advanced nursing skills day
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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. - PowerPoint PPT PresentationTRANSCRIPT
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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.
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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.
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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.
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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
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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
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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
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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
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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
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IV Insertion
1. Chloroprep 1. Prep for at least 10 seconds2. Allow to air dry before insertion
2. Distal/circumferential traction3. Low approach angle…bevel up
directly on top of vein4. Upon blood flash go level and
advance 1/8” 5. Slide jelco in slowly6. Pressure on vein 1” distally once
removed stylette7. Stabilize PIV securely with tape or
Stat-lock if available (preferred)8. Transparent dressing
IV Therapy Complications: Infiltration
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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
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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
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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
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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
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Site Assessment
• Assess tenderness by palpation• Redness• Moisture/leaking• Swelling distally if continous infusion• Dressing labeled
Date insertedSize of IV jelco Initials of nurse
• If >4 days since inserted DC and restart
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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
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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
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PIV Troubleshooting
Pain• 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
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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
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Central Lines: Implanted Port
Accessing ports Access needle/tubing changed q 7days Dressing changed q 7 days Site assessment
Central Lines: Non-Tunneled
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Indications• Length of therapy
Complications Nursing Priorities
• Risk of Infection Insertion Accessing device Systemic infection Remove as soon as
possible
Arterial Lines
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Locations Indications Nursing priorities
• Site care• Pressure bag• CMS• Complications
Infection Infiltration Bleeding
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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
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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
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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
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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
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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
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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
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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