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

6. IV Med Administration Principles
COMPATIBILITY
Correctly calculate rate of IV push to q15-30 seconds
Label all syringes brought into room once aspirated
Assess site
Aseptic technique w/port
Knowledge 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 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. S: Scrupulous hand hygiene A: Aseptic technique
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. 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. 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
Do not use PIV same side as pt. who has had axillary node dissection, dialysis shunt
Need MD order if no other options
Hair removal if needed-use clippers or scissors
Shaving can cause micro abrasions which increase risk of infection

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

12. IV Therapy Complications: Infiltration
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
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. 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 DC’d and event documented

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. 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. 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
Irritants, 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 policy
Q 4 days (ANW)
TPN/Lipids changed q day
Intermittent IVPB tubing changed q 24 hours
When IV dc’d assess site and make sure jelco tip intact
If 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 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. Central Lines: PICC Indications Complications Nursing Priorities
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. Central Lines: Implanted Port
Accessing ports
Access needle/tubing changed q 7days
Dressing changed q 7 days
Site assessment

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

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

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 PRBC’s over 2 hours (appx 300cc/unit)
Consider Lasix chaser if hx CHF
Refer to p.731
90% hemolytic transfusion reactions-worst life threatening due to giving blood product to wrong pt
Asses closely first 15-30” infuse at rate no more than 125cc/hr
Transfusion 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 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
Who is at risk?...how can you minimize this potential problem?
Hemolytic-due to incompatible blood-antibodies of pt. attaching to incompatible antibodies of unit
Febrile-most common-due to sensitization to donor WBC’s, platelets or plasma proteins
Mild allergic due to sensitivity to plasma proteins

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. 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
Check 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 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
Modes
Assist Control (AC)
Synchronized Intermittent Mandatory Ventilation (SIMV)
Bi-pap
Continuous Positive Airway Pressure (CPAP)

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. 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
Positive pressure decr. venous return & CO
Increases intrathoracic pressure

31. Mechanical Ventilation:Nursing Priorities
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