NUR 241: Exit skill

1. NUR 241: Exit skill Exit skill for Heparin Administration

2. Nursing simulation lab contract • For this skill, you will be given a Nursing Simulation Lab Contract, which you will have to sign • Students will be required to: • Calculate IV administration rate of medication; e.g. Heparin Drip before beginning • Correctly mix & set up a drip to be piggybacked to an existing IV • Correctly set an IV pump to administer the correct dosage of medication prescribed • Set up for blood administration • SKILL: IV Administration on Pump* • Heparin Drip • Secondary IV (Piggyback) • Administration of Blood & blood products – 45 minutes

3. EXIT SKILL HEPARIN ADMINISTRATION • ASSESSMENT: • Reviewed accuracy & completeness of health care provider’s order for IV therapy. • Assessed for clinical factors & conditions that are affected by IV fluid administration. • Assessed patient’s previous experience with IV therapy • Collected information about the IV solution, any medications the patient is taking & possible incompatibility.

4. BEFORE STARTING HEPARIN • Heparin is used to prevent blood clots from forming in people who have certain medical conditions or who are undergoing certain medical procedures that increase the chance that clots will form. • Heparin is also used to stop the growth of clots that have already formed in the blood vessels, but it can’t be used to decrease the size of clots that have already formed. • The instructor may ask “why is Heparin given?” You should know why you give every medication and what it does before giving it!

5. Let’s talk about thrombocytopeniA • Mild to serious bleeding causes the main signs and symptoms of thrombocytopenia. • Bleeding can occur inside your body (internal bleeding) or underneath your skin or from the surface of your skin (external bleeding). • External bleeding usually is the first sign of a low platelet count. • External bleeding may cause purpura or petechial. • Purpura are purple, brown & red bruises. • Petechia are small red or purple dots on your skin.

6. Other signs of bleeding include: • Prolonged bleeding, even from a minor cut. • Bleeding or oozing from the mouth or nose, especially nosebleeds or bleeding from brushing your teeth. • Vomit that is bloody or looks like coffee grounds • Stool that contains bright red blood or is black & tarry. • Blood in the urine • Coughing up blood • Chills, Fever, Hives, Rash, Wheezing or shortness of breath

7. Exit skill heparin administration • Determined if patient is to have surgery or receive blood • Assessed for risk factors associated with IV therapy • Assessed laboratory values including PTT & history of allergies • Determine if heparin drip is safe to hang. Lab values within range 1 ½ - 2 ½ x control • Assessed patient’s understanding of IV therapy

8. Exit skill heparin administration • IMPLEMENTATION: • Explained procedure to the patient • Assisted patient to a comfortable position. Provided adequate lighting • Correctly verified patient’s identity. • Performed hand hygiene. Organized equipment at bedside. • Assisted patient to a gown with snaps on the shoulders, if available.

9. HEPARIN ADMINISTRATION – CONT’D • IMPLEMENTATION – CONT’D • Prepared IV infusion tubing & heparin drip • A. Verified IV solution correctly & prepared & labeled. Checked expiration date. • B. Opened Infusion set • C. Placed roller clamp about 2 to 5 cm (1 to 2 inches) below drip chamber in the off position. • D. Removed protective sheath over IV tubing port on IV solution bag. • E. Inserted infusion set spike (sterile) into fluid bag or bottle. • F. Primed infusion tubing by compressing drip chamber & filling to 1/3 to ½ full.

10. HEPARIN ADMINISTRATION – CONT’D • G. Removed protector cap on end of tubing (if necessary), released roller clamp & allowed fluid to fill tubing. Added extension tubing. • H.Removed Air Bubbles • I. Replaced protector cap on end of infusion tubing. • 8. Prepared heparin or normal saline lock for infusion

11. Heparin administration – cont’d • ASSESSMENT: • Reviewed accuracy & completeness of health care provider’s order for IV therapy. • Performed hand hygiene • Assessed patient’s knowledge of how positioning affects flow rate. • Observed IV site & patency of VAD (Ventricular Assist Device) & IV flow rate. • Identified patients risk for fluid imbalance

12. Heparin administration – cont’d • IMPLEMENTATION: • Correctly verified patient’s identity. • Calculated hourly rate in milliliters per hour (mL/hr) to be used with EID (Electronic Infusion Device). • Calculated correct dosage of heparin to be given • Placed adhesive tape on IV bottle or bag next to volume markings & timed as per order. • Calculated drops per minute (gtt/min) for gravity flowing IV. • Timed flow rate by watch • Followed correct procedure for using infusion controller or pump

13. Heparin administration – cont’d • Followed correct procedure for using gravity volume control device. • Smart pump configured to specific patient care unit: • A. Provided for patient privacy. Inserted tubing into the pump & selected patient care unit. • B. Selected medication & concentration of drug. • C. Programmed dose & rate. Initiated infusion. • D. Reconfirmed ordered rate if alarm sounded • Placed volumetric device between IV container & spike using aseptic technique • A. Filled with 2 hours of fluid volume • B. Assessed hourly & refilled as needed

14. HEPARIN ADMINISTRATION – CONT’D • IMPLEMENTATION – CONT’D • Instructed patient on how to move safely with IV & purpose of alarms. Advised patient to report any discomfort or alterations & alarms and not to touch settings. • EVALUATION: • Monitored infusion hourly & patency of site. • Observed patient to determine effect on IV therapy • Monitored PTT levels. • Assessed for signs of infiltration or phlebitis • Identified unexpected outcomes

15. What is ptt & why do you have to obtain in prior to administering heparin? • PTT – Partial Thromboplastin Time • PTT is a blood test that measure the time it takes your blood to clot. • A PTT test can be used to check for bleeding problems • Blood clotting factors are needed for blood to clot (coagulation). The partial thromboplastin time is an important test because the time it takes your blood to clot may be affected by: Blood thinners, such as Heparin.

16. Heparin administration – cont’d • Recording & Reporting: • Recorded appropriate information pertaining to IV therapy • Recorded new fluid rates • Documented use & type of infusion device • Reported appropriate IV information to nursing personnel

17. CONTRAINDICATIONS TO ANTICOAGULATION THERAPY • When should a patient not receive Heparin? • CONTRAINDICATIONS OF ANTICOAGULATION THERAPY: • Lack of patient cooperation • Bleeding from the following systems: • Gastrointestinal • Genitourinary • Respiratory • Reproductive • Hemorrhagic blood dyscrasias (abnormal condition of the blood) • Aneurysms • Severe Trauma • Alcoholism • Infections • Recent delivery of a baby • Open ulcerative wounds • Severe hepatic or renal disease

18. CONTRAINDICATIONS – CONT’D • Heparin sodium should not be used in patients: • With severe thrombocytopenia: • In whom suitable blood coagulation tests – e.g., the whole blood clotting time, partial thromboplastin time, etc. – cannot be performed at appropriate intervals • With uncontrollable active bleeding state

19. Heparin – cont’d • Symptoms: • Bleeding is the chief sign of heparin over-dosage. • Nosebleeds, blood in urine or tarry stools may be noted as the first sign of bleeding. Easy bruising or petechial formations may precede frank bleeding

20. Treatment of heparin overdose • When clinical circumstances (bleeding) require reversal of heparinization, protamine sulfate (1% solution) by slow infusion will neutralize heparin sodium. • Administration of protamine sulfate can cause severe hypotensive & anaphylactoid reactions.

21. END OF POWER POINT PRESENTATION • This is the end of the power point presentation for Heparin. • I found most of this information on the inter-net on Web M.D. • I understand that you may want to print some of the information on this power point presentation, but I’m not sure how well it will print. • If this is the case, don’t be afraid to “TAKE NOTES!” Also, by taking notes, you are more likely to remember the information that you write down! • Good Luck & don’t forget to practice!

22. VIDEO I FOUND ON YOU-TUBE FOR YOU • I realize that you do not have a video to go hand-in-hand with this skill. • I found one on you-tube for you, but you MUST REMEMBER that I am not affiliated with the school, and while you are more than welcome to watch the video, that I have included, you must follow the directions from your hand-out! • VIDEO: • Heparin Infusion clinical scenario • https://www.youtube.com/watch?v=oSYu59KUYgo • Remember, to watch any video, just “cut & paste” the link!