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Advanced Nursing Skills Day

Keith Rischer RN, MA, CEN

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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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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 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

Mechanical Ventilation:Nursing Priorities

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Ventilator Alarm Troubleshooting• High pressure

Secretions-needs sxTubing obstructed or kinkedBiting ET

• Low pressureDisconnection of tubingFollow tubing from ET to ventilator