Clinical Tricks

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Tricks to jumpstart your advanced practice career

I was inspired to write this series to serve as a guide for student and new nurse practitioners. I remember being faced with so many things to consider during the last year of my family nurse practitioner program and my first year after graduation, and wishing I had someone to guide me through that transitional time. Now that I have worked as an NP in a few different specialties, I have compiled information that I feel would benefit new NPs. I love teaching and using knowledge I’ve acquired to help others. It is my hope that this article can provide navigation for student and new NPs.

In follow-up to, “Clinical Tips for New NPs,” Part 4 of the series provides clinical tricks to help student and new NPs as they begin their career as an advanced practice nurse.

Clinical Trick #1: Obtaining Certain Vital Signs Simultaneously
If you are using an automatic blood pressure (BP) device, after getting the BP cuff on and device turned on, slip the covered thermometer probe under the patient’s tongue. Not only does this improve time management, but it also keeps the patient quiet while their BP reading is being conducted, since oftentimes, patients want to talk while having their BP reading obtained which can interfere with the accuracy of their reading, potentially producing a falsely high measurement.1

Clinical Trick #2: Prescription Liquid Medication Flavorings
Certain liquid medications do not taste well but numerous flavorings are available and can be added to most of them. They can increase compliance without affecting the safety or effectiveness of the qualifying medication. An example of prescription flavoring which many pharmacies carry is FLAVORx. Examples of flavors include, but are not limited to, grape, watermelon, strawberry, and banana. Most of their flavors are dye free (or have a dye free alternative), sugar free, and alcohol free.2

Practitioners can check with parents to see how well a child tolerates such medications and if a parent reports their child has trouble taking one due to the taste, then the practitioner can recommend discussing a flavoring option with their pharmacist. Though especially helpful for kids, they can be for patients of all ages. It is best to check with a pharmacist to verify whether flavoring is available at the particular pharmacy, whether or not the medication qualifies for flavoring, and the options for flavoring (i.e. strawberry, grape, banana, watermelon, etc.).

SEE ALSO: Certification Basics

Clinical Trick #3: Medical Information Cards
I found when taking health histories from patients, that they may know the medication they were taking, but not the dose. Many may not know how to pronounce the medications they are on or may only know it as the “X color” pill. It is very important patients know at least what medications they are on, if not also the dose and the condition they are taking it for. I would recommend patients make a list of the medications they take, doses, for what conditions and any medication allergies on a notecard, consider having it laminated, and keep this information with them, for example, in their wallet or purse.

Not only is it helpful to educate patients on this at the time of obtaining a health history, but also to educate them on the importance of inclusion of any vitamins, herbal supplements, over-the-counter (OTC) medications, and birth control, since oftentimes, patients do not consider these when asked about medications. Encouraging patients to keep this information with them promotes health awareness and empowers patients to be responsible for their healthcare. As healthcare providers, we want to take advantage of any and all teachable moments. Always remember, patient education is a strength of nurse practitioners!

Clinical Trick #4: Optimal Examination of Oropharynx and Use of Flavored Tongue Depressors
Placement is important. The tongue depressor should be placed on the mid-point or middle third of the tongue. If placed too anteriorly, the posterior portion of the tongue can retract and curl back making inspection of the oropharynx difficult, and this may also cause the tongue blade to break which can pose a hazard to the patient or at least make the patient and practitioner uneasy. If the tongue depressor is placed too posteriorly, the gag reflex may be stimulated.3 Flavored tongue depressors may also improve tolerance with this procedure and come in different flavors, including grape, cherry, strawberry, and banana. They can promote participation and compliance, especially for pediatric patients, and provide an alternative to traditional, wooden tongue depressors.

Clinical Trick #5: Using Helpful Mnemonics
While reviewing a patient’s cholesterol readings with him, he told me the way he remembers HDL the “good cholesterol” from LDL the “bad cholesterol” is this little helpful mnemonic he thought of and applies, Hot for HDL the “good cholesterol” and Lousy for LDL the “bad cholesterol,” and that it really helped him distinguish between the two.

All practitioners will develop their own set of mnemonics to help remember, mentally store and organize information, but we can also learn from our patients. I keep that mnemonic in mind when I educate other patients who have difficulty remembering the difference between HDL and LDL cholesterol, as it’s an easy mnemonic for patients to use to differentiate between the two. We have to remember that provider-patient relationships can be reciprocal, in that just as our patients learn from us, we can stand to learn from them, too.

Clinical Trick #6: Hold the Tone
I learned this trick while working in reproductive health. When you are examining a female patient with lax vaginal tone, place a condom with the tip cut off over the speculum before inserting. The condom stretches when you open the speculum, then make sure you lock it in place securely so it won’t snap shut. This technique helps to promote visualization of the cervix through facilitating cervical access by keeping the lateral walls of the vagina from collapsing and obscuring the cervix.

Clinical Trick #7: Phrase and Rephrase
When you are obtaining a health history on a patient, it can be difficult to get correct information. I have found that if a patient seems confused or the information I am receiving isn’t adding up, that if I ask the question in a different way, I get a different answer. For example, when I inquire about current medications, I may ask, “Are you on any medications currently or in other words, are you on any medications that you take on a regular or daily basis?” This may prompt the patient to remember inclusion of a daily thyroid medication as well as a weekly medication for osteoporosis. I have also found that it is important when asking patients about current medications, to let them know that this includes herbal supplements, vitamins, OTC medications, and birth control. Many times, patients have told me they didn’t think those counted. This is necessary for you to be able to avoid a drug interaction such as: St. John’s Wort (herbal supplement) and antidepressants; levothyroxine (Synthroid) whose absorption is reduced by iron (vitamin); azithromycin (Zithromax) in which it is advised to avoid concomitant use of aluminum or magnesium antacids (OTCs); or methotrexate (Trexall) whose toxicity is increased by non-steroidal anti-inflammatory drugs (NSAIDs) and salicylates (OTCs).4

It also allows you to plan patient education accordingly. For example, if prescribing an antibiotic to someone on oral contraceptives, it is important to educate that antibiotics may decrease the effectiveness of oral contraceptives4 and advise a non-hormonal back-up method, i.e. a condom.

When I inquire about medication allergies, I may ask, “Do you have any allergies to any medications or in other words, are there any medications you were told you should not take?” This may be the difference between being told none and later being told penicillin. When I inquire about medical conditions, I may ask, “Do you have a history of any medical conditions, for example, allergies, asthma, high cholesterol, etc.?” If the patient previously admitted to taking different medications, but then when I ask about medical conditions, the patient states none, that then prompts me to rephrase.

For instance, if when asked about current medications, a patient previously admitted to taking lisinopril and fluoxetine, but then when asked about a history of medical conditions, the patient states none, I may ask, “What are you taking each of the medications you are on for?” Then, the patient reanswers with, “Well I take the lisinopril for high blood pressure and fluoxetine for depression.” When I feel the patient is apprehensive about divulging such information, I may state the following, “With multiple uses for the same medications, this is necessary information for me to collect and I want to make sure that I have the most accurate information for you on file.”

Clinical Trick #8: Improving Cerumen Removal Technique
I used to use non-lighted curettes and I have to say dreaded the process especially with children, who in my experience were not fans of ear curettage. Since I started using lighted ear curettes, I feel this improves the cerumen removal process, is better tolerated by all patients including pediatric patients, and I am now more comfortable performing cerumen removal as a result. According to the University of Michigan Health System otitis media guideline,5 cerumen removal can improve visualization of the tympanic membrane. The Lighted Ear Curette with Magnification from Bionix Medical Technologies makes cerumen removal easier, and increases safety and comfort for the patient.6 This device consists of three separate components: a reusable light source, disposable ear curette, and magnifier. The efficiency and convenience of the self-contained light source eliminates the need for a separate source to enhance visualization such as having to hold the otoscope in one hand and curette in the other, to assist with cerumen removal simultaneously.

Clinical Trick #9: Streamlining Influenza Visits
When I worked in urgent/retail health, I made a suggestion for improvement of our electronic medical record (EMR) to include a specific inquiry for influenza vaccine in the subjective portion of a patient visit for preliminary influenza diagnosis. For those patients presenting with influenza symptoms as well as influenza testing, I found it helpful to ask them whether or not they have had a flu vaccine within the year and then if so, when in a month/year format. I would ask them this in an attempt to gauge their risk. For example, a patient who had their flu vaccine too early in the season may now have the flu late in the season. Another example, is that if a patient had their flu vaccine within the recommended timeframe and it’s now been optimal time for protection to be built up (about two weeks), but well within the period of immunity (the following three to four months), then though possible, it’s not as likely they may have the flu, rather may be more likely to be an upper respiratory infection (URI). The best time to get the flu vaccine is ideally mid-October.7,8 Individuals should avoid getting the flu vaccine too early because protection from flu can begin to decline within a few months after getting the vaccine.8

Clinical Trick #10: Easing the Immunization Process
A suggestion for easing the immunization process is using distraction. I remember getting ready to give immunizations to a baby who was being breastfed by his mother. Concerned that he may clamp down hard on the nipple causing discomfort for his mom, I asked her if she wanted to temporarily discontinue breastfeeding to resume after he received his immunizations. She responded she would let him continue breastfeeding and to go ahead. To my surprise, the immunizations did not interrupt his feeding; rather, the feeding provided a distraction from the immunizations. The Centers for Disease Control and Prevention (CDC) actually suggest breastfeeding as a way to soothe a baby as a tip for a less stressful shot visit.9 To expand on this, breastfeeding has been shown to be a soothing measure for young children receiving injections, and there is some evidence that breastfeeding can decrease the incidence of fever after immunizations.10

Another example for distraction that comes to mind, involves administering a TB test to an intellectually disabled adult female. I remember her guardian from the group home she resided at that accompanied her, expressing to me her fear of needles. I noticed that she had a bracelet on that she seemed very proud of so as I was inserting the needle, I complimented her on her bracelet and asked her where she got it. Before she knew it, the test was administered and she was responding to my compliment and question. Finally, another tip to help ease the discomfort from injections is to consider using the ShotBlocker from Bionix Medical Technologies. It’s a plastic device shaped like a disk with an underside covered with blunt skin contact points. When pressed firmly against the skin, the pressure from the contact points anesthetizes the skin. The injection can then be inserted in the middle of the device. The ShotBlocker distracts the patient from the pain caused by the shot.11 Every tip to help improve compliance and comfort can help.

Clinical Trick #11: Increasing Compliance with Strep Tests and Pediatric Patients
If doing both a rapid strep test and culture on a patient, test and culture are usually performed separately. However, this may not always be possible. With some pediatric patients, you may not get that second chance to get in their mouth to obtain the sample you need, so it may be helpful in the case of such patients, for practitioners to perform the tests at the same time. Then, if the rapid test is positive, you could just discard the culture; otherwise, if the rapid test is negative, you already have your culture collected and you’re done.

I have also found it very helpful when performing strep tests on pediatric patients, especially those who are more anxious about the process, to use distraction with reward in the following way. I tell my pediatric patients, “Now I’m just going to tickle your tonsils. I need you to open your mouth big for me, say ‘ahhh,’ and by the time you count to five, one thousand one, one thousand two, I’ll be done. If I’m not, I’ll give you a prize.” Keep in mind, this “prize” is their choice of a sticker from the basket, which I would offer them at the end of their visit anyway, but they don’t know that. Not only does this serve to distract them, but they want to prove me wrong to get their “prize.” This is a good distraction technique and it’s a win-win situation for the practitioner and the patient!

References
1. Kaur G, Arora AS, Jain VK. Prediction of BP reactivity to talking using hybrid soft computing approaches. Computational and Mathematical Methods in Medicine. 2014; 2014. doi: 10.1155/2014/762501

2. FLAVORx. http://www.flavorx.com/

3. Swartz MH. (2014). Chapter 9: The oral cavity and pharynx. In the Textbook of physical diagnosis: History and examination (7th ed.), 278-303. Philadelphia, PA: Elsevier Saunders.

4. Skidmore-Roth L. (2014). Mosby’s 2014 nursing drug reference (27th ed.). St. Louis, MO: Elsevier Mosby.

5. University of Michigan Health System. Otitis media guideline. http://www.med.umich.edu/1info/fhp/practiceguides/om.html

6. Bionix Medical Technologies. The lighted ear curette with magnification. http://www.bionixmed.com/MED_Pages/LightedEarCurettes.html

7. Centers for Disease Control and Prevention. Key facts about seasonal flu vaccine. http://www.cdc.gov/flu/protect/keyfacts.htm

8. Horizon Primary Care. Can it be too early or too late for a flu shot? http://horizonprimarycare.com/can-it-be-too-early-or-too-late-for-a-flu-shot/

9. Centers for Disease Control and Prevention. Tips for a less stressful shot visit. http://www.cdc.gov/vaccines/parents/tools/tips-factsheet.html

10. Centers for Disease Control and Prevention. Vaccine administration. http://www.cdc.gov/VACCINEs/recs/vac-admin/default.htm

11. Bionix Medical Technologies. ShotBlocker. http://www.bionixmed.com/MED_Pages/ShotBlocker.html.

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About Author

Jenni Hoffman, DNP, FNP-C, CLNC

Jenni L. Hoffman is an assistant professor at Eastern Michigan University School of Nursing and a Nurse Practitioner with the Washtenaw County Department of Public Health.

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