasal bridge, cheeks, behind ears). Avoid getting the product in your eyes or mouth.Covid Nursing Tips Skin Prep locations

Good skin protectants to use:

Make sure to always allow the product to fully dry before applying your N95.

Protective Dressing

If skin protectant doesn’t do the trick – you can try a protective dressing.

The issue with protective dressings is they can alter the fit of the N95. Unfortunately, that could mean catching COVID. This is why skin protectant is a safer option. Still – if your skin really needs it – you can likely put a protective dressing in a safe manner.

Cut a thin dressing into small pieces, and apply a thin layer to the nasal bridge, the cheekbones, and behind the ears.

You should use a foam dressing that has a non-permeable outer layer, so any hydrocolloid dressing should work well. A good example is the Duoderm Hydrocolloid Dressing.

You should attempt to confirm the N95 fit by blowing out and seeing if there are any leaks. Definitive fit testing can also be done and is more accurate, although may not be feasible on the unit.

5. Surgical Mask Woes

Even with using our N95s, we are still recommended to be using a surgical mask on top of that. This prevents soiling of the N95 mask and adds that extra layer of protection for splashes.

Unfortunately, surgical masks wrap around your ears and they can lead to skin breakdown of your ears and just hurt.

There are scrub caps and headbands with buttons sowed on which you can loop the surgical mask onto, which takes the pressure off of your ears entirely.

They also make plastic devices that connect both sides and loop around the back of your neck. You can even MacGyver your own version with some rubber hands and/or paper clips.

Covid Nursing Tips paperclip hack

 

 

6. Bad Breath

No – wearing a mask won’t give you hypercarbia… But it can give you hyper-halitosis. If you have bad breath – you’ll definitely notice it now. Sure, bad breath won’t kill you, but it’s just not fun to be breathing in for 12 hours.

Working 12-hour shifts without time for water breaks will cause dry mouth and will increase the odor of your breath as well!

Covid Nursing Tips bad breathOne easy fix is to buy some gum. This leaves your breath smelling minty and fresh. If you’re someone who needs more help for your halitosis, you can try special toothpaste or special mouthwash.

Make sure you are able to stay hydrated. Drink plenty of water before your shift (not that you’ll have much time to pee). Try to take a few breaks throughout the shift just to drink some water and stay hydrated.

7. Wrap it Before you Tap It

No – I’m not talking sex-ed. I’m talking about your smartphone!

Let’s be real, we all bring our phones to work. No, we probably don’t have time to scroll Instagram (follow me!), but we occasionally check the time and maybe our messages.

I personally use multiple apps on my phone throughout my shift to help with antibiotic selection or to reference something related to patient care.

The problem is, we don’t want to contaminate our phones with COVID or who knows what else.

One simple COVID nursing tip is to bring a Ziplock baggie to work that your phone easily fits in. Ziplock it shut. Your touch screen actually works through the ziplock bag!

You could also just leave your phone at home – but if that doesn’t give you anxiety thinking about it, then something is wrong with you.

If you risk it and just use your phone while at risk, you should know how to decontaminate your phone. Pro Tip: Don’t put your phone in the oven like the N95!

Covid Nursing Tips ziplock bag phone

8. Decontamination Station

After a long shift working with COVID patients ALL day (or night), there is nothing you probably want more than to get home and crawl in bed. But you are also aware of all the NASTINESS on your body, scrubs, and everything else you’ve touched.

You need to have a procedure for how you clean yourself and your items. The last thing you want to do is infect members of your household!

Leave anything items you can at work, like your stethoscope, scissors, pens, penlights, etc. If you have a locker – use that!

Make sure you carry hand sanitizer in your car. Use it immediately once you get in before touching the steering wheel. Do not touch your face now that you are maskless.

Once you get home, find a way to strip quickly without touching anybody or anything. I put anything in my pockets (like my phone) on the island counter. I put my clothes directly in the washing machine. Take an immediate shower with hot water and plenty of soap.

After this, I personally go through and wipe down everything I touched including the doorknob, the bathroom door, etc with a disinfectant. I then wipe down all the items I had placed on the island counter. You can use clorox wipes, lysol wipes, but I personally use Original Pine-sol which kills COVID within 10 minutes (THAT’S the power of Pine-sol baby).

Other related content:

COVID Nursing Tip: Always Follow Hospital Policy

As always you should ALWAYS be following hospital policy and procedures whenever implementing any of these COVID nursing tips. This is an unconventional time, so there may not be much oversight regarding infection control practices, but make sure anything you do is safe for you and your patients.

Comment down below your COVID Nursing tips!

Covid Nursing Tips Pinterest Pin

How to Start an IV

How to Start an IV

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

Learning how to start an IV is a very important skill that every nurse needs to know. Inpatient and ER nurses deal with IVs every day – whether they are inserting them, removing them, or administering fluids or medications through them. If you are new to nursing, then you will need to learn how to insert an IV with confidence and knowledge!

How to start an IV: Feat

When to put in an IV

The short answer to this is “when an IV is ordered”. However, it is important to critically think as a nurse, and anticipate what will need to be done. Especially as an ER nurse, you may see your patient before the Provider and can start placing an IV if indicated.

If you work as an inpatient nurse, most patients should have at least an IV, midlines, PICC lines, or other central access. These IVs often go bad, and you will need to know how to start an IV in these settings as well.

Indications for an IV:

  • IV fluids or medications – this is the usual reason
  • Diagnostic Imaging – CTs or MRIs often require an IV for IV contrast to help visualize the anatomy and any potential pathology
  • Inpatient Admission – usually required unless refusal

Contraindications:

There is no outright contraindication to placing an IV, but certain factors will exclude specific locations. These include extremities with:

  • AV Fistulas or grafts (dialysis patients)
  • Previous mastectomy or lymph node dissection
  • Blood clots
  • Significant burns or edema
  • Overlying infection (cellulitis)

It may be best to avoid limbs with significant motor or sensory deficits, as there is unclear evidence that may suggest increased DVT in these extremities. If their arm is numb, they also may not feel when it is infiltrated.

Choosing the IV Size

The IV gauge will determine how big the actual needle and catheter are. The bigger the IV – the faster fluid can be administered. Unfortunately, bigger sizes are also more painful and usually more difficult to insert. Bigger IVs also come with increased risk of phlebitis and can cause some serious irritation to the vein.

24 gauge: The Baby Needle

These are typically used for babies and generally should be avoided in adults. They are very short, flimsy, and won’t last long.

  • Good for: Infants
  • Bad for: Most other scenarios

22 gauge: The Safe Choice

This is used for many kids and adults, especially older adults with fragile “easily-blown” veins. These are usually OK for IV contrast dye as well, but not for CTA. These are also generally easier to place.

  • Good for: Peds, many Med-Surg adult patients, easily blown veins
  • OK for: IV contrast, blood return
  • Bad for: Massive trauma or fluid resuscitation needs, CT Angiography

20 gauge: The One-Size-Fits-All

20g IVs are an ER nurse’s best friend. This is because a 20g IV is adequate for multiple fluid boluses, IV medication infusions, and most CTA requirements. They often give great blood return and labs can often be drawn without hemolysis.

  • Good for: Most adult patients, CT Angiography
  • OK for: Emergency situations (code blues, RRTs)
  • Bad for: Massive trauma or fluid resuscitation needs

18 gauge: The Big Daddy

18g IVs are your standard “large bore” IV. These are great in critical situations as they provide for rapid administration of fluids or blood products, rapid infusion of critical medications. The down-side is they tend to be a little more difficult to place in the absence of large veins.

  • Good for: Critical or emergency situations, rapid fluid administration, CTA, severe sepsis, burns, acute MI, etc
  • Bad for: Small, fragile veins

14-16g: The Monsters

The 16g and 14g IVs are very large, and unnecessary for most indications. However, in critical situations these may serve you well.

  • Good for: Rapid fluid resuscitation or critical situations as above
  • Bad for: Small veins – Unnecessary for most indications

Clinical Tip: Some nurses may tell you to place the largest IV catheter that the vein can support. However, this is contrary to good nursing judgment. If you ask my friend Brian (@TheIVGuy), he will tell you that you should choose your size based on the appropriate ordered therapy and anticipated needs. This means that for most patients, a 20-22 gauge is likely the best and safest choice.

How-to-start-an-IV-IV-gauges

IV Insertion Equipment

Before learning how to start an IV, you need to first know which equipment you will need. This becomes like second nature, but when starting out as a new nurse, this is often important to memorize. For an IV insertion, you will need:

  • IV Insertion Kit, which usually includes:
    • Chlorhexidine / ETOH swab
    • Tegaderm dressing +/- securement device
    • 2×2 gauze
    • Tourniquet
  • IV catheter of choice (18-22g)
  • Blood transfer device (Vacutainer) – if drawing blood
  • Extension Loop or cap
  • 1-2 10cc flush
  • Tape

Once you have your equipment, you are ready to know how to start an IV.

How to Start an IV

Prepare the Patient

To start an IV, you will first want to wash your hands (always the right starting point). You will also want to use universal precautions, so put on a pair of clean gloves as you will be possibly interacting with the patient’s blood.

You should already have an idea of where you are going to place the IV and which size IV catheter you are going to use.

Place the tourniquet on the patient’s arm proximal to the area of cannulation. Look for straight, large veins. Palpate them as veins may not always be visible but can still be felt. Strong veins will have a good amount of bounce to them.

Once you are happy with your vein selection, you can start prepping your area. Use a chlorhexidine (CHG) or alcohol swab to gently clean the surrounding area for 30 seconds, and allow to completely dry. Start with the center and move outward in a circular fashion with alcohol, while CHG requires a back and forth scrubbing action.

With deeper non-visible veins, some nurses will also apply alcohol to a finger of their non-dominant hand to help palpate during the procedure without “contaminating” the site. Please note that this is not the best practice for infection control. You should never tear off the finger of your glove either, instead – learn to palpate with your gloves on.

Preparing the IV

While your site is drying, open your 10cc flush and your extension loop and/or cap. If you are drawing blood, hook up the blood transfer device to the dry extension loop or cap. Otherwise, you can connect the flush and prime the loop or cap. Set this aside back into your kit to keep it clean.

Open up your IV, take off the needle cap, and twist the end of the catheter to make sure it is loose and ready for cannulation.

Inserting the IV

Hold the skin taut with your non-dominant hand to secure the vein. This helps to stabilize the vein and prevent it from rolling. Place the tip of the needle against the skin at a 10-30 degree angle. If the vein is deeper, use a slightly more angular approach initially. With the bevel up, puncture the skin and advance through to the vein.

If done correctly, you should see a flashback of blood in the flash chamber and/or catheter. This location will depend on the brand and size of the specific IV catheter. Once flashback is seen, lower the angle even more parallel with the skin, and advance the whole unit about 2-6mm. Now advance only the catheter forward, sliding it off of the needle and cannulating the vein. If done correctly, the catheter should easily slip into the vein without resistance. If there is dimpling of the skin, the IV is likely within the extravascular space.

Clinical Tip: If you initially don’t see flash of blood, pull the needle and catheter both out almost completely (but do not leave the epidermis). Re-palpate the vein, adjust your angle and advance again. This is termed “digging” and some patients will not tolerate this well. However, oftentimes it may only take 2 or 3 “digs” until success.

Before pressing the activation button to retract the needle – take off the tourniquet and apply digital pressure beyond the catheter tip. Some brands will have a septum or shield function with gauges 20-24, which prevents the backflow of blood and negates the need for venous compression. Press your activation button to retract the needle.

Draw Blood

If ordered, now is the point where you will draw your blood. Hook up your loop/cap with the blood transfer device to the IV hub. Draw your blood tubes, and flush with a 10cc pulse flush afterward.

Clinical Tip: Blue Tops for coags (PT/PTT) are often drawn first, and it is necessary to fill these tubes up completely for the lab to run the tests. If you have an extension loop, that .5-1cc in the loop can unfortunately cause the tube not to be full enough and you will need to redraw it. Best practice is to waste a tube first.

If you are not drawing blood, skip this step and instead just connect the primed cap or extension loop to the IV and flush. After flushing a few mLs, make sure you can pull back blood return. This is reassurance that the IV is in the correct place. Then pulse flush the remaining amount through.

Secure the IV

Secure the IV with a securement device or tape, and a dressing like Tegaderm. Make sure the insertion site is covered. If you used an extension loop, secure the loop with tape as this can easily get caught on something and pull out the IV.

If the patient is confused or may try pulling the IV out, wrap the IV with Coban, only leaving the cap accessible.

Administer any medications or fluids through the IV as ordered.

How to start an IV: infographic

How to Remove an IV

If the patient is discharged or if there is a compilation with the IV, it will need to be removed. Removing the IV is easier, and can be performed by a nurse or a patient care assistant.

1. Collect 2×2 gauze and tape or bandaid

2. Wash your hands and don clean gloves

3. While holding the catheter in place, start peeling off the Tegaderm and/or tape. Use an alcohol pad if very sticky and painful.

4. Once the dressing is no longer secured to the skin, place a 2×2 gauze over the insertion site, and pull out the IV in a smooth fashion.

5. Hold pressure for 1-2 minutes until bleeding as stopped

6. Dress with gauze and tape or bandaid

    How to start an IV

    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!

    Cardiac Lab Interpretation and Troponin

    Cardiac Lab Interpretation and Troponin

    If you work in the hospital – it is essential that you know and understand cardiac labs like troponin.

    Cardiac labs are life and death, and knowing these labs inside and out will help you in the clinical setting.

    Cardiac labs are used to identify cardiac conditions and will often guide diagnostic and treatment courses for your patients – so buckle up because you’re about to become an expert!

    Cardiac Labs FB

    Troponin

    Troponin is the most important cardiac lab that you will see, and it is also the most common.

    But what exactly is Troponin?

    Troponin is a family of enzymes or proteins found within muscle cells. Two members of this family, Troponin-I and Troponin-T, are found pretty much exclusive to cardiac tissue.

    When heart damage occurs, the cells of the heart lyse or split apart, releasing this troponin. 

    Since the heart is really the only tissue to have this type of troponin, the presence of troponin the bloodstream signifies myocardial necrosis or cell death.

    The higher the level of troponin – the more cell death has occurred. As you can see – this can come in handy when diagnosing heart attacks.

    Troponin is the preferred blood test in evaluating patients for a myocardial infarction (heart attack).

    Normal Troponin Levels

    Normal levels of Troponin (whether T or I) are zero, as or close to zero as you can get.

    Labs may utilize different assays which may have different specific cutoffs, but generally, you will find that levels should be:

    Troponin-I = < 0.04 ng/mL

    Troponin-T = ≤ 0.01 ng/mL

    Pattern of Troponin

    Both types of Troponin will typically show up within 2-3 hours after cell death has begun – but they may not be detectable until 6-12 hours later.

    It will peak in 24 hours but can take up to 1-2 weeks for the troponin to return back to non-detectable levels.

    Significance of Troponin

    As stated above – Troponin signifies myocardial cellular death.

    The prime example of this is during a Myocardial infarction (whether STEMI or NSTEMI… see below).

    However, there are other causes that can cause mild elevations in troponin, such as:

    • Demand-ischemia: Sepsis, hypovolemia, shock, arrhythmias, CHF exacerbation.
    • Other cardiac damage: Various forms of carditis, aortic dissection, post-cardiac surgery, post-cardiac cath, CPR, defibrillation, chest trauma.
    • Kidneys: Renal damage, Acute Kidney Injury, Chronic Kidney Disease (especially if on dialysis).
    • Vascular: Pulmonary embolism and Stroke.

    This isn’t a complete list, but most of these may cause minor elevations in the Troponin.

    When cardiac damage is sustained, the troponin level should rise significantly.  

    STEMI

    It doesn’t matter what the Troponin level is during a STEMI – if it’s new-onset – expect the troponin to be negative. Remember – it can take time for the troponin to become positive.

    If the EKG reads STEMI – you need to hook your patient up to the defibrillator, establish 2 large-bore IVs, give aspirin, possibly another antiplatelet medication like Brlinta, pain relief, nitro, and get that pt to the Cath lab ASAP.

    NSTEMI

    This is really where troponin shine. NSTEMIs are a type of myocardial infarction that don’t have ST elevation on the EKG (Non-ST-Elevation-MI).

    Serial checks of the troponin can determine whether or not the pt is actually having a heart attack.

    It will vary based on the facility, but most facilities will check the troponin Q6-8hrs at least 2-3 times. 2-3 negative troponins in a row basically rule out any type of acute coronary syndrome (heart attack).

    This doesn’t mean that the patient does not have a high-grade blockage of their coronary arteries.  Stress tests and cardiac caths are needed to definitively detect significant cardiac blockages.

    Is there a specific level that a troponin has to rise to be considered an NSTEMI?

    Not really, it just needs to be above the 99th percentile – which is any positive number. However, just because there is an elevation in troponin doesn’t mean it is an NSTEMI (See above for other causes of troponin elevation).

    These patients should be having some symptoms of an MI (chest pain, SOB, nausea), and/or EKG changes (ST-depressions or T-wave inversions).

    Something important to remember is that NOT ALL PATIENTS EXPERIENCE CLASSIC SYMPTOMS of an MI.

    Diabetics are well-known to be at higher risk for “silent” MIs, and women can have atypical symptoms as well.

    Related Content:

    NEXT STEPS

    So you’re on your unit and your patient’s troponin level comes back elevated.

    What do you do?

    It will depend on the patient’s symptoms and what unit you are on, but in general, you should:

    1. Remain calm.
    2. Communicate it to the Provider (Physician or APP).
    3. Make sure the patient is connected to the heart monitor and is getting frequent vital signs. Apply oxygen if SPO2 < 94%.
    4. Obtain an EKG if they have not had one recently – worry about the order later.
    5. Monitor your patient and follow the orders given by the Provider.

    Cardiac Biomarkers | Learn about troponin, CK, CK-MB, and BNP (and NT-ProBNP)

    CK / CK-MB

    CK and CK-MB are cardiac labs that are somewhat outdated and have been replaced – for the most part – by troponin.

    But there are still some important clinical situations in which using these labs may be beneficial.

    CK, or Creatine Kinase, is found within most muscle cells and is released into the bloodstream when muscular cellular necrosis or damage occurs.

    This includes the heart – so with the same principle as troponin – elevations in CK could indicate heart muscle damage. However – CK is NOT specific.

    This is why a more specific isoenzyme – CK-MB (Creatine Kinase Muscle/Brain), is used to help differentiate musculoskeletal muscle damage from heart damage. CK-MB is found in higher concentrations within the heart.

    Current Indications

    CK and CK-MB have mostly been replaced by troponin, but they can be used in certain instances.

    These include:

    • Suspected heart attack after heart instrumentation (CABG or PCI)
    • To detect a second MI – since troponins have such a long half-life and do not return to baseline levels until 1-2 weeks after the initial incident.

    Pattern

    The reason CK-MB can be useful is that while the onset is similar to troponin (can take 4-12 hours to be detectable), the half-life is shorter and levels drop back down to undetectable levels in 36-48 hours.

    Troponin levels can take 10-14 DAYS to return to normal. This means that if a patient has a 2nd heart attack >2 days after the first, an elevated CK-MB level can indicate a 2nd MI.

    The same principle is related to myocardial instrumentation. If someone had a stent placed or especially a CABG, their Troponin will be expected to be elevated from the irritation within the heart.

    If it has been >48 hrs, an elevated CK-MB could indicate further myocardial injury.

    Normal Levels

    CK Male Normal: 39-308 U/L
    CK Female Normal: 26-192 U/L
    CK-MB Normal: 5-25 IU/L

    Myocardial Infarction: Levels should be >2x the patient’s baseline.

    Remember that CK and even CK-MB are not as specific as troponin-I or T to the heart. In the presence of musculoskeletal injury – the usefulness of these tests diminishes greatly.

    Any type of muscular damage or surgery can increase CK. Rarely, chronic muscle disease, hypothyroidism, and alcoholism can increase CK-MB.

    Also check out:

    BNP

    BNP stands for Brain Natriuretic Peptide – however, it is primarily released by the ventricles of the heart.

    This hormone impacts how the kidneys manage fluid and sodium. When the ventricles experience high-pressures, the cells release this enzyme.

    BNP has a diuretic (fluid out) , natriuretic (salt out) , and hypotensive effect. BNP has actually been found to be somewhat protective in cardiac remodeling (cardiomyopathies).

    What’s confusing about BNP is that some hospital labs utilize BNP, and some utilize NT-ProBNP – basically an inactive byproduct of the enzymatic reaction that occurs to produce BNP.

    It is important to know which kind of BNP your hospital utilizes in order to be able to understand and interpret the results.

    While BNP levels can assist in the diagnosis of HF if it is uncertain, they are especially helpful in evaluating treatment response as the BNP half-life is only about 20 minutes.

    This means that BNP levels will quickly go down if ventricular pressures improve.

    BNP levels infographic | BNP heart failure exacerbation

    Regular BNP

    Baseline BNP levels – no matter which kind – are affected by genetic variation. However, people with Heart Failure will have baseline elevations along with increases during exacerbations.

    Baseline levels tend to increase in age and are higher in women over men, and lower in obesity.

    Levels <100 pg/mL have a great negative predictive value – meaning they likely are NOT in an exacerbation.

    Levels >400 pg/mL have a high likelihood that they ARE in an acute HF exacerbation.

    Levels between these (100-400 pg/mL) is the gray zone – meaning they may or may not be in an acute exacerbation.

    It is ALWAYS important to take the clinical exam into account.

    Do they have clinical signs or symptoms of HF? These symptoms include:

    • Dyspnea
    • Pulmonary crackles
    • Peripheral edema
    • JVD

    Never rely only on labs – especially with BNP levels. BNP levels should be used as an adjunct to, and not a substitute for, clinical assessment.

    NT-ProBNP

    NT-ProBNP levels rise much higher than regular BNP levels.

    They also have a longer half-life (25-70min), which means they do not fluctuate as quickly. It is also impacted by renal failure more-so than regular BNP levels.

    All ages: Levels <300 pg/mL –  you can be almost completely sure they are not in a heart failure exacerbation.
    Age <50: Levels >450 pg/mL indicate acute exacerbation.
    Age 50-75: Levels >900 pg/mL indicate acute exacerbation.
    Age >75: Levels >1800 pg/mL indicate acute exacerbation.

    With any BNP level, obesity can decrease the results, and age and renal failure can increase them.

    Non-HF causes of elevated BNPs include renal failure, constrictive pericarditis, valvular disease, pulmonary hypertension, and sepsis.

    And those are the main cardiac lab tests used to evaluate the heart. An EKG should always be performed for these patients above, and they should all be admitted with continuous cardiac monitoring as well.

    Whether you’re a nurse, nurse practitioner, or physician – it’s very important to understand these labs and be able to interpret them to provide the best care for your patients.

    Check out some of my other articles:

    Cardiac Labs Pin

    10 IV Insertion Tips for Nurses

    10 IV Insertion Tips for Nurses

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

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

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

    1. IV Insertion: Location Location Location

    AC

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

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

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

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

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

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

    Forearm

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

    However, not everyone has great forearm options.

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

    Hand

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

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

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

    2. Small veins? Make them Larger

    Heat

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

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

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

    Gravity

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

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

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

    Nitroglycerin Ointment 2%

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

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

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

    3. IV Insertion with Fragile Veins

    Change your Selection

    Sometimes, elderly patients tend to have crappy veins.

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

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

    Forget the Tourniquet

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

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

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

    4. Don’t Give Up during IV Insertion

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

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

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

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

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

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

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

    Related content: “How to Start an IV”

      5. Go Big or Go Home

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

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

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

      Related content: “5 Vital Signs Error to Avoid”

      6. Arterial Stick

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

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

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

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

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

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

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

      Remove the catheter and try again in an actual vein.

      7. Inserting the IV Outside the Box

      Or rather – think outside the lower arm.

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

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

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

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

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

      8. Angle Danger

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

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

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

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

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

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

      Related content: “How to Start an IV”

      9. Rollie Pollie Ollie

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

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

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

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

      10. Patient Comfort

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

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

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

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

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