NRS 221B Open Lab Assignment Skill Scenario #1: IM & SQ meds, including insulins At this station, you will practice preparing & injecting IM/SQ meds, including insulins. Prior to completing the scenario, practice mapping the following injection sites on a family member or lab partner. Palpate and map on bare skin if possible (but only with mutual consent and while wearing gloves and PPE): Abdominal & posterior arm (SQ) Deltoid (IM) Ventral gluteus (IM) Dorsal gluteus (IM) Vastus lateralis (IM) Yousef Abadi is a 56-year-old male admitted for NSTEMI. He also has a hx of DM2, and he’s currently experiencing a pruritic rash attributed to a mild allergic reaction to hospital socks. He will d/c home later today. This morning, he has orders for: 1. Enoxaparin 100 mg SQ Hydroxyzine 25mg IM Pneumovax (pneumococcal vaccine) 0.5ml IM NPH Insulin 16 units SQ Regular Insulin, sliding scale 2 units for every 20mg/dl cbg >160 What is the appropriate needle size, site & technique for administering the enoxaparin? Admin this medication into an injection pad. - Needle size: 25-30 Gauge, ⅜ - 1-inch needle for sq (pre-loaded) - Site: abdomen - Technique: evaluate the skin/pt to see how much skin available to be pinched for the shot. Ask them where they previously got the last shot so that I can avoid it this time. clean the skin with an alcohol wipe; create a skinfold by pinching the area surrounding the injection site, avoiding the 2” around the umbilicus and belt line. Inject the needle quickly at a 45–90-degree angle, depending on the size of the patient and/or the amount of subcutaneous fat in the area. Inject the medication slowly and quickly withdraw the needle. Do not massage the area. 2. What is the appropriate needle size, site and technique for administering the hydroxyzine? Administer this medication into an injection pad. o Needle size: 1.5-inch, 22-25 G o Site: Ventrogluteal o Technique: Map ventrogluteal site by placing palm on greater trochanter and index finger toward anterosuperior iliac. Clean the injection site between the second and third fingers, and then inject medication at a 90-degree angle. Withdraw needle and do not massage site. 3. What is the appropriate needle size, site and technique for administering the Pneumovax? Administer this medication into an injection pad. o Needle size: 1 inch, 25 G o Site: Deltoid o Technique: Map deltoid site by locating the acromion process, place three fingers below and use the other to make a V-shape and give the injection at a 90degree angle in between the V. Withdraw needle and do not massage site. 4. Mr. Abadi’s morning cbg is 244 o What is the correct dose of each insulin to prepare? NPH 16 units + Regular 8 units o Can they be mixed and given as one injection? If so, describe the process. Yes, they can be mixed and given as one injection. swab both vials with an alcohol swab and roll the NPH vial between my fingers, I would inject 16 units of air into the NPH vial. Withdraw the needle and then inject 8 units of air into the regular insulin vial. I would then turn the vial upside down and draw out 8 units of Regular insulin, then Put the same needle into the NPH vial, turn it upside down, and draw 16 units (pulling the syringe back to 24 unit mark). What is the appropriate needle size, site & technique for administering these insulins? Admin this med into an injection pad. Needle size: 28-31 G, 3/16 -½ inch Site: abdomen (or back of arm) Technique: After cleaning the skin, I would pinch the skin fold area surrounding the injection site, avoiding the 2” around the umbilicus and belt line. I would then Inject the needle quickly at a 45-90 degree angle, depending on the size of the patient and amount of subcutaneous fat that is in the area. I would Inject the medication slowly and quickly then withdraw the needle, making sure not to massage the area. I would Rotate sites for each injection. Skill Scenario #2: IV Meds and Fluids At this station, you’ll practice preparing & administering IV fluids and medications. Ms. Lola Yamamoto is an otherwise healthy 38-year-old female admitted for pyelonephritis that she reports she contracted after being bitten by a spider. Her pain and nausea have not been well controlled by oral medications, and she is not tolerating anything by mouth today. Her vitals are within normal limits, and she has an IV that is currently saline locked. The hospitalist enters these new orders: NS @ 100ml/hr IV, continuous infusion Levofloxacin 250 mg IV once daily, infuse over 60 minutes Ondansetron 4mg IV once now Ketorolac 15mg IV once now Morphine 2mg IV prn 5. Implement the order for IV fluids Use one of the 500ml bags from your kit. 6. Prepare to administer the levofloxacin as a piggyback. Use one of the 50ml bags from your kit. Do you have any concerns with this order? Justify your answer (think DRIPh) I do not have any concerns with levofloxacin as a piggyback because it’s compatible with NS; it must be given over 60 minutes, which is what the order is. If safe, administer the levofloxacin. While the levofloxacin infuses, what is happening with the maintenance fluid? Because the maintenance fluid is hung lower than the piggyback, the levofloxacin (piggyback) will infuse first. When the piggyback is complete, the maintenance fluid will resume at its normal rate. 7. Prepare to administer the ondansetron. Do you have any concerns with this order? Justify your answer. There are no concerns because ondansetron is compatible with NS & levofloxacin. Describe how you will safely administer this medication. Perform these actions. Pause the IV pump and pinch the tubing above the injection port. I would scrub the injection port with alcohol for 15 secs and allow to dry, I then would flush 5ml saline over 1 minute, clean injection port with alcohol swab for 15 secs, allow to dry, administer ondansetron via IV push over 2-5 mins, clean hub again 15 secs, flush 5 ml saline over 2-5 mins, un-pinching the IV tubing and unpause IV pump to continue running maintenance fluids. 8. Prepare to administer the ketorolac. 1. Do you have any concerns with this order? Justify your answer Ketorolac is incompatible with levofloxacin 2. Describe how you will safely administer this medication. Perform these actions. Pause the IV pump, pinch the tubing above the injection port, scrub the injection port with alcohol swab for 15 secs, allow to dry, I then would clean the injection port with alcohol swab for 15 secs and administer ketorolac via IV push over 15 secs, clean the hub again for 15 secs and flush 10ml saline with the first 3ml at the same rate as the med (15 secs/ml, for a total of 45 secs), then flush the remaining 7ml slowly, un-pinch IV tubing, un-pause IV pump to continue running maintenance fluids. 9. Can you describe a more efficient way to have implemented these four orders? I would give the ketorolac and ondansetron first while the patient is saline-locked (prior to setting up maintenance & piggyback IV) to avoid having to pause the IV maintenance fluid and piggyback. This would also get pain meds and anti-nausea meds into the patient more quickly. 10. Ms. Yamamoto reports bilateral flank pain 8/10 despite your previous interventions. Prepare to administer the morphine. Do you have any concerns with this order? Justify your answer. Yes, w/ how the order was worded as it did not give parameters for pain levels and how often to give the med.. The hospitalist clarifies the order: Morphine 2mg IV q1hr prn if pain >6/10 after ketorolac. Describe how you will safely administer this medication. Perform these actions. After reassessing pain and making sure it is at least 6/10, I would Pause the IV pump, pinch the tubing above the injection port, then scrub the access port with alcohol for 15 secs and allow to dry, then I would administer morphine via IV push over 15 secs, clean hub again 15 secs, flush 10ml saline with the first 3ml at the same rate as the med, then flush the remaining 7ml slowly, un-pinch IV tubing, un-pause IV pump to continue running maintenance fluids. Describe how you will reassess Ms. Yamamoto after these interventions I would assess them immediately after administering morphine, and then I would reassess after 15 mins including the patient’s pain level, RR, HR, BP, and LOC. 11. As you are charting the last medication, you see the hospitalist has added this additional order: NS 500ml IV bolus now, infuse over 30 minutes. Describe how you can implement this order without disrupting the antibiotic infusion. You do not need to perform this action. I would set up the bolus on a separate IV pump and attach the IV tubing from the new pump to the Y-port closest to the patient (original IV tubing). 12. 13. Ms. Yamamoto states “I need to pee and I can’t go with all this stuff connected to me.” - Pause the infusions, disconnect and saline lock her IV so she can use the bathroom. - She returns to the bed and says “false alarm.” Reassess the IV and restart the infusions. When the levofloxacin infusion is finished, what actions will you need to take? What will you do with the empty bag and secondary tubing? Assess the IV pump and tubing that is still running the maintenance fluids to make sure that it’s running at the correct rate. Then I would disconnect the levofloxacin infusion IV bag and tubing and throw it away in the garbage. Skill Scenario #3: Foley catheters At this station, you will practice Foley catheter insertion and removal. Ms. Brenda Parsons is a 64-year-old woman admitted for generalized weakness and heart failure exacerbation. She has a history of chronic CHF and obesity with a BMI of 52. She reports suffering from occasional urinary incontinence at baseline, which she says started after her cat died of COVID-19. This has become worse with aggressive diuresis, which is challenging to manage due to her decreased mobility and body habitus. 14. Ms. Parsons and the off-going nurse had become frustrated by the frequency of bed changes needed because of urinary incontinence, so the nurse text paged the hospitalist requesting an order for a Foley catheter. The hospitalist catches you before rounding on the patient and asks about the request. Does this request seem appropriate? Justify your answer. NO, this request is not appropriate because the CDC guidelines for catheterization states that a catheter should not be inserted based on incontinence and high BMI only (this is not an approved use). there is a high risk for CAUTI’s with foley’s and they should not be used for convenience purposes, nor can a patient’s request for a catheter justify using it. What are the six appropriate indications for a urinary catheter according to CDC guidelines? Patient has acute urinary retention or bladder outlet obstruction. Need for accurate measurements of urinary output in critically ill patients. Perioperative use for selected surgical procedures o Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract. o Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU). o Patients anticipated to receive large-volume infusions or diuretics during surgery. o Need for intraoperative monitoring of urinary output To assist in healing of open sacral or perineal wounds in incontinent patients. Pt requires prolonged immobilization (potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures). To improve comfort for end-of-life care if needed. What are some alternatives to a catheter that you could try? External caths like a purewick, bedpan, depends or a female urinal Intermittent catheters can be used to drain the urine and avoid the risk of a cauti Putting a bedside commode closeby so that she does not have to walk as far a distance Making sure the longer chucks are under her to gather more urine which will hopefully avoid frequent bed changes 15. Later in the day, Ms. Parsons’ condition deteriorates, and the hospitalist requests transfer to a critical care unit. You receive several new orders, including an order to insert a Foley catheter for intensive urine output monitoring. Does this order seem appropriate? Justify your answer. The order is appropriate because the patient’s condition has deteriorated with the need for intensive urine output monitoring; this is one of the CDC’s appropriate indications for a foley catheter. 16. You have completed all higher-priority orders and the ICU bed is not yet ready. Gather equipment, provide teaching, and insert a Foley catheter. [You can use either gender model] Once inserted, how will you secure the catheter? I will use a statlock stabilization device to secure the cath to the leg of the patient, and make sure there is enough slack for ease of movement. How will you leave the tubing and collection bag? The tubing will need to be free of kinks and with an independent loop and the collection bag needs to be hung lower than the patient on the side of the bed (not on a bed railing). 17. You receive a new order to collect a urine specimen. Implement this order. There will not be urine in the drainage system but perform the actions as if there were. 18. A week has passed, and Ms. Parsons is transferred back to your unit in stable condition. She no longer requires intensive output monitoring and will likely discharge to a rehab facility tomorrow. Her Foley is still in place. What should you do with regards to her Foley? Justify your answer. Since she is no longer critically ill and doesn’t need intensive output monitoring, her foley needs to be discontinued (based on the CDC criteria for appropriate foley catheter use). However, I would first make sure that I had an order to DC her foley, and then once there was an order, I would D/C and remove the foley. Your charge nurse reminds you that you have an order for the nurse-driven protocol for d/c’ing urinary catheters, which requires that you discontinue the Foley if the patient no longer meets one of the 6 CDC indications. Implement this order. What teaching will you provide the patient regarding post-Foley care? Let the patient know that it is normal to have some discomfort and irritation after the foley is removed. There may also be some pink colored urine in addition to some hesitancy when starting your urination stream, which should both resolve on their own. if this continues the patient should contact us (her hcp). The patient should urinate on her own within 1-2 hours after discontinuing the foley. 19. Practice inserting and removing a Foley catheter again, this time using the other gender model. When inserting a catheter into a male patient whose penis is uncircumcised, what action is necessary after the catheter balloon has been inflated? Why? The foreskin should be returned to its normal position (it would have been pulled back to insert the foley). Pulling the foreskin back is for comfort and also safety so that the penis has proper blood circulation. Skill Scenario #4: Nasogastric (NG) Tubes At this station, you will practice NG tube insertion, assessment, suction, irrigation, medication administration, feeding and removal. Mr. Ricky Smith, age 44, presents to the ED with abdominal pain and distention as well as copious vomiting. He reports a history of abdominal surgery several years ago “to remove an alien baby...or maybe it was a tumor, I can’t remember.” A CT scan finds evidence of a small bowel obstruction, so Mr. Smith is admitted for observation and a surgical consult. The surgeon orders insertion of a Salem sump NG tube for gastric decompression and bowel rest. 20. Gather equipment, provide teaching, and insert the NG tube. How far will you insert the NG tube? Measure NEX & mark it with a marker or tape; to the level of the diaphragm. 21. Once inserted, assess for proper placement of the NG tube. How will you assess placement immediately following insertion? I would Aspirate the stomach contents and check pH (less than 5.5), color, and consistency and whether the patient tolerated well. What other data do you need to definitively ensure proper placement? An x-ray will show proper placement Where might a misplaced tube be, if not the stomach? Trachea or duodenum 22. You have an order to connect the NG tube to low continuous suction. Implement this order. What is the appropriate suction level for this order? 40mmHg or lower How will you position the tube and the patient before leaving him unattended? Secure the tube to the patient’s nose with tape (and padding under) after applying skin barrier cream and leave slack for the patient to turn their head from side to side, and secure the tube to the gown. They Should be in semi-fowler position to reduce aspiration risk. What should the patient expect to experience, and what should he call you for? Patient may experience dry mouth, dry nares, and throat irritation. The patient should call if he experiences new pain or discomfort, and/or abdominal bloating, nausea, or pain. 23. An hour later, Mr. Smith reports increasing nausea and abdominal discomfort. You note no additional NG output since insertion. What might be going on? What actions will you take to address this change? The tube may be clogged or there may be a problem with the suction, or possibly tube displacement. I would assess the patient first, and check the suction with connections. Then if I could see any chunks in the tubing, I would milk the tubing to clear it. If this didn’t resolve the problem, I would inject 10-30ml of air to clear the tubing of anything stuck to the insides. Also, check the depth of the tube from where it was marked. You have an order to irrigate the NG tube with 30ml sterile water PRN. Perform this action. Use the lab model set up to receive fluids 24. The next morning, the night nurse reports that tube has been functioning properly with about 500ml of output overnight. You receive two new orders: Administer Tylenol 500mg and Toprol XR 50mg via NG. How will you assess the tube prior to use? First, aspirate for gastric contents and assess the contents, then flush with 30-50ml sterile water. Do you have any concerns with these orders? Justify your answer and perform the appropriate action(s). Use the lab model set up to receive fluids. I would possibly be concerned about Toprol XR because per Davis Drug Guide this med should not be crushed; however, if Kapspargo sprinkle was available, it could be given instead with the NG tube. Tylenol can be crushed and can be administered via the NG tube. How will you leave the tube and patient after administering the medication? I would Leave the suction off for at least 30 minutes after administering meds. The Patient should be left with the head of the bed raised at least 30 degrees. 25. Typically, a Salem sump NG tube is used for gastric decompression and not feeding; however, short-term tube feeding may be done through this tube and the procedure uses the same technique as with feeding tubes. The following day, you receive a new order: Discontinue NG suction and initiate a trial of tube feeding via NG with Jevity 1 cal formula @ 50ml/hr for 2 hours. Perform this action Use the lab model set up to receive fluids. Prior to next feeding, what additional assessment would you expect to perform? gastric residual volume. 26. Following successful tube feedings and evidence that the small bowel obstruction is resolving, Mr. Smith is expected to discharge the following day. You have a new order to remove the NG tube. Perform this action. Use the lab model in which you inserted the NG. What action do you perform to decrease the likelihood that the patient aspirates gastric contents or tube feeding solution during the removal? Pinch/clamp the tube and have the patient take a deep breath and hold it while quickly removing all the tubing. 27. Inspect the additional gastric and enteric tubes on the supply cart. Keo-feed or small-bore feeding tubes are commonly used for adult and pediatric patients requiring long-term tube feeding (but not suction) both in the inpatient and outpatient settings; these are nasoenteral tubes that require special training to insert. For patients requiring permanent tube feeding, a percutaneous endoscopic gastrostomy (PEG) tube is typically placed by a surgeon or interventional radiologist. Skill Scenario #5: Central Lines At this station, you will practice central line assessment, maintenance, medication administration, dressing change & removal. Mr. Jorge Guerrero, age 63, is post-op day 5 following a 2-vessel coronary artery bypass (CABG). His recovery had been unremarkable and he tells you he is very excited to go home today to cuddle with his therapy tortoise, Arnold. He has a triple-lumen subclavian central line in place with each port currently saline locked. 28. As part of your initial shift assessment, assess the central line site and flush each port. Describe your process: - Check chart for xray placement via ekg & allergies to chg and tegaderm - Wash hands & don gloves - Look for swelling/redness/purulent drainage/sx of infection - Ask pt if have allergies - Make sure lines have not shifted - Scrub hub for 15sec - Aspirate with push/pause technique o 29. Aspirate blood into tube & pulsate push 10ml (last few close clamp) - Grab new curos cap and place on hub - Repeat process for each port You find that the medial port will not flush. What do you do? Get a new hub and replace old one; try to aspirate new hub Document “Unable to aspirate blood from (name of port. i.e., proximal, medial or distal) port. Port not used. Reported to PCN” & report to iv team 30. You note the dressing has partially peeled off and there is some dried blood at the site. Perform a dressing change on the central line site. 31. A little while later, the hospital phlebotomist finds you and asks if you can draw a blood sample because he missed several attempts. Can you do this? If yes, collect a 2ml sample. Describe your process: - Check chart for xray placement via ekg & allergies to chg and tegaderm - Wash hands & don gloves - Look for swelling/redness/purulent drainage/sx of infection - Ask pt if have allergies - Make sure lines have not shifted - Use distal port (biggest gauge & flow rate) - Scrub hub for 15sec (unclamp) - Aspirate with push/pause technique (10ml & pulsate) & throw away - Scrub hub for 15sec - Take new syringe and aspirate 5-10ml & push slowly back in 4 times (being careful not to hemolyze the blood) - With same syringe, take 2ml blood & scrub hub 15sec (clamp) 32. - Grab new hub and prime unclamp & add new hub to port & flush 10ml saline w/ push pause technique - Clamp port and new curos cap You receive these new orders: Ketorolac 15mg IV once now NS @ 125ml/hr IV now. Implement these orders. Set up the fluids and load the pump, but do not start the infusion perform 33. Later, you notice the cardiac surgeon has rounded on the patient. Soon, several new orders appear in the EMR: Transfuse 2 units packed red blood cells now Initiate TPN per pharmacy now 0.45%NS @125ml/hr IV now Regular insulin IV infusion per TPN insulin protocol Describe or draw how you would implement these orders on Mr. Guerrero ( do not perform these actions). Assume the medial port is now patent: Distal port used for blood transfusion since it is the largest, the medial will be the safest location for the tpn, and the proximal is the only one open to allow for the medication (but all can be used for admin the med). Then make sure to label each port with the correct information. 34. Your phone rings, and the surgeon says “Oops, I entered those orders on the wrong patient, please disregard. I am discharging the patient, go ahead and pull the central line”. Can you follow this telephone order? Yes, you can remove the cvad, and make sure to ask the doc to do written portion is in the pt file within 24hrs. 35. You see that the EMR orders have been updated, and there is an order that reads: Remove central line now. What do you need to check before implementing this order? - Confirm there is an order 1. Check most recent coagulation labs (PT/INR, aPTT, platelets); if abnormal, consult provider 2. Assess for sx of catheter-associated thrombus (edema, redness & pain in the region distal to the cath) 3. Assess for pt’s ability to tolerate supine positioning 4. Instruct & assess for ability to perform Valsalva maneuver 2. Know facility policies. Locally, med-surg RNs can remove subclavian or IJ central lines that are 8Fr or smaller 3. Ensure there is a functional peripheral IV before removing the central line 36. Assuming all patient data supports the safe removal of the central line, gather your supplies and remove the central line. 37. After removing the central line, describe how you will monitor Mr. Guerrero. What will you instruct to him to do with regards to the central line site? After Putting pressure on the site for at least 5mins, I would have them lay flat flat for 30mins and check on them every 15mins for the first hour. I am looking for signs of an air embolism, hematoma. Or drainage if an embolism was suspected, I would lay them on the left side in Trendelenburg position. If everything is fine after the hour, I would have him do one last Valsalva maneuver and check the gauze and then cover with tegaderm and tell him not to do any strenuous activity for the next 24 hours as well as leave the bandage on for that long.
