Nursing Tips

 

Your everyday practice is filled with assessments, documentation, planning, interventions, and evaluations. Then there’s patient and family education, medication reconciliation, communication with other healthcare professionals, and transferring and discharging patients. The list goes on and on. The point is that as nurses, our days are full! And if you are a new nurse, the reality of the number of nursing tasks and responsibilities can be quite overwhelming.

The clinical team here at Lippincott NursingCenter has assembled this list of nursing tips to help make your days run a little smoother, improve your practice, and optimize patient care. Here you’ll find handy definitions, practice pointers, and more. Find tips for new nurses to help you manage your day, tips for all nurses to remember key points related to different body systems, and some more focused tips if you are working night shift or working as a travel nurse. There really is something here for everyone!

You can send it to us at editor@nursingcenter.com. Thank you!

Tips for New Nurses
Organization and teamwork	Documentation
Assessment	Communication
Clinical Tips
Pain management	Renal system
Laboratory values	Musculoskeletal system
Medication administration	Hematologic and immunologic systems
Cardiovascular system	Neurologic system
Respiratory system	Integumentary system
Gastrointestinal system	Endocrine system
Test-Taking Strategies and Other Tips for Nursing Students
Tips for Night-Shift Nursing
Travel Nursing Tips

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Tips for New Nurses

 Organization and teamwork 

1. Nursing is a 24/7 operation that requires teamwork. Do your best to prioritize and work safely and pass on the rest.
2. Organize tasks by “must do” (within 30 minutes), “should do” (within 4 hours), and “could do” (before the end of the shift).
3. When the number of tasks to be done seems out of control, stop and take a deep breath. Even a 5-second break can help!
4. The five rights for delegating care are right person, right task, right circumstances, right direction, and right supervision.
5. Take the lead to inspire teamwork! Pitch in and help your colleagues; perhaps others will follow your lead!

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 Assessment POCKET CARD

1. A successful assessment requires critical thinking. Think “how does this finding fit in with the big picture?”
2. A patient’s behavior and appearance can offer subtle clues about their health. Carefully observe for unusual behavior or signs of illness.
3. In general, the younger a child, the higher the pulse and respiratory rates.
4. Accurate measurements of height and weight are important for evaluating nutritional status, calculating medication dosages, and assessing fluid loss or gain.
5. The four parts of a nutritional assessment are health history, lab tests, body systems assessment, and anthropometric measurements.
6. When assessing the abdomen, inspect first, then auscultate, percuss, and palpate.
7. If a patient is frightened or ticklish, begin palpation of the abdomen with your hand on top of their hand.
8. When assessing a patient, palpate tender areas last.
9. Percussing over a solid organ, such as the liver or kidney, should create a dull sound.
10. To avoid hearing extraneous sounds during auscultation, keep the stethoscope tubing off the patient's body and other surfaces.
11. When listening to heart or breath sounds, close your eyes to help focus your attention.
12. Use the bell of the stethoscope to hear low-pitched sounds; use the diaphragm to hear high-pitched sounds.

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 Documentation POCKET CARD

1. When documenting a patient’s behavior, include only the facts, not your opinion on why the patient is behaving a certain way.
2. When documenting the reason for seeking care, record the information in the patient's own words.
3. When in doubt, spell it out. Are you familiar with acceptable abbreviations where you work?

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 Communication

1. Good communication is essential when transferring care to another person, speaking with and educating patients, and interacting with families and other visitors.
2. Introduce yourself to patients and visitors and identify yourself as a nurse.
3. At the start of the shift, tell the patient what is expected to occur and what treatments and procedures are planned.
4. Believe in yourself and your instincts, but always listen to the patient.
5. Consider asking, "Does anyone have any ethical concerns with this patient's care?" to open dialogue during rounding.
6. Working with students? Offer a warm greeting, include them in the daily routine, treat them with respect, and model professional behavior.
7. To conclude history taking, consider stating, “I think I have all the information I need now. Is there anything you’d like to add?”
8. Closed questions elicit yes or no, or one- or two-word answers. They can help you zoom in on specific points, but they don't allow patients to elaborate.
9. Use open-ended questions as needed; for example, “Can you tell me more about that?”
10. Use open-ended questions to assess for abuse: When do you feel safe? When do you not feel safe?

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Clinical Tips

 Pain management POCKET CARD

1. The goals of pain management are to reduce pain intensity, improve ability to function, and improve quality of life.
2. When choosing a pain rating scale, consider the patient’s visual acuity, age, reading ability, and level of understanding.
3. Patients with dementia who are in pain may have atypical behaviors (i.e., aggression). Remember that behavioral changes can signal pain.
4. Physiologic markers of pain, such as vital sign changes, grimacing, or diaphoresis, may not be present in a patient with chronic pain.
5. Patients who are nonverbal or unresponsive can still experience pain. Note changes in vital signs, facial expression, level of agitation or withdrawal to guide pain assessment and management.
6. Breakthrough pain is a worsening of pain that occurs intermittently and spontaneously or in association with certain activity.

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 Laboratory values POCKET CARD

1. The four causes of hyperkalemia are excess intake, decreased excretion, cellular disruption, and intracellular to extracellular shifts.
2. The signs of hyperkalemia (K⁺ level greater than 5.5 mEq/L) are wide QRS complex, peaked T waves, dysrhythmias, nausea, and hypotension.
3. The general goal for hemoglobin A1C level among nonpregnant adults is less than 7%.
4. When the thyroid gland is hypoactive, as in hypothyroidism, the thyroid stimulating hormone (TSH) level is high. When the thyroid gland is overactive, as in hyperthyroidism, the TSH level is low. POCKET CARD
5. Myxedema coma occurs when thyroid hormone levels drop too low; thyroid replacement with levothyroxine (T4) is priority.
6. Severe or prolonged hypoxemia leads to tissue hypoxia and anaerobic metabolism, which alters a patient's acid-base status.
7. When interpreting arterial blood gas (ABG) results, remember that a pH less than 7.35 equals acidosis (more Acid) and a pH greater than 7.45 equals alkalosis (more Base). Think *A* before *B*.  POCKET CARD
8. The two causes of metabolic acidosis you are most likely to see in hospitalized patients are lactic acidosis and ketoacidosis.
9. Serum lactate is a marker of anaerobic metabolism (occurs when tissue oxygenation demands are greater than supply).
10. The most common cause of an acute lactate elevation is shock (including septic, cardiogenic, & hemorrhagic).
11. Decreased albumin levels may be caused by overhydration, liver or renal disease, or excessive protein loss due to burns, major surgery, infection, or cancer.

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 Medication administration

1. The five rights of medication administration are right patient, right medication, right dose, right time, and right route.
   1. Five additional “rights” of medication administration include documentation, history & assessment, drug approach & right to refuse, drug-drug interaction & evaluation, and education & information.
2. When asking about medications, don’t forget to ask about over-the-counter products, vitamins, and complementary and alternative therapies.
3. Double-checks work best when done independently. Nurses should calculate the dose separately and then compare answers.
4. When asking about drug use, tell the patient that honest disclosure of all drug use will lead to improvement, not denial, of care.
5. The vastus lateralis muscle is the preferred site for giving an I.M. injection to a newborn.
6. Extravasation is the infiltration of a vesicant drug from an I.V. line into surrounding tissue. POCKET CARD
7. When floating to a different unit, look up unfamiliar drugs or familiar drugs in unfamiliar places as the doses may differ.
8. Don't refill a syringe after it's already been used, even for the same patient.
9. Elderly patients taking an anticoagulant have an increased risk of bleeding, especially if they also take NSAIDs.
10. A drug’s half-life is the amount of time required for a drug's plasma concentration to decrease by 50%.
11. Use lowercase letter “g” to abbreviate the word “gram” or “grams.”
12. Before giving a medication through an enteral feeding tube, flush the tube with at least 15 mL of sterile water and then flush again after medication administration.
13. Avoid mixing medications before giving them through an enteral feeding tube; each should be administered separately.
14. Before administering any vaccine, screen the patient for contraindications and precautions, even if they’ve received that vaccine in the past.  
15. The green halo sign is one of the most common signs of digoxin toxicity. It refers to patients seeing a green halo around lights.
16. Flumazenil is the reversal agent for benzodiazepines; naloxone is used to reverse opioids.

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 Cardiovascular system POCKET CARD

1. When measuring the pulse rate for the first time, obtaining baseline data, if the rhythm is irregular or the patient has a pacemaker, count the beats for a full minute.
2. Use the pads of your index and middle fingers to take a pulse. Don’t use your thumb; it has a strong pulse of its own.
3. Don't palpate both carotid arteries at the same time or press too firmly; the patient could faint or become bradycardic.
4. Ensure the use of a properly sized blood pressure cuff, as erroneous values can be obtained with a cuff that is either too small or too large.
5. If you need to repeat a blood pressure measurement, wait at least 2 minutes before retaking.
6. To calculate mean arterial pressure (MAP), add the systolic blood pressure and twice the diastolic blood pressure, then divide result by 3.  BLOG PODCAST
7. The three positions for cardiac auscultation are supine with the head of bed elevated 30-45 degrees, sitting up, and lying on left side.
8. When auscultating the heart, if the heart sounds are faint, try repositioning the patient in the left lateral decubitus position or seated, forward-leaning position.
9. The six characteristics of heart sounds are location, intensity, duration, pitch, quality, and timing.
10. A thrill is a palpable vibration felt over the heart or a blood vessel; it results from turbulent blood flow.
11.  A displaced apical impulse may indicate an enlarged left ventricle; possible causes include heart failure or hypertension.
12. When describing a murmur, crescendo means it increases in intensity; decrescendo means it decreases in intensity. BLOG
13. The first heart sound, S1, which produces the "lub" sound, is associated with closure of the mitral and tricuspid valves.
14. The second heart sound, S2, which produces the "dub" sound, is associated with closure of pulmonic and aortic valves.
15. An S3 is a normal finding in a child. In an adult, however, this heart sound can indicate heart failure. BLOG
16. An S4 heart sound may be heard in elderly patients or those with hypertension, aortic stenosis, or history of myocardial infarction. BLOG
17. The right side of the heart pumps blood to the lungs to get oxygen; the left side of the heart pumps oxygenated blood to rest of body.
18. The myocardium is the middle layer of the heart wall; it has striated muscle fibers that cause the heart to contract. Think Myocardium=Middle=Muscle.
19. Cardiac output (CO) is the amount of blood the heart pumps in one minute. CO equals the heart rate multiplied by the stroke volume (amount of blood ejected with each heartbeat). BLOG
20. The stroke volume depends on three factors: preload, contractility, and afterload.
21. Preload equals stretching of muscle fibers in the ventricles. This stretching results from blood volume in the ventricles at end-diastole. BLOG
22.  Contractility equals the inherent ability of the myocardium to contract normally; it is influenced by preload (the greater the stretch, the more forceful the contraction).
23. Afterload equals the pressure that the ventricular muscles must generate to overcome the higher pressure in the aorta to get blood out of the heart. BLOG
24. The normal pacemaker of the heart is the sinoatrial (SA) node; it generates impulses 60-100 times/minute.
25. On the horizontal axis of ECG paper, a large block equals 0.2 seconds and a small block equals 0.04 seconds.
26. The QRS complex represents ventricular depolarization; it's normally 0.10 second or less.
27. The QRS complex in bundle branch block is 0.12 second or greater because the ventricles aren't depolarized simultaneously.
28. The predisposing factors for venous thromboembolism (VTE) are venous stasis, endothelial or vessel wall injury, and hypercoagulable states.
29. Post-op atrial fibrillation usually occurs within five days after open heart surgery, with peak incidence on day two.
30. The clinical consequences of atrial fibrillation include decreased cardiac output and potential for thrombus formation.
31. An enlarged waist circumference indicates central obesity and is a key risk factor for metabolic syndrome.
32. Patients with metabolic syndrome are at increased risk for coronary artery disease, stroke, and type 2 diabetes.
33. Pulsus paradoxus is characterized by increases and decreases in pulse amplitude associated with the respiratory cycle (decreased with inhalation). It is associated with pericardial tamponade, heart failure, constrictive pericarditis. BLOG
34. Pulsus alternans refers to an alternating pattern of weak and strong pulse; it is associated with left-sided heart failure. BLOG
35. A fever, plus a new or changed heart murmur, is the classic sign of endocarditis.
36. The most common causes of orthostatic hypotension are volume depletion and autonomic dysfunction. BLOG

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 Respiratory system POCKET CARD

1. The left lung has two lobes; the right lung has three lobes. (Remember L comes before R, and 2 comes before 3).
2. Assess the respiratory rate while taking the patient’s pulse; if the patient knows you are counting respirations, they may subconsciously alter the rate.
3. The ratio of inspiration to expiration (I:E) is normally about 1:2.
4. To check for tactile fremitus, ask patient to fold his arms across chest; this shifts the scapulae out of the way.
5. Production of pink, frothy sputum is a classic sign of acute pulmonary edema.
6. Absent breath sounds in patients with asthma is concerning for extreme bronchospasm.
7. In acute respiratory distress syndrome (ARDS), the alveolar membranes are more permeable, and spaces are fluid filled. The alveoli collapse, impairing gas exchange. BLOG
8. Positive end-expiratory pressure (PEEP) reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to left side of heart.
9. A patient with orthopnea (shortness of breath while lying down) tends to sleep with their upper body elevated. Ask how many pillows they use.
10. The most common causes of massive hemoptysis are lung cancer, bronchiectasis, active tuberculosis (TB) infection, and cavitary pulmonary disease from necrotic infections or TB.
11. Subcutaneous emphysema feels like puffed rice cereal crackling under the skin; it indicates air leaking from the airways or lungs. If it involves the neck or upper chest, airway patency may be compromised.
12. Clubbing is thickening of the flesh under the toenails and fingernails and causes the nails to curve down. Clubbing is typically a sign of pulmonary or cardiovascular disease, such as emphysema, chronic bronchitis, lung cancer, or heart failure.
13. A barrel chest indicates loss of lung elasticity and flattening of the diaphragm. It is seen in patients with chronic obstructive pulmonary disease (COPD).
14. To prevent ventilator-associated pneumonia (VAP), keep the head of bed elevated 30 to 45 degrees, unless contraindicated.
15. Dead space ventilation means there is normal ventilation (air movement) but without adequate perfusion (blood flow). This can be caused by pulmonary embolism.
16. With shunting, there is perfusion without adequate ventilation, and this usually results from airway obstruction, as with atelectasis or pneumonia.

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 Gastrointestinal system POCKET CARD

1. Auscultate the abdomen before percussion or palpation, as these may alter the bowel sounds.
2. Abdominal angina is abdominal pain resulting from compromised perfusion to digestive tissue. It is usually due to mesenteric atherosclerosis.
3. McBurney's point is located between umbilicus and the right anterior iliac crest; pain here associated with appendicitis. BLOG
4. If you suspect appendicitis, check for Rovsing sign (right lower quadrant pain during left-sided pressure) and referred rebound tenderness. BLOG
5. Appendicitis pain typically begins near the umbilicus, and then shifts to the right lower quadrant. Coughing usually worsens the pain. BLOG

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 Renal system

1. The kidneys form urine to remove wastes from the body, maintain acid-base and fluid-electrolyte balance, and assist in blood pressure control.
2. The kidneys help manage acid-base balance by regulating bicarbonate concentration of the blood.
3. The rate of bicarbonate formation by the kidneys is affected by the amount of CO₂ in the blood and the potassium content of the tubular cells.
4. The kidneys secrete erythropoietin in response to low arterial O₂ tension; it travels to bone marrow to stimulate red blood cell production.
5. In renal failure, the kidneys are no longer able to excrete potassium, resulting in hyperkalemia. BLOG
6. To help prevent catheter-related urinary tract infections, keep the drainage bag below the level of the bladder at all times.
7. Diabetes insipidus is characterized by polydipsia and large amounts of dilute urine with specific gravity 1.001 to 1.005.
8. Patients with syndrome of inappropriate diuretic hormone need to be closely monitored for hyponatremia.

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 Musculoskeletal system POCKET CARD

1. Adduction is to move a limb toward body's midline (think “added” to the body”); abduction is to move a limb away from midline.
2. Osteoarthritis is a localized disease; rheumatoid arthritis is systemic.
3. Restricted range of motion occurs in bursitis, capsulitis, connective tissue tears, and tendinitis.
4. Unequal shoulder heights may be suggestive of scoliosis or abnormal curvature of the spine.
5. Radiating pain down the extremities elicited by spinal range of motion maneuvers is concerning for spinal nerve involvement.
6. Internal rotation and shortening of the leg are suggestive of hip fracture.
7. Tenderness of the medial collateral ligament of the knee on palpation is suggestive of injury or tear.

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 Hematologic/immunologic systems

1. Neutropenia is defined as a neutrophil count less than 1000 cells/mm³. Infection risk increases as neutrophil count decreases.
2. The functions of the spleen are to break down worn out red blood cells, filter and remove bacteria and other foreign substances, and interact with lymphocytes to initiate immune response.
3. Acute hemolytic transfusion reactions can occur anytime during transfusion, but usually appear within the first 5 to 15 minutes.
4. Compatible blood groups are type A with A or O; type B with B or O; Type AB with A, B, AB, or O; and type O with O only.

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 Neurologic system POCKET CARD

1. When assessing mental status, be sure to ask questions that require more than a yes or no answer. POCKET CARD
2. When communicating with an aphasic patient, use short phrases and pause between phrases to allow time for the patient to process and understand. BLOG
3. The trigeminal nerve (cranial nerve V) has sensory (corneas, nasal & oral mucosa, facial skin) & motor functions (jaw & chewing muscles). POCKET CARD
4. To assess the Babinski reflex, stroke the lateral aspect of the sole of the foot. In adults, the toes contract & draw together; in newborns, the toes fan out & draw back.
5. When assessing memory, be sure you can validate responses.
6. Remote memory is usually preserved in early stages of dementia but may be impaired in its later stages. Recent memory is impaired in dementia and delirium.
7. The hallmark sign of severe neurologic injury is a change in pupil size and reactivity.
8. Use a wisp of cotton to assess corneal sensitivity; don’t use gauze or a tissue as they could cause corneal abrasion & irritation.
9. Not all self-destructive behavior is suicidal in intent.

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 Integumentary system POCKET CARD

1. The elements of a basic skin assessment are temperature, color, moisture, turgor, and integrity.
2. The risk factors for pressure ulcers are advanced age, immobility, incontinence, infection, hypotension, and malnutrition.
3. Fluid-filled lesions transilluminate with a red glow when a penlight is placed against its side. Solid lesions don't transmit light.
4. Psoriasis lesions are generally red and circular, with a patchy appearance, and covered with heavy, dry, silvery scales.
5. The deeper a burn, the more extensive the damage to nerve tissue and the more intense the pain.

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 Endocrine system

1. To remember the location of the adrenal glands, think ADD RENAL. They're "added" to the renal organs, the kidneys.
2. Diabulimia refers to skipping insulin to lose weight; this can lead to rapid progression of macrovascular and microvascular complications.
3. Exophthalmos, or protrusion of the eyeballs, is seen in patients with hyperthyroidism.

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 Test-Taking Strategies and Other Tips for Nursing Students

1. Form study groups.
2. Take advantage of every opportunity to learn.
3. Prioritize time management and find a method that works for you; consider using a calendar, app, or alarm. BLOG
4. Divide large tasks into smaller items that are more manageable.
5. Be prepared! Make sure you have the required apparel and supplies for your clinical rotation. BLOG
6. Set a timeline for NCLEX preparation! Start with this Countdown to NCLEX.

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 Tips for Night-Shift Nursing BLOG

1. Give yourself permission to sleep during the day; prioritize sleep and allow adequate time to obtain at least 7 hours of continuous rest.
2. Develop a non-stimulating routine prior to bedtime and stick to it.
3. Limit caffeinated drinks to the earlier hours of the night shift; avoid caffeine toward the end of the shift.
4. Limit bright lights and screen time about an hour before bed; blue wavelength light is disruptive to your brain and melatonin secretion.
5. Clear your mind before sleep; make a to-do list for the next day so your mind is not consumed trying to remember things.
6. Block out normal daytime noise. Consider ear plugs or using noise, such as a fan or sound machine.
7. Switch telephones to silent mode.
8. Keep your bedroom dark and cool.
9. Try relaxing exercises before bed to unwind, such as progressive muscle relaxation
10. Use caution when taking over the counter (OTC) and prescription sleep aids as long-term use can lead to physical and psychological dependence.

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 Travel Nursing Tips

1. Make sure your licenses, certifications, and malpractice insurance meet the requirements of the state(s) where you will be working.
2. Demonstrate your strong work ethic and desire to be part of the team.
3. Be ready to share your strengths and knowledge with colleagues but be receptive to learning how things are done in each different setting.
4. Be open to learning new ways of doing things.
5. Be flexible and have a positive attitude.
6. Take advantage of opportunities and explore your new surroundings!

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