Advanced Nursing Skills Day Keith Rischer RN, MA, CEN

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.

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

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.

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

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

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?

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)

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 600-50%-+5

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

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