Advanced Nursing Skills Day: IV Meds, Carb Counting, IV Insertion, Central-Arterial Lines, Chest Tubes, ET-Ventilator, I

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 • 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. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Central Lines: Implanted Port

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

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

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Mechanical Ventilation:Nursing Priorities • Monitor VS-breath sounds closely • Assess ET securement/length at lip • Clearance of secretions • Closed suction-maintains sterility • Do not do routinely • Pre-oxygenate • Sedation • Propofol • Oral care • Nutritional support

34. 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

35. Arterial Blood Gases:Ventilator Case Study 40 yr male w/seizure disorder Chief complaint Altered mental status Vague abd pain Weakness Hypotension Physical assessment Epigastric-LUQ tender VS T-101.2/P-110/R-24/BP 92/42/sats 95% RA Admission Labs WBC-11,000 Hgb-12.2 Platelets-64,000 Creatinine-2.7 ALT-502 AST-219 Ammonia-68 Lipase-1947 Glucose-322 CT-encephalopathy Abd CT-inflamm. pancreas

36. Case Study:Later… Day of Admission Increasing lethargy, resp. distress ABG pH- 7.28 CO2- 59 O2- 52 HCO3- 23 O2 sats- 84 FiO2-100% vent…AC12, PEEP +5 CT-abd. Ileus-hepatic infarcts

37. Case Study:Day 1 CVP-21 VS-101.2-118-24-82/40 NG placed Labs WBC-12.7 Platelets-56 Creatinine-.7 ALT-243 AST-219 Lipase 523 ABG pH-7.25 CO2-52 O2-76 O2 sats-92% FiO2-100% PEEP now +10 Weight up 8 kg Non icteric IV Infusions Insulin gtt Lasix gtt TPN-Lipids Fentanyl gtt Versed gtt Levophed gtt Neosynephrine gtt Vasopressin gtt Heparin gtt

38. Case Study:Day 2 CVP-16 –weight up another 7.5 kg…poor u/o VS-100.5-110-24-84/44 Labs WBC-21.5 Hgb-12.5 Platelets-77 Creatinine-0.9 ALT-143 AST-41 Ammonia-30 Lipase 114 CXR-white out ABG pH-7.11 CO2-78 O2-58 HCO3-24 O2 sats-75% Vent-FiO2-100%, +15 Treatment Plan CRRT IV abx-Cipro/Flagyl Hold Lasix gtt NG LCS Lactulose Wean vasoactive gtts as able Continue all previous gtts Pan cultures Physical assessment Distended abd-hypoactive NG bile output Coarse crackles bilat Cool to touch Nursing Priorities…