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1 Advanced Nursing Skills Day Keith Rischer RN, MA, CEN.

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Presentation on theme: "1 Advanced Nursing Skills Day Keith Rischer RN, MA, CEN."— Presentation transcript:

1 1 Advanced Nursing Skills Day Keith Rischer RN, MA, CEN

2 2 Todays Objectives… IV Meds In a simulated clinical situation, demonstrate hanging an IV piggyback and calculate correct rate and set up on Horizon pump. In a simulated clinical situation, demonstrate calculation to safely administer IV medication bolus per PDA and administer. In a simulated clinical situation, calculate correct dose of Heparin bolus and drip rate per SCH policy and protocol. Carb Counting-Insulin In a simulated clinical situation, calculate the correct dose of insulin to administer based on CHO intake at meal. In a simulated clinical situation, based on sliding scale calculate the correct dose to administer and demonstrate correct technique to mix Regular and NPH or Lente. Demonstrate correct technique to administer insulin via insulin pen.

3 3 Todays Objectives… IV Insertion State the veins of the hands and arms that could be used for intravenous insertion for all ages. Implement measures to promote venous distention. State potential complications when initiating IV therapy and measures to prevent complications. Demonstrate IV insertion, dressing of the IV site and application of a saline lock safely with the simulation arm. Central-Arterial Lines Identify indications for placement of central/arterial lines. Identify significance of CVP and normal ranges Describe nursing responsibilities and priorities for the client with central/arterial lines. State potential complications and measures to prevent complications with central/arterial lines.

4 4 Todays Objectives… Chest Tubes Identify indications for placement of chest tubes. Describe the principles and patho that support the use of chest tubes. Describe nursing responsibilities and priorities for the client with chest tubes. Identify significance of bubbling in the waterseal chamber and what assessments are required by nurse. ET-Ventilator Identify indications for placement of endotracheal tube/ventilator. Describe nursing responsibilities and priorities for the client during intubation with ventilator. Identify principles of ABG interpretation and relevance to ventilator management. Describe different modes of ventilation and significance of ventilator settings. State potential complications and measures to prevent complications with ventilator.

5 5 Insulin & Carb Counting Time action profiles of… Novolog Regular Lente NPH Mixing Insulin pen

6 6 IV Med Administration Principles COMPATIBILITY Correctly calculate rate of IV push to q seconds Label all syringes brought into room once aspirated Assess site Aseptic technique w/port Knowledge of most common side effects

7 7 IV Meds IV Push Morphine 4mg/1cc PDA 1mg per minute…how much volume q minute IV Piggyback Rocephin 1Gram in 50cc bag Give over 30-what do you set IV pump to infuse IV Heparin 215 lbs. 70u/kg bolus….15u/kg hourly rate

8 8 SAVE that Line! S : Scrupulous hand hygiene Before and after contact w/vascular access device and prior to insertion A : Aseptic technique During catheter insertion & care V : Vigorous friction to hubs With alcohol whenever you make or break a connection to give meds, flush E : Ensure patency Flush all lumens w/adequate amount of saline or heparin to maintain patency per hospital policy

9 9 IV Insertion:Venous Selection Start distally LE not routinely used in adults due to risk of embolism/thromboplebitis Visualize veins if possible Avoid areas of flexion Use smallest IV possible 22 ga. (blue) Standard Ensure vein can handle size of jelco

10 10 Principles of IV Therapy BP cuff-keep on opposite arm if continuous IV infusion Do not use PIV same side as pt. who has had axillary node dissection, dialysis shunt Hair removal if needed-use clippers or scissors

11 11 IV Insertion 1. Chloroprep 1. Prep for at least 10 seconds 2. Allow to air dry before insertion 2. Distal/circumferential traction 3. Low approach angle…bevel up directly on top of vein 4. Upon blood flash go level and advance 1/8 5. Slide jelco in slowly 6. Pressure on vein 1 distally once removed stylette 7. Stabilize PIV securely with tape or Stat-lock if available (preferred) 8. Transparent dressing

12 IV Therapy Complications: Infiltration 12 Progression Skin blanched…edema<1 in any direction…cool to touch…may or may not have pain Edema 1-6 in any direction At this level or greater requires incident report Gross edema >6 in any direction…mild to moderate pain Skin tight, leaking, discolored, bruised or swollen, deep pitting edema, circulatory impairment

13 Infiltration/Extravasation: Nursing Priorities 13 DC infusion immediately Document…notify MD Ongoing assessment of CMS and appearance Follow guidelines depending on if vesicant medication Dopamine & vasopressors most common Extravasation injuries are a sentinel event

14 14 IV Therapy Complications: Phlebitis Progression Initially redness at site with or without pain Pain at access site site w/redness In addition red streak…palpable venous cord Palpable venous cord >1 and purulent drainage At first sign of phlebitis IV must be DCd and event documented

15 15 IV Therapy Complications:Infection Prevention Use aseptic technique when accessing ports and upon insertion Monitor site and integrity of dressing Infection Present Blood cultures from catheter and separate venous site Monitor for sepsis

16 16 Site Assessment Assess tenderness by palpation Redness Moisture/leaking Swelling distally if continous infusion Dressing labeled Date inserted Size of IV jelco Initials of nurse If >4 days since inserted DC and restart

17 17 Nursing Responsibilities Frequent IV site assessment Be aware of medications that irritate vein Vigilant with meds that can cause cellular damage if infiltrate Infiltrated? Stop IV immediately Elevate extremity Warm packs Check w/pharmacy if additional measures needed

18 18 Nursing Responsibilities Primary/secondary tubing changed per hospital policy Q 4 days (ANW) TPN/Lipids changed q day Intermittent IVPB tubing changed q 24 hours When IV dcd assess site and make sure jelco tip intact If Heparin used to flush central access device…assess for HIT

19 19 PIV Troubleshooting Pain Assess site…always a red flag and IV should be DCd unless has irritating solution infusing Distal occlusion alarm on IV pump AC site-extend arm Flush site and assess for occlusion Leakage Make sure is not from loose attachment to jelco ? Infiltration Flush IV slowly w/5-10cc NS Assess for leakage/swelling/pain

20 20 Central Lines: PICC Indications Length of therapy Complications Phlebitis Measure mid arm circimference and document Nursing Priorities Dressing intact Site assessment Note how many cm. out to hub & validate

21 21 Central Lines: Implanted Port Accessing ports Access needle/tubing changed q 7days Dressing changed q 7 days Site assessment

22 Central Lines: Non-Tunneled 22 Indications Length of therapy Complications Nursing Priorities Risk of Infection Insertion Accessing device Systemic infection Remove as soon as possible

23 Arterial Lines 23 Locations Indications Nursing priorities Site care Pressure bag CMS Complications Infection Infiltration Bleeding

24 24 Blood Product Administration Minimum 22 g.(blue hub) IV-prefer 20g. (pink) or 18g. (green) Informed consent obtained Administer within 30 once received from Blood Bank Blood tubing with filter-use NS to prime/flush Validate pt., type of blood product, expiration date, blood tag # VS before, 15 after initiation, end of each Infuse PRBCs over 2 hours (appx 300cc/unit) Consider Lasix chaser if hx CHF

25 25 Complications Blood Products Circulatory Overload Acute Hemolytic Reaction Chills, fever, flushing, tachycardia, SOB, hypotension, acute renal failure, shock, cardiac arrest, death Febrile-Nonhemolytic Reaction Sudden onset of chills, fever, temp elevation >1 degree C. headache, anxiety Mild Allergic Reaction Flushing, urticaria, hives

26 26 Nursing Responsibilities STOP transfusion Maintain IV site-disconnect from IV and flush with NS Notify blood bank/MD Recheck ID Monitor VS Treat sx per MD orders Save bag and tubing-send to blood bank

27 27 Chest Tube: Nursing Priorities Assess resp. status closely Check water seal for bubbling Milk NOT strip every 2 hours Assess color-amount drainage Call MD if >100cc/hr x2 hours first 24 hours Sterile quaze/occlusive dressing at bedside

28 28 Mechanical Ventilation The use of an ET and POSITIVE pressure to deliver O2 at preset tidal volume Modes Assist Control (AC) TV & rate preset Additional resp. receive preset TV Synchronized Intermittent Mandatory Ventilation (SIMV) Additional resp. receive own TV Used for weaning Continuous Positive Airway Pressure (CPAP) Bi-pap Non-mechanical receive both insp. & exp. Pressures w/facemask

29 29 Mechanical Ventilation Terminology Rate Tidal volume 10-15cc/kg Fraction of inspired O2 concentration (FiO2) Use lowest possible to maintain O2 sats Positive End Expiratory Pressure (PEEP) Minute volume RR x TV AC12-TV %-+5

30 30 Mechanical Ventilation: Adverse Effects Complications Aspiration Infection-VAP Stress ulcer of GI tract Tracheal damage Ventilator dependancy Decreased cardiac output Positive pressure decr. venous return & CO Barotrauma pneumothorax

31 Mechanical Ventilation:Nursing Priorities 31 Ventilator Alarm Troubleshooting High pressure Secretions-needs sx Tubing obstructed or kinked Biting ET Low pressure Disconnection of tubing Follow tubing from ET to ventilator

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