Presentation on theme: "Advanced Nursing Skills Day"— Presentation transcript:
1 Advanced Nursing Skills Day Keith Rischer RN, MA, CEN
2 Today’s 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-InsulinIn 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 Today’s 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 LinesIdentify indications for placement of central/arterial lines.Identify significance of CVP and normal rangesDescribe nursing responsibilities and priorities for the client with central/arterial lines.State potential complications and measures to prevent complications with central/arterial lines.
4 Today’s 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-VentilatorIdentify 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 Insulin & Carb Counting Time action profiles of…NovologRegularLenteNPHMixingInsulin pen
6 IV Med Administration Principles COMPATIBILITYCorrectly calculate rate of IV push to q15-30 secondsLabel all syringes brought into room once aspiratedAssess siteAseptic technique w/portKnowledge of most common side effects
7 IV Meds IV Push IV Piggyback IV Heparin Morphine 4mg/1cc PDA 1mg per minute…how much volume q minuteIV PiggybackRocephin 1Gram in 50cc bagGive over 30”-what do you set IV pump to infuseIV Heparin215 lbs.70u/kg bolus….15u/kg hourly rate
8 S: Scrupulous hand hygiene A: Aseptic technique SAVE that Line!S: Scrupulous hand hygieneBefore and after contact w/vascular access device and prior to insertionA: Aseptic techniqueDuring catheter insertion & careV: Vigorous friction to hubsWith alcohol whenever you make or break a connection to give meds, flushE: Ensure patencyFlush all lumens w/adequate amount of saline or heparin to maintain patency per hospital policy
9 IV Insertion:Venous Selection Start distallyLE not routinely used in adults due to risk of embolism/thromboplebitisVisualize veins if possibleAvoid areas of flexionUse smallest IV possible22 ga. (blue) StandardEnsure vein can handle size of jelco
10 Principles of IV Therapy BP cuff-keep on opposite arm if continuous IV infusionDo not use PIV same side as pt. who has had axillary node dissection, dialysis shuntHair removal if needed-use clippers or scissorsDo not use PIV same side as pt. who has had axillary node dissection, dialysis shuntNeed MD order if no other optionsHair removal if needed-use clippers or scissorsShaving can cause micro abrasions which increase risk of infection
11 IV Insertion Chloroprep Prep for at least 10 seconds Allow to air dry before insertionDistal/circumferential tractionLow approach angle…bevel up directly on top of veinUpon blood flash go level and advance 1/8”Slide jelco in slowlyPressure on vein 1” distally once removed styletteStabilize PIV securely with tape or Stat-lock if available (preferred)Transparent dressing
12 IV Therapy Complications: Infiltration ProgressionSkin blanched…edema<1” in any direction…cool to touch…may or may not have painEdema 1-6” in any directionAt this level or greater requires incident reportGross edema >6” in any direction…mild to moderate painSkin tight, leaking, discolored, bruised or swollen, deep pitting edema, circulatory impairment
13 Infiltration/Extravasation: Nursing Priorities DC infusion immediatelyDocument…notify MDOngoing assessment of CMS and appearanceFollow guidelines depending on if vesicant medicationDopamine & vasopressors most commonExtravasation injuries are a sentinel event
14 IV Therapy Complications: Phlebitis ProgressionInitially redness at site with or without painPain at access site site w/rednessIn addition red streak…palpable venous cordPalpable venous cord >1” and purulent drainageAt first sign of phlebitis IV must be DC’d and event documented
15 IV Therapy Complications:Infection PreventionUse aseptic technique when accessing ports and upon insertionMonitor site and integrity of dressingInfection PresentBlood cultures from catheter and separate venous siteMonitor for sepsis
16 Site Assessment Assess tenderness by palpation Redness Moisture/leakingSwelling distally if continous infusionDressing labeledDate insertedSize of IV jelcoInitials of nurseIf >4 days since inserted DC and restart
17 Nursing Responsibilities Frequent IV site assessmentBe aware of medications that irritate veinVigilant with meds that can cause cellular damage if infiltrateInfiltrated?Stop IV immediatelyElevate extremityWarm packsCheck w/pharmacy if additional measures neededIrritants, such as nafcillin and clindamycin, shorten the dwell time, or lifespan, of peripheral IVs. They often trigger a mild pruritic allergic reaction related to histamine release. However, these “flares” usually subside in about 30 minutes and do not require intervention.9 Other common irritants are cefotaxime and amphotericin B.Extravasation refers to infiltration that occurs when vesicant medications or solutions are inadvertently infused into surrounding tissue.3 Common vesicants include diazepam, dopamine, vincristine, and calcium chloride. Even minute amounts of infiltrated vesicants can cause significant cellular damage. Whenever a vesicant is involved, the severity of the infiltration automatically becomes a Stage IV (4), the most severe stage (see Figure 1). Concentrated vesicants cause deep tissue damage. Depending on the vesicant type, there may be pharmacy protocols for administering an antidote, such as hyaluronidase, which promotes the rapid diffusion of extravasated fluids. Increasing the surface area for more rapid absorption of the vesicant will reduce tissue destruction.1,10 Until the nurse knows whether an antidote will help, he or she must not remove the peripheral IV; in fact, antidotes can be injected through the catheter into the extravasated tissue.To help disperse the vesicant for quicker absorption, the nurse can elevate the extremity. When there is an infiltration, it is important to consult with a pharmacist or pharmacy formulary to determine whether the infiltrated solution or medication is an irritant or vesicant before intervening.
18 Nursing Responsibilities Primary/secondary tubing changed per hospital policyQ 4 days (ANW)TPN/Lipids changed q dayIntermittent IVPB tubing changed q 24 hoursWhen IV dc’d assess site and make sure jelco tip intactIf Heparin used to flush central access device…assess for HIT
19 PIV Troubleshooting Pain Distal occlusion alarm on IV pump Leakage Assess site…always a red flag and IV should be DC’d unless has irritating solution infusingDistal occlusion alarm on IV pumpAC site-extend armFlush site and assess for occlusionLeakageMake sure is not from loose attachment to jelco? InfiltrationFlush IV slowly w/5-10cc NSAssess for leakage/swelling/pain
20 Central Lines: PICC Indications Complications Nursing Priorities Length of therapyComplicationsPhlebitisMeasure mid arm circimference and documentNursing PrioritiesDressing intactSite assessmentNote how many cm. out to hub & validate
21 Central Lines: Implanted Port Accessing portsAccess needle/tubing changed q 7daysDressing changed q 7 daysSite assessment
22 Central Lines: Non-Tunneled IndicationsLength of therapyComplicationsNursing PrioritiesRisk of InfectionInsertionAccessing deviceSystemic infectionRemove as soon as possible
23 Arterial Lines Locations Indications Nursing priorities Site care Pressure bagCMSComplicationsInfectionInfiltrationBleeding
24 Blood Product Administration Minimum 22 g.(blue hub) IV-prefer 20g.(pink) or 18g. (green)Informed consent obtainedAdminister within 30” once received from Blood BankBlood tubing with filter-use NS to prime/flushValidate pt., type of blood product, expiration date, blood tag #VS before, 15” after initiation, end of eachInfuse PRBC’s over 2 hours (appx 300cc/unit)Consider Lasix chaser if hx CHFRefer to p.73190% hemolytic transfusion reactions-worst life threatening due to giving blood product to wrong ptAsses closely first 15-30” infuse at rate no more than 125cc/hrTransfusion reaction—… …People older than 65 use 43% of all donated Blood. The demand for Blood and Blood products will increase as the population ages. 25% of all Blood products are used to treat cancer patients. One out of every ten people entering a hospital requires Blood. The average liver transplant patient needs 40 units of red Blood cells, 30 units of platelets, 20 bags of Cryoprecipitate, and 25 units of fresh frozen plasma. heart surgery uses, on average, the red Blood cells and platelets provided by from six Blood unit donations. People who have been in car accidents and suffered massive Blood loss can need transfusions of 50 units or more of red Blood cells. The average bone marrow transplant requires the platelets from about 120 donations, and the red Blood cells from about 20 Blood unit donations.
25 Complications Blood Products Circulatory OverloadAcute Hemolytic ReactionChills, fever, flushing, tachycardia, SOB, hypotension, acute renal failure, shock, cardiac arrest, deathFebrile-Nonhemolytic ReactionSudden onset of chills, fever, temp elevation >1 degree C. headache, anxietyMild Allergic ReactionFlushing, urticaria, hivesWho is at risk?...how can you minimize this potential problem?Hemolytic-due to incompatible blood-antibodies of pt. attaching to incompatible antibodies of unitFebrile-most common-due to sensitization to donor WBC’s, platelets or plasma proteinsMild allergic due to sensitivity to plasma proteins
26 Nursing Responsibilities STOP transfusionMaintain IV site-disconnect from IV and flush with NSNotify blood bank/MDRecheck IDMonitor VSTreat sx per MD ordersSave bag and tubing-send to blood bank
27 Chest Tube: Nursing Priorities Assess resp. status closelyCheck water seal for bubblingMilk NOT strip every 2 hoursAssess color-amount drainageCall MD if >100cc/hr x2 hours first 24 hoursSterile quaze/occlusive dressing at bedsideCheck water seal for bubbling…IF YOU CLAMP THE TUBING CLOSE TO THE PT-IT STOPS…WHAT DOES THIS TELL YOU?
28 Mechanical Ventilation The use of an ET and POSITIVE pressure to deliver O2 at preset tidal volumeModesAssist Control (AC)TV & rate presetAdditional resp. receive preset TVSynchronized Intermittent Mandatory Ventilation (SIMV)Additional resp. receive own TVUsed for weaningContinuous Positive Airway Pressure (CPAP)Bi-papNon-mechanicalreceive both insp. & exp. Pressures w/facemaskModesAssist Control (AC)Synchronized Intermittent Mandatory Ventilation (SIMV)Bi-papContinuous Positive Airway Pressure (CPAP)
29 Mechanical Ventilation TerminologyRateTidal volume10-15cc/kgFraction of inspired O2 concentration (FiO2)Use lowest possible to maintain O2 satsPositive End Expiratory Pressure (PEEP)Minute volumeRR x TVAC12-TV %-+5
31 Mechanical Ventilation:Nursing Priorities Ventilator Alarm TroubleshootingHigh pressureSecretions-needs sxTubing obstructed or kinkedBiting ETLow pressureDisconnection of tubingFollow tubing from ET to ventilator