Advanced Nursing Skills Day

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Advanced Nursing Skills Day

• Keith Rischer RN, MA, CEN

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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.

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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.

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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.

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Insulin Carb Counting

• Time action profiles of
• Novolog
• Regular
• Lente
• NPH
• Mixing
• Insulin pen

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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 minutehow 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 InsertionVenous 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

• Chloroprep
• Prep for at least 10 seconds
• Allow to air dry before insertion
• Distal/circumferential traction
• Low approach anglebevel 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

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IV Therapy Complications Infiltration

• Progression
• Skin blanchededemalt1 in any directioncool to
  touchmay or may not have pain
• Edema 1-6 in any direction
• At this level or greater requires incident report
• Gross edema gt6 in any directionmild to moderate
  pain
• Skin tight, leaking, discolored, bruised or
  swollen, deep pitting edema, circulatory
  impairment

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Infiltration/Extravasation Nursing Priorities

• DC infusion immediately
• Documentnotify 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 streakpalpable venous cord
• Palpable venous cord gt1 and purulent drainage
• At first sign of phlebitis IV must be DCd and
  event documented

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IV Therapy ComplicationsInfection

• 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 inserted
• Size of IV jelco
• Initials of nurse
• If gt4 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 dcd assess site and make sure jelco tip
  intact
• If Heparin used to flush central access
  deviceassess for HIT

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PIV Troubleshooting

• Pain
• Assess sitealways 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

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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

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Central Lines Non-Tunneled

• Indications
• Length of therapy
• Complications
• Nursing Priorities
• Risk of Infection
• Insertion
• Accessing device
• Systemic infection
• Remove as soon as possible

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Arterial Lines

• 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 PRBCs 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 gt1
  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 gt100cc/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

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Mechanical VentilationNursing 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