NRSG 249 – NURSING SKILLS LAB IIII
WEEK 1 – DEMENTIA CARE
Dementia
- is a syndrome, not a specific disease and it is used as an umbrella term that encompasses many different types
Dementia Type
Alzheimer’s Disease
(AD)
-approx. 50% to 80%
of all Dementia
History
-gradual, progressive
onset
- irreversible
-presently,
Alzheimer’s is the
most common
neurological
degenerative
disease that
progressively
worsens over time
(Parkinson’s is 2nd)
Signs & Symptoms
-issues with memory loss
(short-term lost first, longterm lost late stage)
-may have difficulty
recalling phone # and
address
-confusion
-communicating/language
impairment (late state
speech may become
incomprehensible)
-anxiousness, frustration,
irritable, aggression due to
difficulties
-misplace or forget items
which leads to paranoia
(think that items have
been are stolen)
-hallucinations and/or
delusions could be
present
-normal gait (until later on
in the disease then will
have issues)
-struggle with ADL’s (more
assist. required as
disease progresses)
-difficulty with special
awareness
-personality/behaviour
changes
-withdrawal socially to
avoid difficult situations
-make impulsive/odd
decisions
-can be apathetic
-late stage: may forget
family members names
-late state can include:
incontinence, difficulty
swallowing, breathing
Pathophysiology
-some of the known risk factors include:
genetics/heredity, increased age, gender
(female higher risk), head injury, Down
Syndrome, CVD, Diabetes, poor diet,
smoking, inactivity, racial and ethnic
disparities (African American and
Hispanics highest risk)
-the hippocampus (looks like a seahorse,
one on each side of the brain) is one of
the first areas of the brain to be affected
(it atrophies/shrinks); the hippocampus
contributes to memory, learning,
emotional & behavioural responses,
spatial awareness, and navigation
-deposits of amyloid plaques and tau
tangles in the brain that clump together to
cause nerve cells to die (can only be
detected with a PET scan to support the
AD diagnosis)
-increased levels of glutamate (excitatory
neuro-transmitter - causes
chronic/persistent increased neuron
stimulation which over time will actually
cause the neurons in the brain to die)
-increased ventricle space in the brain
(where the CSF is produced, transported,
and removed)
-over time there is generalized cerebral
cortex atrophy (shrinkage)
-signs and symptoms may vary
depending on which area or side of the
brain the neurons are affected
Vascular Dementia
(VD)
-approx. 20% to 30%
of all Dementia
-abrupt or gradual
onset (progression;
depends on location
and extent of
damage)
-irreversible
-signs of vascular disease
-memory loss
-confusion
-impaired judgment and
abstract thinking
-decreased ability to plan
or organize
-depression, loss of
motivation
-frustration
-mood swings; impulsive
-risk factors are often linked to risk factors
for: CVD, CVA and Type 2 DM; racial
and ethnic disparities (African American
highest risk); gender (males higher risk);
genetics/heredity
-blood flow to the brain is reduced or
blocked in the brain, depriving brain cells
of oxygen and nutrients
-post- stroke (ischemic or hemorrhagic
stroke) or post-TIA’s or if not strokerelated then due to narrowing of the
-impaired
flexibility/wiliness to
change
-once onset present,
cognitive decline is slower
than the other types of
dementia
-reduced balance/falls risk
cerebral arteries (linked to CVD &/or Type
2 DM)
-white matter lesions present due to
microvascular disease
-signs and symptoms may vary
depending on which area or side of the
brain the cerebral artery(s) has been
affected
-risk factors: genetics/heredity (family
history of Lewy Body Dementia or
Parkinson’s Disease); gender (males
higher risk); increased age; CVD risk
factors; REM sleep behaviour disorder
-less conclusive data available about the
ethnic/racial differences
-Lewy Bodies (abnormal proteins) deposit
and build up in masses in the brain which
impair brain function – researchers are
less sure why these deposits form in
some people’s brain
-generalized brain atrophy occurs
-signs and symptoms may vary
depending on which area or side of the
brain is affected by the Lewy Bodies
(detected best with a PET Scan to
support the diagnosis of LBD)
-risk factors: genetics/heredity; gender
(males higher risk); traumatic brain injury;
CVD risk factors
-less conclusive data available about the
ethnic/racial differences
-Pick’s Bodies (abnormal proteins)
deposit and build up in masses in the
brain which impair brain function –
researchers are less sure why these
deposits form in some people’s brain
-frontal and temporal lobe atrophy occurs
-signs and symptoms may vary
depending on which area or side of the
brain is affected by the Pick’s Bodies
(detected best with a PET Scan to
support the diagnosis of FTD)
Lewy Body Dementia
(LBD)
-approx. 10% to 25%
of all Dementia
-insidious onset with
progressive
fluctuations
-irreversible
-symptoms can be similar
to Parkinson’s including:
shuffling gait, slow
movement, tremors, rigid
muscles, falls BUT
cognitive decline occurs
first for at least 1 year with
LBD including all below:
memory loss, depression,
apathy
-sleep problems
-visual hallucinations
-frequents
swings/fluctuation in
alertness (periods of
drowsiness or staring into
space)
Frontotemporal
Dementia
(FTD)
-approx. 10% to 15%
of all Dementia
-insidious onset with
rapid progression
-symptoms typically
occur earlier
compared to the
other types of
dementia’s
(typically in the 40’s
to 50’s but onset can
begin younger or
older than this)
-irreversible
-decreased inhibition
(frequently leading to
inappropriate behaviour)
-poor judgement
-poor executive
functioning
-apathy and loss of
motivation
-memory loss
-repetitive of compulsive
behaviour
-language impairment
-anxiety and depression
-changes in
personality/behaviour
Other examples that may cause Dementia include: Parkinson’s Disease (similar to Lewy Body Dementia but the order of
the onset is different with Parkinson’s Disease Dementia the onset of cognitive symptoms occur at least one year after the
movement symptoms occur with PDD); Huntington’s Disease; Creutzfeldt Jacob Disease (subacute spongiform
encephalopathy), Alcoholism, AIDS, Normal Pressure Hydrocephalus, Multiple Sclerosis, Head Injury, Brain Tumor
***mixed Dementia = more then 1 type of Dementia (e.g., having both Alzheimer’s Disease and Vascular Dementia)
7 A’s of Dementia
- Anosognosia (no knowledge of illness)
- Aphasia (loss of language)
- Agnosia (loss of recognition)
- Apraxia (loss of purposeful movement)
- Amnesia (loss of memory)
- Altered perception (loss of visual perception)
- Apathy (loss of initiation/concern)
WEEK 2 – NEUROLOGICAL ASSESSMENTS
Epidural & Spinal Block Assessment, Glasgow Coma Scale Assessment, Canadian Neurological Scale Assessment and
Seizure Care:
Nerve Blocks: Epidural & Spinal
• Primarily for acute or chronic pain management, labour, during surgery, post-surgery, oncology, palliative
• Single (one-time dose) administration, continuous infusion, or intermittent bolus technique
• Preservatives are neurotoxic to the spinal cord (medication must be preservative-free)
• Types of medications:
• Analgesic
• Anaesthetic
• Steroid
• muscle relaxant
• chemotherapy
Epidural vs. Spinal Block 
Action of the Block
• introduction of a small amount of medication into the
epidural space (epidural) or subarachnoid space (spinal)
in the lumbar region
• contraindications: CNS infection or trauma on insertion
• Examples of sites: T5-T8 for chest and upper abdominal
surgery; L2-L4 for lower abdominal and leg surgery (note
location may vary depending on the specific surgical
location)
Dermatome 
• The skin surface can be divided into sections that are supplied by a corresponding spinal
nerve. Each section is called a dermatome.
• A dermatome is an area of skin which is innervated by a single spinal nerve. There are 30
pairs of dermatomes in the body, from the skull to the toes, and each can be traced back to a
specific nerve root.
Sensory Levels
- Common Landmarks:
o T4 – nipple line
o T6 – xiphoid process
o T12 – top of pubis
o L1 – pubis
Insertion Procedure for an Epidural or Spinal Block 
• Anesthesiologist inserts the epidural catheter or spinal block needle
• The patient must stay very still, in either a side lying or sitting
position with his/her back arched to resemble the letter C; or back
arched like a mad cat (similar position for a lumbar puncture)
• This arching of the back will maximize the “opening” of the vertebral
interspaces
Epidural and Spinal Block – Advantages and Disadvantages
- Advantages
o less sedation and respiratory depression, improved pain
control
- Disadvantages/Complications
o requires frequent monitoring, hematoma, migration of catheter (epidural), local infection, risk of sepsis,
meningitis, fever, headache, overmedication, spinal cord damage
Examples of Side Effects R/T Analgesic
• Resp. Depression (decreased and shallow RR)
• Decrease in LOC
•
•
•
•
Pruitis
N&V
Urinary Retention
Seizures
Examples of Side Effects R/T Anaesthetic
• Hypotension
• Nausea & Vomiting
• Excessive sensory and motor loss
Pain
•
•
•
Conduct a focused pain assessment (including VAS scale assessment of 0-10)
Monitor LOC – do not administer analgesics if patient is lethargic
Breakthrough pain medication PRN (as long as patient is not suddenly drowsy, lethargic, confused) – any
concerns notify Dr.
Respiratory Status
• ABC’s and resp assessment: if deterioration in resp. rate = or < 8 breaths/min or 02 sats < 90% (if not COPD) or
sedation score is 3 = a RESP EMERGENCY
• Stimulate patient, 02 therapy, turn infusion off, notify anesthesiologist, MD and the RT
• IV access should be a priority with any patient having a spinal or epidural block – if hypotensive IV bolus of fluid
may be ordered (e.g., 0.9% NS)
• Narcan (Naloxone) IV may be ordered to counteract an opioid – administered as per Dr’s orders
Epidural and Spinal Block Assessment
• Ongoing comparison to baseline assessment
• Vital signs and 02 saturation
• Chest assessment
• Allergies
• Assess pain
• Sedation level
• Sensory Level
• Dose delivered
• Ability to move, cough
• Side effects/Adverse reactions
Sensory Assessment Technique
• Using a cold object (e.g., ice), test areas to see if there is any change in sensory perception (patient should
describe the sensation)
• Anesthetic level should be recorded
• Significant changes should be reported
Sedation Scale
• 0 = no sedation; alert and awake
• 1= normal sleep, easy to rouse
• 2= mild drowsiness, but easy to rouse
• 3= moderate to severe drowsiness, difficult to rouse (emergency)
• 4 = unresponsive, unable to rouse (emergency)
Nursing Considerations
• Tubing should be taped up the back and to the clavicle
• Assess and document as per agency’s policy & PRN
• Strict sterile technique for dressing change and tubing changes (monitor for leaking)
• Students DO NOT change, reinforce the dressing, discontinue the epidural, or give medication via the epidural
• Warning: Do not administer systemic opioids or CNS depressants without approval from the MD and/or Pain
Service
Epidural and Spinal Block – Patient Teaching
• usually done pre-op so the patient understands how it works
• should provide both written and verbal instructions
• how to notify staff if inadequate control, change in pain intensity, machine malfunction, alarms
• the use of pain rating scales
•
•
•
the different routes of analgesia administration
the possible side effects of the analgesia and the management of these side effects
activity levels expected of the patient while receiving epidural or spinal block analgesia
Patient Controlled Analgesia (PCA)
• breaks the pain cycle
• gives the control to the patient (often uses less narcotic)
• avoids peaks and valleys
• decreases chance of errors
• decreases nursing workload
• RN programs pump according to Dr’s orders in dose increments
• minimum interval between doses (lock out period)
• the patient initiates medication administration by pressing the hand-held button
• usually morphine, dilaudid or fentanyl
• RPN role – assesses and monitors after the initial assessment is completed by the RN
Glasgow Coma Scale (GCS) Assessment
• Standardized tool to assess the patient’s level of consciousness (LOC) over time
• Take care when using the scale with patients who have sensory loss or motor paralysis – document what their
abnormal baseline was prior to the reason you are doing the GCS (e.g., a patient who has fallen and hit their head
may already have had a severe motor weakness d/t a previous stroke)
GCS Assessment
• Test used to detect early
neurological (LOC) changes in
patients
• 15 = normal
• 13 to 15 = minor injury
• 9 to 12 = mod. Injury
• 3 to 8 = severe injury
• < 7 = coma
• 3 = death
Types of Strokes 
Canadian Neurological Stroke Scale
(CNS / CNSS) Assessment
• Measures 6 physiological
deficits/impairments due to
stroke
• To be completed during the
patient’s acute phase poststroke (e.g., admitted from ER
with Dx. of stroke)
• GCS is not felt to be sensitive
enough for stroke patients who
do not have impaired LOC
GCS cs. CNS/CNSS Assessment
- No DR..’s order is required for nurses to initiate neuro assessments
o GCS: to assess level of consciousness (e.g., for head injury, brain infections, loss of consciousness, new
confusion, overdoses, becomes drowsy, stuporous/semi-comatose, or comatose)
o CNS/CNSS: to assess for deficits from a stroke if the patient is awake, alert or drowsy (e.g., assesses
motor function, expressive deficits, and receptive deficits)
Types of Seizures 
- During a seizure, there are bursts of electrical activity in the brain,
sort of like an electrical storm. This activity causes different
symptoms depending on the type of seizure and what part of the
brain is involved. Seizures can take on many different forms and
affect different people in different ways.
Focal vs. Generalized Seizure
1. Focal (previously “partial”) seizure: sudden uncontrollable
electrical discharges in 1 part of 1 cerebral hemisphere (may progress to generalized)
 Consciousness may be maintained, impaired or lost (may go through the post-ictal phase below if consciousness
is impaired or lost & muscles affected)
2. Generalized seizure: sudden uncontrollable electrical discharges from both cerebral hemispheres occur
 may go through all or some of these 4 phases:
i) Prodromal ii) Aura iii) Ictal iv) Post-ictal
Examples of Seizure Triggers
• CNS Disorder or Disease (e.g, Epilepsy, Multiple Sclerosis, Stroke, Brain Tumor, Alzheimer’s)
• CNS infection (e.g., Meningitis, Encephalitis, Brain Abscess)
• Metabolic Disorder: Hepatic failure or Renal failure
• Traumatic Brain Injury
• High fever or Heatstroke
• Stress and/or lack of sleep
• Some people have sensory triggers (e.g., rapid flashing lights, 3-D films, virtual reality, loud/chaotic noises, strong
smells)
• Metabolic and/or Electrolyte Imbalance (e.g., malnutrition, dehydration, hyponatremia, hypomagnesemia,
acidosis, hypoglycemia, hyperglycemia)
• Missed anticonvulsant med. Withdrawal (e.g., alcohol, benzodiazepines, barbiturates)
• Drug use (illicit drugs such as cocaine, amphetamines; prescribed medications such as certain antidepressants,
antipsychotics, analgesics, and certain med’s for smoking cessation or TB treatment)
• Pregnancy or Post Partum complications
Seizure Care (for tonic clonic convulsions)
• Monitor and protect ABC’s – notify RT STAT
if needed
• Don’t panic, stay calm and assign at least 1
nurse to stay with patient during the seizure
• Cushion patient’s head
• Remove hazards
• Do not put anything into the patient’s mouth
• Do not hold patient down or try to prevent
patient from convulsing
• Monitor for vomiting
• Time the seizure with a watch
• Administer medication as ordered on the
MARS (e.g., 1st choice: IV Ativan or Valium;
2nd choice if no IV access: IM or Intranasally
Versed or IM Ativan or PR Valium. This is
followed usually by an IV infusion of Dilantin)
**all patients admitted with a history of
seizures should have an IV site in case
needed and anti-convulsant PRN orders
• Let patient sleep afterwards (post-ictal period)
• Notify Dr. during if needed for orders otherwise afterwards; notify patient’s family afterwards
WEEK 3 – CYTOTOXIC PRECAUTIONS
Considerations with Cytotoxic Precautions
- hazardous medications can either be cytotoxic or non-cytotoxic that require special precautions (refer to your
agency’s pharmacy’s policy, WHIMIS and the drug manual for specific policy’s when handling any type of
hazardous medication)
- cytotoxic precautions refer to the safe handling of cytotoxic medications and related body fluids/wastes (these
precautions are only needed when storing, preparing and administering the cytotoxic medication and when
handling, moving or disposing of that patient’s body fluids/wastes and contaminated laundry & garbage and
cleaning up spills)
- the agency must provide health care providers, employees, volunteers, and the patient’s visitors information,
instruction and training in regards to cytotoxic precautions if they have the potential risk of having direct or indirect
exposure (e.g., this would include blood tech’s, pharmacy, nursing, PSW’s, physicians, OT, PT, RT,
housekeeping, porters, laundry servers, maintenance workers, waste workers, morticians etc.) **this is to ensure
the health, safety and welfare of all
- all cytotoxic and non-cytotoxic hazardous medications must be clearly labelled by pharmacy so that nurses can
identify them and take appropriate precautions to manage their risk of exposure when preparing and
administering the medication
- cytotoxic medications are intended primarily for the treatment of cancer but sometimes is also used for the
treatment of other non-cancer conditions (e.g., multiple sclerosis, psoriasis, systemic lupus, rheumatoid arthritis);
cytotoxic medications are known to be highly toxic to cells, principally through their action on cell reproduction and
many have proven to be carcinogens, mutagens or teratogens
- cytotoxic medications can be ordered in a variety of routes, depending on the specific medication (e.g., IV which
would require advanced training; oral or injectable)
- if the cytotoxic medication is to be given intravenously, the patient will require a central line in place (for IV med’s)
so that there is IV access for long term caustic medications that would be too harsh for peripheral veins (IV tubing
is to be labelled cytotoxic)
- examples of common oral cytotoxic medications that RPN’s may be approved to administer include Methotrexate
and Cyclophosphamide (**always check with your agency’s specific policy whether you can give this type of
medication or not)
- when administering an oral cytotoxic or hazardous non-cytotoxic medication - do not crush, split, or open up a
capsule; the patient will need to be able to swallow the pill whole and not chew it **if this is not possible, do not
give and contact the pharmacy to request an alternate form of the medication (e.g., liquid)
- for both cytotoxic and non-cytotoxic hazardous medications: do not touch pills with bare hands and always wear 2
pairs of gloves when handling this type of a medication; **double gloving is best practice and if any risk of
splashes, also wear eye protection, mask, and a gown (then dispose of the gloves in the cytotoxic waste container
bin found either in the dirty utility room or in the patient’s room)
- if you are pregnant, breast feeding or planning a pregnancy you have the right to ask to be reassigned as needed
to avoid adverse reproductive complications; **visitors who are pregnant, breastfeeding, or planning a pregnancy
can be near the patient but they should use extra care to avoid contact with the patient’s cytotoxic medication and
the patient’s body fluids/wastes
- administer the medication with or without food and at the specific time it has been ordered (otherwise it may react
with other medications, foods, supplements)
- cytotoxic medications will attack not only cancer cells but also healthy cells and tissue (e.g., hair follicles, the bone
marrow, mucous membranes in the mouth, stomach and intestines)
- cytotoxic medications will also attack the blood and lower blood counts: decreases WBC’s which makes the
patient immunocompromised and in turn increase the risk for infection; decreases RBC’s which lowers the
hemoglobin and in turn decreases 02 perfusion, circulation, decreases the presence of glucose for energy and
causes anemia; decreases Platelets which in turn increases the risk for bleeding
- if the patient is taking a hazardous medication at home, storage considerations would include storing the
medication high and separate from other medications (to prevent med. errors and children being exposed), some
may also be sensitive to light and/or need to be refrigerated which would mean that it would require a safe secure
spot in the fridge
- cytotoxic medications leave the body through all types of body fluids (e.g., urine, stool, vomit, phlegm/sputum,
blood, sweat, vaginal fluid, semen, wound drainage)
- nurses who come into contact with cytotoxic medications and related waste are also at risk of occupational
exposure and possible adverse effects which could include: liver damage, infertility, fertility changes, miscarriage,
birth defects, organ toxicity, nasal sores, abdominal pain, N&V, skin rashes, leukemia & other cancers
- exposure can be direct (administering the medication or managing a medication spill) or indirect (e.g., handling
body fluids, touching medical equipment that is contaminated, changing linen that was soiled)
-
-
-
-

follow cytotoxic precautions while the patient is receiving the medication for at least 48 hours after the medication
is finished (but in the hospital the precautions may continue for 7 days after the medication has been
discontinued)
clear cytotoxic precautions signage in/outside of patient’s room is required along with appropriate cytotoxic waste
& laundry container bins in the patient’s room (do not throw garbage or laundry in regular bins in the dirty utility
room if they may have bodily fluids on them); most agency’s do not require the patient to be in a private room (but
this will depend on the agency’s specific policy regarding cytotoxic precautions)
a cytotoxic spill-management kit should be available and easy to access on your unit in case needed; **follow
your agency’s specific instructions for accidents such as cleaning up body fluids on the floor or liquid medication
spills
to prevent occupational exposure, use special precautions when handling body fluids/wastes that include:
protective eye coverage (goggles/face shield), mask, PPE gown or coveralls, double gloving, and if needed head
& foot covering – this will then be disposed of in a designated cytotoxic bin in the patient’s room
close the toilet when flushing and also double flush the toilet, if the patient is at home prevent pets from drinking
the toilet water (keep the toilet lid closed)
complete an incident report and contact ER, Occupational Health and your Manager if an occupational exposure
occurs (direct or indirect)
casual contact between the patient and his/her visitors is safe (e.g., hugging, touching) but if any exposure to
body fluids/waste it is important that they follow cytotoxic precautions
Cytotoxic vs. Non-Cytotoxic Hazardous Medications?
Add information sheet?
WEEK 3 LAB – INTRADERMAL INJECTIONS & INTERPRETATION OF TB SKIN TEST
Tuberculosis
• Infectious disease caused by Mycobacterium tuberculosis (aerobic
bacterium)
• Involves: Lungs, Larynx, Kidneys, Meninges, Bones,
Adrenal glands, Lymph nodes
• Spread via airborne droplets when infected person
• Coughs
• Speaks
• Sneezes
• Sings
• Laughs
Tuberculosis in Canada
 TB rate – 4.9 per 100, 000
 65% of cases in Foreign Born persons (1068 cases)
 21% Canadian-born Indigenous (344 cases)
 13% Canadian-born non-Indigenous (221 cases)
 over 1600 new cases reported in Canada each year
 1% cases are not accounted for
 Nunavut has the highest incidence rate - 186.7 infected
persons per 100,000
 Atlantic Region has the lowest incidence rate – 1 infected
person per 100,000
Latent & TB Disease
• latent TB can stay dormant for years (not active)
• patients are infectious when symptoms appear
• diagnosing TB:
- exposure to someone with TB
- S&S
-sputum smear; sputum culture for acid-fast bacilli
- chest x-ray
- TB Skin Test (TST)
- CSF
- fluid from an abscess or effusion
- IGRA’s interferon gamma release assay:
QuantiFERON-TB (QFT-GIT) and T-SPOT (T-spot)
Intradermal Administration of Tuberculin
• Use safe injection practices
• Use inner forearm (volar aspect) or upper back
• Region needs to be free from lesions and relatively hairless
• Use TB syringe or small hypodermic syringe (1 mL syringe, 26 – 27 gauge in diameter and ½ to 3/8 inches in
length)
Intradermal Injection 
• The medications are potent, so inject into the dermis because
the blood supply is reduced and medication absorption
occurs slowly
Identify and Apply
• The 3 checks for medication administration (take it out of the
cart/ADU; after drawing it up from the vial or ampule; prior to
putting it away/or disposing of it)
• The 10 Rights for medication administration (the right
medication; the right dose; the right patient; the right route;
the right time and frequency; the right documentation; the
right reason; the right to refuse; the right patient education;
the right evaluation)
Medication Considerations
• Store Tubersol in the refrigerator between 2 – 8 degrees Celsius and do not freeze.
• Store and transport in the dark and avoid exposure to light to ensure potency and
accuracy of the solution.
• Record on vial the date it was opened; vials should be discarded if they have been
opened for more than 30 days or if the expiration date has passed.
• refer to handout for procedure of the TB Skin Test (TST)
• Post-procedure document on the MAR (include site) and record in the patient’s
chart the date and time of test, Tuberculin lot number and expiration date, dose of
Tuberculin injected and the site(s) of injection
Reading the Mantoux Test 
• The reaction should be evaluated 48-72 hours after the injection
• Only the induration, which is a hard, dense, raised formation, with definite borders
is to be measured (you cannot always see it, you will need to feel for it with your
fingertips)
• Remember that the area of erythema/rubor/redness is not included in the
measurement
• 1) Inspect arm
• 2) Palpate. Using a light, gentle motion, run the fingertips over the surface of the
forearm to locate the margins or edges of induration. **If there is difficulty in
identifying the edges of induration it may help to flex the elbow up to 45 degrees
• 3) Mark. It will be helpful to mark lightly the induration with a pen at the widest edges
• 4) Measure. The longest diameter of induration, transverse to the long axis of the forearm, is measured in mm.
Use a caliper ruler if available.
TB Skin Test Results
• 0 - 4 mm = In general this is considered negative and no treatment is indicated. *Close contacts in children less
than 5 years of age and also close contacts in HIV positive individuals
• 5 - 9 mm = Considered positive in certain cases: any individual who has had close contact with an individual with
active TB within the past 2 years; a diagnosis of HIV positive; a diagnosis of End-Stage-Renal Disease; an Organ
transplant recipient; an immune compromised individual; if taking an immunosuppressant medication or
treatment; anyone with an abnormal chest x-ray with nodular or fibrotic changes.
• 10 mm or over = Positive for all others
Contraindications
• Severe blistering; extensive burns or other skin conditions
• An allergic reaction in the past to the TST
• Major infections (feeling very unwell with a viral, bacterial or fungal infection)
•
•
•
Received an immunization with a live (attenuated) virus in past month (e.g., MMR)
Have a past history of receiving the BCG vaccination (**this is a false positive result; better to do a CXR)
Present or past hx of TB (if the patient has had a
positive TB skin test then the TST will always be positive
even after completing Tx; better to do a CXR)
Eligible for Testing
• Pregnant or are Breastfeeding
• If feeling unwell but with only a mild infection like a mild cold (check 1st with Dr. if unsure)
• Recent immunization with non-live (inactivated) virus vaccine (e.g., influenza IM injection is okay – BUT if given
intranasal then the influenza vaccine is alive/attenuated and would be contraindicated)
• Have a past history of BCG vaccination OR has a present diagnosis of TB or has a history of TB (the TST can be
done however will require further testing; better to do a CXR)
Mantoux/TB Skin Test (TST)
- Use hand sanitizer to wash hands
- Verify MARS (bring MARS to the bedside); check pt. for identifiers (name, DOB, ID number) check for allergies; explain
procedure and ask patient for consent
- Identify the 3 checks when preparing a medication: check when picking it out; after drawing it from the vial; prior to
disposing it in the sharps or putting it back in the fridge
- the 10 Rights for medication administration (the right medication; the right dose; the right patient; the right route; the
right time and frequency; the right documentation; the right reason; the right to refuse; the right patient education; the right
evaluation)
- Check the expiry date on the Tubersol vial (if it is new then write today’s date on the vial)
- Apply non-sterile gloves
- Remove the medication cap and swab off the top of the vial with an alcohol swab
- Cleanse the patient’s site with a new alcohol swab (not the same one used for the Tubersol vial) from cleanest to dirtiest
in a circular motion and allow it to dry (injection site is the volar aspect of the patient’s inner forearm, 2 to 4 inches below
the elbow)
- Inject 0.1 mL of air into the Tubersol and then draw up 0.1 mL of Tubersol as ordered for the 1-Step Mantoux/TB Skin
Test today (use TB syringe only)
- Position the patient’s arm by holding their forearm with your non-dominant hand (make sure to support the volar aspect
of the patient’s forearm)
- Insert the needle approx. an 8th of an inch in (until resistance is felt) and at a 5 to 15 degree angle with the bevel up
- Do not aspirate; remember to inject the medication slowly and ensure that a bleb/wheal (looks like a mosquito bite) is
created that is a minimum of approximately 6 mm in diameter **If no bleb/wheal appears, repeat the injection on the
opposite forearm or at least 10cm away from the previous site
- Withdraw the needle, apply gentle pressure only with a cotton ball or gauze (not an alcohol swab and do not massage
the site)
-Do not apply a band-aid over the site and instruct patient not to scratch or rub site
- Activate the safety guard on the needle (do not recap) and then dispose of the needle/syringe into the sharps container
- Remove gloves
- Document on the MARS (signature, status, initials, date, time, location/site)
- Inform the patient that he/she will need to stay resting for 20 minutes now in order to be assessed for a reaction and that
the test will be read in 48 to 72 hours (when reading do not record the result as “positive” or “negative”. Results should be
recorded in mm of induration. e.g, if there is no induration, record as 0 mm).
- Wash hands with hand sanitizer
- In the patient’s chart record the date and time of test, Tuberculin lot number and expiration date, dose of Tuberculin
injected and the site(s) of injection
-Note – if the patient requires a 2-Step Mantoux/TB Skin Test, the second test should be repeated as above 1 to 4 weeks
after the first test has been fully completed (including the assessment phase)
-2-step skin tests may be requested for the following individuals who are: health care / correctional workers; becoming
residents in a long-term care facility / retirement home / group home; are traveling to a TB endemic country for a month or
more
WEEK 4 – CHEST TUBES

Suction container = helps remove air from pleural
space and protects against excess suction pressure in
pleural cavity (not always attached to the wall – Dr’s
order)
Water seal container = sterile water, prevents air
from entering chest, checks for air leak, should have
intermittent small gentle bubbling (not large amounts
or vigorous bubbling = could be a kink or leak)
Collection container = drainage from the patient
- 3 chambers, disposable
- suction (dry or wet suction) is normally set at -20 cm and water seal set at + 2 cm (approx. 45 mL)
Mark at the end of shift with a marker date and time and document
output in patient’s chart 
 Medium to high fowler’s
position

Tubing is to be free from kinks
**Do not clamp the tubing
(Clamping an lead to a
pneumothorax) RPN’s should
not clamp a chest tube; call the
RT if you think there is an
air leak.
Sterile airtight, occlusive dressing and secured into place
(stitches or sutures) & tape/dressing.
 Do not milk/strip tubing (can increased negative pressure)
In case of an Emergency (Leave at the Bedside):
- VS equipment, stethoscope, tape, syringe, chest tube clamp (only for emergency), sterile gloves, haemostats, sterile
occlusive petroleum coated dressing (e.g., Jelonet), 250 mL sterile water bottle, tape
-02 and suction equipment set up
Blood Products and Plasma Derivatives
Packed Red Blood Cells
Major Uses:
-Bleeding or anemic non-bleeding patients
with signs and symptoms of impaired
tissue oxygen delivery
Considerations:
-Blood tubing required –
-Initiate transfusion slowly for first 15 minutes unless massive
blood loss
-Transfuse over no more than 4 hours
(may be ordered over 1 ½ - 2 hours with slower rates up to 4
hours in total
ordered for patients at risk for circulatory
overload)
Fresh Frozen Plasma
Major Uses:
-Liver disease coagulopathy
-Massive transfusion
-Plasma exchange
procedures for Thrombotic
Thrombocytopenic
Purpura/Hemolytic
Uremic Syndrome (TTP/HUS) – when
Cryosupernatant plasma not available
Considerations:
-Blood tubing required
-Initiate transfusion slowly for first
15 minutes unless massive blood loss
-Transfuse over no more than 4 hours
-Typically over 30 minutes - 2 hours
Platelets
Major Uses:
-Control or prevent bleeding in patients
with:
-Low platelet counts
(Thrombocytopenia)
-Congenital platelet dysfunction
-Platelets not functioning due to the effects of medications (ASA,
Clopidogrel - Plavix®)
-Platelet dysfunction following
Cardiopulmonary bypass
Considerations:
-Blood tubing required
-Initiate transfusion slowly for first
15 minutes unless massive blood loss
-Transfuse over no more than 4 hours but typically over 60
minutes
Albumin
Major Uses:
-Ascites patients undergoing large
volume paracentesis greater than 5 litres
-Spontaneous Bacterial Peritonitis (SBP)
-Hepato-renal syndrome
-Plasma Exchange Procedures
Considerations:
-Standard vented IV set – no blood tubing
or filtering required
-Bottles must be vented – most standard IV sets have a vent that
can be opened otherwise a vented set is required
-Begin infusion slowly then as tolerated
Cryoprecipitate
Major Uses:
To replace:
-Fibrinogen: In patients actively
bleeding who have a low fibrinogen level
-Specific Coagulation Factors (Only when specific factor
concentrates are
not available)
Considerations:
-Blood tubing required
-Transfuse as rapidly as tolerated
Intravenous Immune Globulin (IVIG)
Major Uses:
-Replacement of Immunoglobulins
-Control of some infections and
autoimmune diseases
Considerations:
Standard vented IV set – no blood tubing
or filtering required
-Bottles must be vented – most standard IV sets have a vent that
can be opened otherwise a vented set is required
-Infusion pump required
-Begin infusion slowly and increase as
tolerated
-For maximum rate – check package
insert/hospital policy as brand specific
-Frequent Vital Sign monitoring required
Prothrombin Complex Concentrate (Octaplex)
Major Uses:
- Reversal of Warfarin (Coumadin) or Vitamin K deficiency in
bleeding patients and those requiring emergency surgery
Considerations:
-Standard IV set – no blood tubing or filtering required
-Usually infused over 15 - 30 minutes -May be given slow push
usually by physician
- Dosage based on patient weight and INR value – usually 2 - 4
vials
- Effect is immediate and lasts 6 - 12 hours
-For complete reversal, Vitamin K
10 mg. IV must also be
given
Introduction to Transfusion of Blood and Blood Products
Registered Nurses (RNs) and Registered Practical Nurses (RPNs) must successfully complete their agency’s Blood &
Blood Products Transfusion certification requirements as per the agency’s policy. Only after this criterion is met can the
nurse then check blood/blood products, perform the bedside identification checks, hang blood/blood products and monitor
the recipient during and after the transfusion process. ***This skill cannot be delegated to anybody who has not been
certified at their agency as each agency will have their own specific training process for this advanced skill.
Equipment and Supplies
o Unless otherwise specified, administer all blood and blood products through a sterile micron filter during
administration. The filter is designed to retain clots and aggregates that might otherwise harm the patient
(always follow your agency’s policy).
o A blood component administration set containing an in-line blood filter is recommended. Either a "Y-Type"
administration set or a single line set may be used depending on which one the agency uses.
o An add-on filter, such as a leukocyte reduction filter, may be used when the component was not
leukocyte-reduced by the blood supplier. o Because of the large number of filters available, the
instructions for use on the package or on the product insert should be read to determine priming
instructions and the maximum number of units that may be administered using the filter.
Intravenous Solutions:
o Only isotonic normal saline (0.9%) is recommended for use with blood components. o Other commonly
used intravenous solutions will cause varying degrees of difficulty when mixed with red cells. For
example, 5% dextrose in water will hemolyze red cells. Intravenous solutions containing calcium, such as
Lactated Ringer's solution, can cause clots to form in blood. o Prior to blood transfusion, assess the IV
site (larger gauge catheters such as a #18 gauge are recommended to prevent hemolysis) and
completely flush incompatible intravenous solutions and drugs from the blood administration set with
isotonic normal saline (0.9%). If necessary start a new peripheral IV.
Other Equipment:
o clean gloves, tape, vital sign equipment (including a stethoscope), 02 saturation monitor, transfusion
consent form, pen, alcohol swabs
***assess the patient’s laboratory values
Patient Instructions and Preparation
Informed Consent:
o Informed consent for blood transfusion is a process in which the patient is informed of the medical
indications for the transfusion, the possible risks, the possible benefits, the alternatives, and the possible
consequences of not receiving the transfusion. o Before beginning the pre-transfusion process, verify that
the patient’s religious or cultural beliefs do not prohibit receiving blood/blood product therapy. Give the
patient the opportunity to discuss his/her beliefs about receiving a transfusion.
o Informed consent may be obtained by an MD, NP, RN or RPN who is qualified and has the knowledge
about transfusing blood/ blood products and the patient’s condition so as to be able to explain the
elements of informed consent above.
o The procedure along with the risks of transfusion, including adverse symptoms must be clearly discussed
with the patient as early as possible before transfusion. If the agency has written information to share with
the patient provide him/her with this material also.
o The patient is then given a choice to accept or decline transfusion (do not rush the patient). Consent
should be obtained sufficiently in advance of the transfusion that the patient can truly understand what is
said and have sufficient time to make a choice. o Once consent is confirmed, assess the patient’s
knowledge and understanding of the blood-transfusion procedure and its rationale.
o Consent should be documented in the medical chart using the agency’s “Consent to Receive Blood
Transfusion" form. o A single informed consent may cover many transfusions if they are part of a single
course of treatment (check with your agency’s policy)
o It may be advisable, though, to obtain a new consent when there is a significant change in the patient's
care status, such as a transfer for care to another service, an inpatient admission, or an outpatient
transfusion. o In emergency situations the physician ordering the transfusion must make a reasonable
judgement that the patient would accept the transfusion. The transfusion should not be delayed in a
lifethreatening situation if it is likely that the patient would agree to the transfusion. After the event, the
circumstances of the transfusion decision should be documented in the medical chart. o Refusal of Blood
Transfusion – must be clearly documented in the
medical chart, also inform the blood bank and the
physician
Post Transfusion Instructions to the Patient:
o Outpatients or patients who will be leaving the hospital within one week of transfusion should be given
written instructions regarding delayed transfusion reactions.
Preparation, Release and Transport of Blood Components
1.
Notify the Blood bank that the patient has been ordered a blood or blood product via telephone, fax, or
computer (depending on your agency’s policy). The Blood Bank may require a copy of the physician’s order so
it is imperative that this is given them asap. It is critical that the blood bank is clear about the patient’s name,
date of birth, medical record number, blood component ordered, and number of units ordered of the blood
component, and the physician’s name who has ordered the transfusion. The lab will require that the patient
have a Cross and Type collected if not yet done within the past 72 hours (this requires time as the blood tech.
would need to draw this blood sample first in order for the lab to identify the patient’s blood type and Rh
system). Once the patient has been Cross and Typed the blood tech. will apply a Blood ID band on the
patient’s wrist that should not be removed for the remainder of the patient’s hospital stay.
2.
Blood Bank personnel will notify the unit by telephone, fax or computer
(depending on your agency) when the ordered blood is ready for transfusion.
3.
Depending on the agency’s facility the nurse or a transport personnel will pick it up.
IMMEDIATELY PRIOR TO BLOOD TRANSFUSION:
Pre-transfusion Baseline Assessment:
o To provide a baseline, record the patient's blood pressure, pulse, respirations, temperature, 02 sats,
LOC, chest assessment, and skin assess. in the chart along with recording the vital signs on the
transfusion record form
o If the patient is febrile, consideration should be given to postponement of the transfusion, since the fever
may mask the development of a febrile reaction to the blood/blood product itself. Contact the physician if
you if the patient has a fever or you have other concerns related to the baseline assessment. o Check
and confirm with the physician’s orders about the transfusion and that any pre-transfusion medications
have been administered
These steps must never be bypassed. TWO qualified nurses must:
1.
2.
3.
4.
5.
6.
7.
Ask the patient to state his or her name and date of birth. Verify patient and component
identification information.
Perform bedside verification of the patient and the blood/blood product using the: labels on the
bag/bottle, the Transfusion Record Form and the patient’s attached positive patient identifier (blood
ID band and patient’s ID band).
Verify the blood type, donor number, component name.
Verify the product is not outdated.
Sign the Transfusion Record Form before blood transfusion is initiated. The second nurse co-signs
that all of the checks have been performed above and are correct.
The person who hangs the blood must record the date and time the transfusion was started.
Record the date, time, and component and unit number on the appropriate sheet on the patient's
chart. Refer to unit policy and procedures.
***DO NOT START the transfusion if there is any discrepancy. Contact the Blood Bank if there are any discrepancies or
questions. Return the blood to the Blood Bank until the discrepancy has been resolved.
Initiating the Transfusion
Initiate the blood transfusion within 30 minutes of the time the blood is released from the blood bank. If the
transfusion cannot be initiated within this timeframe, immediately return the blood to the Blood Bank, and
retrieve it when you are ready to administer it.
Never store blood in an agency refrigerator. o Immediately before transfusion, very gently mix the unit of
blood or the blood product thoroughly by gentle inversion
o Follow the manufacturer's instruction for the use of special filters when ready to initiate the transfusion
o Refer to agency’s policy regarding flow rates. The physician may include the time-frame in the transfusion
orders. Maximum infusion time for any blood component cannot exceed 4 hours. o If any part of the unit
is transfused, the unit is considered transfused.
o
**During the Transfusion Document (check with your agency’s specific policy):
What
When
•
temperature, blood pressure, respirations and
pulse, and examine the skin for urticaria, LOC,
chest assessment.
•
Assess flow rate and IV site
•
•
•
•
before initiating the transfusion
after the first 15 minutes
after 30 minutes
hourly until one hour after completion of the
transfusion
•
and PRN
If the patient has a pre-existing fever:
The need for transfusion must be balanced with the risk of transfusion. Contact the physician asap to determine if pretransfusion medications should be administered and if the transfusion should or should not proceed.
If a patient is being transported with blood hanging:
Patients should not be transported with blood components infusing unless accompanied by a nurse who can monitor and
respond to a potential reaction. Additionally, the receiving clinic/area must have a clinician who can manage a patient
while they are receiving blood components.
If Blood/Blood Product Is No Longer Needed:
To avoid unnecessary waste of blood resources, notify the Blood Bank staff immediately if components are no longer
needed for a patient, as the component may be suitable for transfusion to another patient. Return any unneeded units to
the blood bank. If the blood was partially transfused and stopped (e.g., reaction, refusal, death) send the remaining blood
and blood tubing (clamp the bag) back down to the Blood Bank.
At the Termination of an Uncomplicated Transfusion:
After the completion of each uncomplicated transfusion, the responsible physician or nurse should verify that the "PostTransfusion" section of the
Transfusion Record Form is complete, including
 date and time transfusion was stopped
 volume of blood infused
 Check the box documenting the presence/absence of a transfusion reaction.
After the line has flushed and is clear, discontinue the normal saline solution used to initiate the transfusion after the
completion of the transfusion unless specifically ordered. Document the patient's response to the transfusion in the
patient's medical record.
If a Transfusion Reaction is Suspected
o Stop the transfusion and recheck vital signs, 02 sats, chest assessment
o Notify the physician and the Blood Bank
o Maintain the IV site but start isotonic normal saline (0.9%) with a new primed tubing
o Save the bag and attached tubing (refer to the agency’s policy regarding how to send this back to the
Blood Bank and with which completed form should accompany it)
o Document clearly the patient’s physical assessment findings
**Disposal of blood bags if No reaction is suspected as per the agency’s policy.
Transfusion Record Form/Documentation:
Following completion of the form, the form should be placed in the patient's chart; an additional copy may be required to
be returned to the Blood Bank if that is the agency’s policy. Also document in the Nurses Notes as per the agency’s policy.
Compatible Blood Types
If you have:
RBC antigen
You can only receive:
Type A(+)
A
A+, A-, 0+, 0-
Type A (-)
A
A-, 0-
Type B (+)
B
B+, B-, 0+, 0-
Type B (-)
B
B- , 0-
AB (+) (universal recipient)
AB
A+, A-. B+, B-, 0+, 0AB+, AB-
Type AB (-)
AB
A-, B-, AB- , 0-
Type 0 (+)
None
0+, 0-
Type 0 (-) (universal donor)
None
0-
-Also important, especially in perinatal care, is the Rhesus, or Rh system. Blood is classified according to the
presence or the absence of the major D antigen on the surface of the red blood cells. A person who has the D
antigen is classified as Rh positive; a person who does not have the D antigen is Rh negative. Rh negative
individuals may donate to Rh positive recipients, but should only receive Rh negative blood to prevent the
formulation of anti-D antibodies.
Blood and Blood Product Compatibility Testing (**always confirm with the Blood Bank what is
required)
Type of
Blood/Blood
Product
Whole
Blood
Red
Cells
Platelets
Fresh
Frozen
Plasma
Cryoprecipitate
Albumin
ABO
testing
Yes
Yes
Yes
Yes
No
No
Rh testing
Yes
Yes
Yes
No
No
No
Blood Transfusion Reactions:
Name of Reaction:
Febrile Nonhemolytic
Allergic/Urticaria
Anaphylactic
Acute Hemolytic
Onset
1-6
hours
Severity Etiology
Caused by leukocyte
Mild
antibodies or
accumulated cytokines.
1-6
Mild
Result of an interaction
hours
between
allergen and preformed
antibody – usually IgE.
0-1 hour Severe Same as allergic
0-1 hour Severe Usually results from
incompatibility of red
blood cells between
donor and receiver.
Most severe is ABO
incompatibility.
Symptoms
Temp increase >1º C above 37º during transfusion;
May have chills, rigor, cold, or discomfort that
cannot be attributed to other etiologies.
Flushing, itching, rash, hives, asthmatic wheezing,
laryngeal edema, nausea. In more severe cases
hypotension, dyspnea, stridor, vomiting, diarrhea.
Asthmatic wheezing, laryngeal edema, dyspnea.
Mild: fever with or without chills, abdominal,
chest, or back pain. Severe: hypotension,
dyspnea, flank pain, can progress to shock with
or without disseminated intravascular coagulation
(DIC: abnormal bleeding, hematuria, bleeding
from puncture sites, bruising, blood clots,
erythema).
Da
ys
to
we
ek
s
or
months
1-4 hrs
Moderat Patient develops an
antibody to antigens on
e
transfused cells or
Autoantibodies.
Fever, anemia, occasionally jaundice and/or
leukocytosis. Hemolysis is typically extravascular.
Patient may not have had a rise in hemoglobin
after transfusion.
MildSevere
Transfus
ion
Related
Acute
Lung Injury (TRALI)
0-6 hrs
MildSevere
Septic
Transfus
ion
Reactio
ns
0-6 hrs
MildSevere
Dyspnea, orthopnea, hypertension, jugular vein
distension, gallop heart sound present, elevated
central venous pressure, elevated troponin levels,
pulmonary edema. Signs of congestive heart
failure or fluid overload. **TACO responds to
diuretics.
Blood/blood product given within 6 hours of
symptom triad: dyspnea, hypotension, and fever
together.
Bilateral pulmonary infiltrates. May have
hypoxemia, cyanosis. TRALI does not respond to
diuretics. **Leading cause of transfusion related
mortality.
Abrupt onset high fever (38.5º or higher), shaking,
chills, hypotension shortly after transfusion started.
Severe cases may develop shock, renal failure, or
DIC. Broad spectrum
antibiotics may be needed.
Delayed
Hemolyti
c
Transfusion
Associated
Circulatory
Overload
(TACO)
High flow rates are often
a co- factor. Infants and
patients >70 years old
are at greatest risk.
Monitor cardiac patients
for overload.
Acute lung injury from
possible autoimmune
reaction to donor
antibodies or plasma
directed against
recipient leukocytes at
the lung cellular level.
Patient receives a
bacterially
contaminated blood
product (or
contamination from IV
site
during transfusion).
Total Parenteral Nutrition (TPN)
Total parenteral nutrition (TPN), also known as parenteral nutrition (PN) is a form of nutritional support given completely
via the bloodstream, intravenously with an IV pump. TPN administers proteins, carbohydrates, electrolytes, fats, vitamins,
and minerals. It aims to prevent and restore nutritional deficits, allowing the GI tract to rest while supplying adequate
caloric intake and essential nutrients, and removing antigenic mucosal stimuli.
TPN may be short-term or long-term nutritional therapy, and is most commonly administered on acute floors (e.g.,
medical, surgical, cardiac) and critical care units, but also occasionally on chronic/LTC areas. The caloric requirements of
each patient are individualized according to the degree of stress, organ failure, and percentage of ideal body weight. TPN
is used with patients who cannot orally ingest or digest nutrition. TPN is recommended to be administered through a
central line. Examples of candidates for TPN are:
 Patients with paralyzed or nonfunctional GI tract, or conditions that require the GI tract to rest (e.g., small bowel
obstruction, ulcerative colitis, or pancreatitis)
 Patients who have had nothing by mouth (NPO) for several days
 Critically ill patients
 Babies with an immature gastrointestinal system or congenital malformations
 Patients with chronic or extreme malnutrition, or chronic diarrhea or vomiting with a need for surgery or
chemotherapy
 Patients in hyperbolic states (e.g., burns, sepsis, or trauma)
TPN is made up of two components: amino acid/dextrose solution and a lipid emulsion solution. It is ordered by a
physician, in consultation with a dietitian, depending on the patient’s metabolic needs, clinical history, and blood work. The
amino acid/dextrose solution is usually in a large volume bag (1,000 to 2,000 ml), and can be standard or custom-made to
also include vitamins & minerals. It is often yellow in colour due to the multivitamins it contains. The ingredients listed on
the bag must be confirmed by the health care provider hanging the IV bag (to be checked with a second nurse prior to
hanging). The solution may also include medication, such as potassium, insulin or heparin. The amino acid/dextrose
solution is reviewed and adjusted each day based on the patient’s blood work. Lipid emulsions are prepared in 100 to 250
ml bags or glass bottles and contain the essential fatty acids that are milky in appearance. Occasionally, the lipid
emulsion is added directly to the amino acid/dextrose solution by the pharmacist.
TPN is prepared by the pharmacist, where the calories are calculated using a formula, and is usually mixed for a 24-hour
continuous infusion. TPN orders should be reviewed each day, so that changes in electrolytes or the acid-base balance
can be addressed appropriately without wasting costly TPN solutions. Prior to hanging the TPN, the 10 rights of
medication administration must be performed to prevent errors.
Amino Acid & Dextrose Solution (yellow, larger bag on right) and Lipid Emulsion
(white, smaller bag on left) 
TPN tubing with Micron Filter for the Amino Acids & Dextrose Solution:
TPN is not compatible with any other type of IV solution or medication and must be
administered by itself. TPN must be administered using an IV pump. Always review
agency policy on setup and equipment required to infuse TPN. The larger bag
(Amino Acids & Dextrose) infuses through this main primary tubing with the special
micron filter to reduce the risk of particles entering the patient (see picture below).
Some agencies allow the smaller bag (Lipid Emulsion) to infuse through a
secondary IV tubing that is piggy-backed into the main primary main IV tubing just
as IV medications are via a secondary IV line. Otherwise, a separate primary line
for the Lipid Emulsion infusion should be primed and y-connected into the Amino
Acids & Dextrose IV tubing.
**Always follow your agency’s specific TPN policy as each site will have their own
policy’s as to which tubing to use and how to infuse it. Note - the lipid tubing does
not need a special micron filter. Often, both bags infuse concurrently.

- The TPN can run on one pump if you have a smart pump that is able to run
separate Infusions concurrently at the same time.

2 TPN tubing’s may be set up. Always follow your
agency’s specific TPN policy.
The physician collaborates with the dietician &
pharmacist to order a total fluid intake for the specific amount of fluid to be infused per
hour to prevent fluid overload in patients receiving TPN. It is important to keep track of all
the fluids infusing (IV fluids, IV medications, and TPN) in order to avoid fluid overload.
Remember - a separate IV site or lumen will be needed for any IV medications. Blood
samples are not to be taken from the same central line lumen as the TPN infusion. To
prevent severe electrolyte and other metabolic abnormalities, the infusion rate of TPN will
be increased gradually. Also, TPN should not be discontinued abruptly unless ordered by
the physician, as an unexpected interruption could lead to hypoglycemia. If for whatever
reason the TPN solution runs out before expected, notify the physician for further orders
along with the pharmacist who is responsible for mixing up new bags and the dietician to
alert that the patient has not rec’d the prescribed caloric requirements. Never try to catch
up with a delayed infusion. Do not use TPN solution if the solution appears abnormal in
any way, or there are any concerns with the labelling on the bags (request a replacement
from the pharmacy).
A patient on TPN must have blood work monitored closely to prevent the complications. Other assessments include: vital
signs (frequency as per agency’s policy); weight; blood glucose
monitoring; intake/output; mouthcare; central line site/dressing.
Apply a label to both the primary and secondary IV tubing with the date and time primed. New TPN tubing (both lines) is
required every 24 hours to prevent catheter-related bacteremia (follow agency’s TPN policy). Both infusions should not
hang longer than 24 hours – after that, must take down and start with new bags/bottles and IV tubing.
Lipid infusion should be no more than 1 mL/minute for the first 15 -30 minutes as this is the time period most likely to
cause a reaction (if no reaction after that, the rate can be adjusted as ordered). The Amino Acids and Dextrose rate will
be as ordered by the physician or follow the agency’s policy. Just like with blood transfusions, best practice is to stay with
the patient for the first 15 minutes of the TPN infusion to monitor for any signs of complications.
Complications Related to TPN
Generally, patients receiving TPN are quite ill and may require a lengthy stay in the hospital. The administration of TPN
must follow strict adherence to aseptic technique, and includes being alert for complications, as many of the patients will
have altered defense mechanisms and complex conditions. There are many complications related to the administration of
TPN. Refer to the chart on the next page that lists potential complications, rationale, and interventions.
Complication
Rationale and Interventions
Sepsis (catheterrelated bloodstream
infection)
Sepsis, which starts at the insertion site, is the spread of bacteria through the bloodstream. There’s an
increased risk of sepsis with TPN, due to the high dextrose concentration of TPN. Symptoms include
tachycardia, hypotension, elevated or decreased temperature, increased breathing, decreased urine output,
and disorientation.
Interventions: Strict adherence to aseptic technique with insertion, care, and maintenance; avoid
hyperglycemia to prevent infection complications; closely monitor vital signs and temperature. IV antibiotic
therapy is required. Monitor white blood cell count and patient for malaise. Replace IV tubing frequently as
per agency policy (usually every 24 hours).
Localized infection at
insertion site
Due to poor aseptic technique during insertion, care, or maintenance of the central line
Interventions: Apply strict aseptic technique during insertion, care, and maintenance. Frequently assess the
insertion site for redness, tenderness, or drainage. Notify physician of any signs and symptoms of infection.
Pneumothorax
A pneumothorax occurs when the tip of the catheter enters the pleural space during insertion, causing the
lung to collapse. Symptoms include sudden chest pain, difficulty breathing, decreased breath sounds,
cessation of normal chest movement on affected side, and tachycardia.
Interventions: Apply oxygen, notify physician and RT. Patient will require removal of central line and
possible chest tube insertion.
Air embolism
An air embolism may occur if IV tubing disconnects and is open to air, or if part of catheter system is open
or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen
saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.
Interventions: Make sure all connections are clamped and closed. Clamp catheter, position patient in left
Trendelenburg position, call physician and RT, and administer oxygen as needed.
Hyperglycemia
Related to sudden increase in glucose after recent malnourished state. After starvation, glucose intake
suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen.
Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and
ketoacidosis.
Interventions: Monitor blood sugar frequently QID (four times per day), then less frequently when blood
sugars are stable. Follow agency policy for glucose monitoring with TPN. Administer insulin as per sliding
scale orders. If needed contact the physician for orders.
Refeeding syndrome
Refeeding syndrome is caused by rapid refeeding after a period of malnutrition, which leads to metabolic
and hormonal changes characterized by electrolyte shifts (decreased phosphate, magnesium, and
potassium in serum levels) that may lead to widespread cellular dysfunction. Phosphorus, potassium,
magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be life-threatening. High-risk
patients include the chronically undernourished and those with little intake for more than 10 days. Patients
with dysphagia are at higher risk. The syndrome usually occurs 24 to 48 hours after refeeding has started.
The shift of water, glucose, potassium, phosphate, and magnesium back into the cells may lead to muscle
weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia.
Interventions: Rate of TPN should be based on the severity of undernourishment for moderate- to high-risk
patients. TPN should be initiated slowly and titrated up for four to seven days. All patients require close
monitoring of bloodwork (Always follow agency’s TPN policy). Blood work may be more frequent depending
on the severity of the malnourishment.
Fluid excess or
pulmonary edema
Signs and symptoms include fine crackles in lower lung fields or throughout lung fields, hypoxia
(decreased O2 sats).
Interventions: Notify both the physician and the RT regarding change in patient’s respiratory status. Patient
may require IV medication, such as Lasix to remove excess fluids. A decrease or discontinuation of IV
fluids may also occur. Raise head of bed to enhance breathing and apply O 2 for oxygen saturation less
than 92% or as per agency protocol. Monitor intake and output. Pulmonary edema may be more common in
the elderly, young, and patients with renal or cardiac conditions.
WEEK 5 – GASTROINTESTINAL BLEED SIMULATION
Common Risk Factors for a GI Bleed:
• Increased age
• NSAID use (e.g., aspirin, ibuprofen, naproxen)
• Acetaminophen
• Alcohol use
• Smoking
• Spicy foods
• Citrus juices
• Caffeine
• Anticoagulation therapy (e.g. Lovenox, Heparin, Coumadin, Apixaban, Dabigatran, Rivaroxaban)
• History of IBD, weight loss, change in bowel habits, cirrhosis, Other medications (e.g., Plavix)
• Certain supplements (e.g., CBD oil, excessive amounts of garlic, ginger, ginseng, high doses of vitamin E, high
doses of omega-3-fatty acid)
Upper GI Bleed
• refers to bleeding from the esophagus, stomach, duodenum (i.e. Proximal to ligmanet of treitz)
• chronic peptic ulcer disease is the most common cause
• is 4 times more common
• approx. 5% to 11% mortality
• Hematemesis (vomiting of fresh blood)
• Coffee ground vomit (looks like coffee grounds)
• Melena (black tarry stools)
Lower GI Bleed
• refers to bleeding arising distal to the ligament of Treitz (but the majority of lower GI bleeding arises from
colon/rectum/anus)
• diverticular disease is the most common cause (vomit could contain fecal matter – there is a heredity link)
• it can range in severity from trivial to massive
• approx. 2 to 4% mortality
• Hematochezia (bright red blood per rectum)
Other Symptoms of a GI Bleed
• Abdominal pain
• Hypotension
• Tachycardia
• Tachypnea
• Desaturation
• Decreased LOC, confusion, restlessnesss
• Pale, cold skin and extremities
• SOB
• Slow capillary refill
• Dehydration
• Light headed, dizzy, weak, faint
Common Test & Treatments for a GI Bleed
• ABC’s and LOC
• Frequent monitoring of vital signs and 02 sats; 02 therapy PRN
• Insert 2 large bore angiocaths for fluid resuscitation **Normal Saline bolus (isotonic fluid best choice) and
transfusion of blood products may be ordered
• Vitamin K may be ordered
• Lab work: CBC (check Hemoglobin and platelets), coagulation profile, troponin, liver profile, kidney profile, type &
cross match
• Cardiac monitoring and/or ECG (R/O cardiac issues)
• NPO and strict intake/output
• NG tube may be ordered
• NSAIDS, anticoagulants and other medications that cause thinning of blood should be D/C’d
• Continuous IV Pantoloc Drip may be ordered
• Stool for occult blood if bleeding is suspected but is not obvious
• Transfusion of blood (e.g., Packed Red Blood Cells) and/or blood products (e.g., Platelets; Fresh Frozen Plasma)
•
•
•
Endoscopy &/or Colonoscopy &/or Sigmoidoscopy if stable
Balloon-assisted enteroscopy
Surgery
WEEK 6 – DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM SIMULATION
•
•
•
•
Deep Vein Thrombosis (DVT) is blood clot that usually occurs in the lower leg, thigh or pelvis, most often on one
side, although it can happen in other parts of the body
Part of the clot can break off and travel to the lung and cause a pulmonary embolism (PE), which can be fatal in
about 1 out of every 3 instances
The term Venous Thromboembolism (VTE) can be used for 2 conditions - both DVT’s and PE’s
At least 90% of pulmonary emboli originate from a DVT from a deep lower extremity vein (but can occur in the arm
as well)
Virchow’s Triad 
- the 3 main contributing physiological factors of thrombosis
formation
 the sequence can occur in different orders
1) Vessel Injury - vascular endothelial damage
2) Venous Stasis - altered blood flow
3) Hypercoagulability - thick venous blood
Common Risk Factors for a DVT/PE
• Smoking
• Heredity
• Cancer (Cancer-associated DVT)
• Chemotherapy
• Obesity/overweight.
• Pregnancy and the postpartum period (weeks following giving birth)
• Hormone therapy (e.g., birth control pills; post-menopausal hormone replacement; hormonal therapy for Cancer
treatment)
• Bed rest, sitting or standing for prolonged time
• Varicose veins
• Indwelling devices (e.g., Peripheral IV; Central Line; Heart Valve; catheter; IV drug use )
• Lack of anticoagulant therapy (if is required or decrease effectiveness of anticoagulant therapy e.g., green tea
and coumadin)
• Lack of wearing anti-embolic stockings (if needed)
• Cardiac disease, HTN, Atrial Fibrillation
• Surgery
• Abnormal bloodwork (e.g., high Calcium; low Magnesium; low INR, low PT, low PTT, high
D-Dimer; platelet count excessively high)
Signs & Symptoms of a DVT
• Edema of the foot, ankle, &/or leg usually on the
affected extremity only; feelings of tightness. to that
affected area
• Cramping/throbbing of the affected area that usually
begins in the calf (can become quite severe/sharp
upon standing or walking)
• May be difficult to palpate pulses
• Skin on the affected area is warmer/hot to the touch
compared to the skin on surrounding areas
• Bluish, reddish, or pale colored skin over the affected
area
• DVT can also be reported without any symptoms
Link between DVT and PE 
PE won’t always cause symptoms but one or more may be present:
• Chest pain, which may get worse with a deep breath
• Sudden shortness of breath or rapid breathing
• Tachycardia, Hypotension, Tachypnea
• Desaturation
• Light-headedness or fainting
• Anxiety
• Shortness of breath that may occur suddenly.
• Sudden, sharp chest pain that may become worse with deep
breathing or coughing
• Sweating
• Sudden cough
• Coughing up blood (hemoptysis) or pink, foamy mucus
Common Tests & Treatments for a PE
• ABC’s, LOC
• Frequent monitoring of vitals and 02 sats; 02 therapy
• Position pt. in the left lateral trendelenburg position
• Lab work: CBC, D-dimer, coagulation profile, troponin, electrolytes, Mg, Ca, ABG’s
• Cardiac monitoring and/or ECG (R/O cardiac issues)
• Chest CT; VQ Scan; Echocardiogram
• Anticoagulant Therapy: recommended initial treatment is an intravenous Heparin infusion; second stage is
subcutaneous form (e.g., Heparin or Lovenox); third stage is oral form (e.g., Coumadin, Dabigatran or Apixaban)
Other treatments for a PE
• Approved Thrombolytic Therapy (e.g., Alteplase which is a tissue plasminogen activator “tPA”)
• Surgical procedure called an embolectomy
• Inferior Vena Cava filter (traps large clot fragments and prevents them from traveling through the vena cava vein
to the heart and lungs)
WEEK 7 – COVID 19 REVIEW
Examples of Reproduction # (note – Beta & Gamma
variant not included)
 Covid 19 virus (original virus) reproduction
number of approximately 2 to 2.5



Covid 19 – Alpha variant virus reproduction number of
approximately 4-5
Covid 19 - Delta variant virus reproduction number of approximately
5-8
Covid 19 – Omicron variant virus reproduction number of
approximately 7-14
Transmission
**note there are other theories regarding the origin of the virus (e.g., labassociated leak) but zoonotic transission is the most widely accepted
conclusion for the coronoviruses (e.g., SARS, MERS, Covid-19)
Fecal-Oral Route
Aerosol; Respiratory; Fomites

Type I Pneumocyte – gas exchange (oxygen and carbon
dioxide)
Type II Pneumocyte – produces pulmonary surfactant which
decreases surface tension and prevents collapsing of the
alveoli
Alveolar Macrophages – WBC linked to the Immune System (2nd Line of
Defence) found in the alveoli; clears the air spaces of infectious, toxic, or
allergic particles if the 1st Line of Defence has been unable to
Covid-19 (is a typed of coronoavirus; and is a single-stranded RNA Virus)
The Type 2 Pneumocytes have ACE 2 receptors that the “S” spike protein molecules on the Covid-19 virus can
attach/bind to which allows fusion of the virus to the receptor to occur thus gaining entry into the host cell (Type 2
Pneumocyte). This host cell is needed in order for the virus to grow and multiply.
The virus can now inject it’s RNA into the host cell’s cytoplasm (this particular virus does not need to enter the host cell’s
nucleus, it is able to replicate and assemble new copies of the original virus within the infected host’s cell). Once
complete, it buds out of the damaged host cell to infect the respiratory system further and overwhelm the immune system.
Inflammatory mediators will be released by the damaged host cell which will stimulate the alveolar macrophages to
release cytokines which in-turn will retract the endothelial cells (walls of the blood vessels) and therefore increase capillary
permeability in the blood vessels, causing vasodilatation. This will cause fluid to leak out of the blood vessels into the
interstitial spaces and into the alveoli causing interstitial edema and alveolar edema, decrease surfactant concentration,
and leading to alveolar collapsing. Also, decreased gas exchange will occur which will result in hypoxemia. Hypoxemia
will then cause hypoxia to tissues, organs and extremities in the body.
Neutrophils (are a WBC that are most abundant and quickest to get to an affected site, nick-named the “first responders”)
will migrate through the blood vessels to assist in destroying the virus. Neutrophils will release products that destroy the
virus and can also perform phagocytosis on the virus but will also do this to healthy cells including the Type 1 and 2
Pneumocytes. This will further cause impaired gas exchange and decrease production of surfactant.
Systemic signs and symptoms could include some of the following (note these are the most common for covid-19): fever,
hypotension, tachycardia, tachypnea, dyspnea, desaturation, chest congestion, cough, sore throat, cyanosis, headache,
dizziness, conjunctivitis, confusion, decreased LOC, tiredness, chest pain or pressure, loss of taste or smell, general
aches or pains, loss of speech or movement, a rash on skin, or discolouration of fingers or toes, severe cases could
include: septic shock and multi-system organ failure.
Nasopharyngeal Collection (NP) Kit Instructions
Resource: Public Health Ontario (updated January 2022)
**please note that changes have been made to Covid-19 testing procedures, this is the latest from Public Health Ontario,
although it is important to be mindful that further changes could occur and so it is critical that as a nurse you keep updated
with your agency’s specific policy and procedure related to Covid-19 testing.
**may be contraindicated in patients with recent nasal trauma or nasal surgery, markedly deviated septum, chronically
blocked nasal passages, or severe coagulopathy – consult with Physician first prior to attempting the NP test.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Perform hand hygiene.
Protect yourself by donning a gown, mask, eye protection/face shield and gloves.
Ask the patient to blow his/her nose to remove excess secretions from the nasal passages prior to the test.
Patient's head should be tilted back slightly so that the nasal passages become more accessible (see next page
picture).
Ask patient to close his/her eyes to lessen the mild discomfort of the procedure.
Unwrap the nasopharyngeal (NP) swab (flexible plastic, not wood) swab using sterile technique and gently insert
it into one nostril (insert approximately one-half the distance from the tip of the nose to the tip of the earlobe).
Place the swab 1 inch (2-3cms) into one nostril until resistance is met. Rotate the swab several times against the
nasal mucosa. Leave the swab in place for a few seconds to absorb secretions.
**if resistance is met, back the swab up and try to reinsert at a different angle, if no success remove and try the
other nostril.
Only one nostril is required to be swabbed for this particular NP swab (**please note that the Deep Nasal Swab
that is also being used during this pandemic is a different make from the NP swab for Covid-19, it has been
recommended that both nostrils are swabbed if you are using a Deep Nasal Swab (use same swab for both
nostrils), otherwise the procedure is the same as for the NP swab. Always refer and follow your agency’s specific
policy when collecting a Covid-19 swab and please note that the swabs and technique may change based on
what is available and best-practice guidelines).
Carefully withdraw the NP swab from the nostril.
Insert it into the specimen tube containing the viral transport medium.
11. Break the excess plastic swab at the scored line/groove on the swab shaft so that the plastic fits securely and the
swab is at least 1-2 cm below the upper lip of the transport media.
12. Close the specimen tube tightly using the original cap lid and agitate several times. Ensure that the tube's cap is
well closed. The Public Health Ontario Laboratory (PHOL) will not process leaking specimens.
13. ***Label the specimen container with: the patient’s full name, date & time of collection and one other unique
identifier (e.g., the patient’s date of birth or Health Card Number), the source of the specimen, and the nurse’s
initials and status who collected the swab. Failure to provide this information may result in rejection or testing
delay.
14. Place specimen in the biohazard bag and seal bag.
15. Ensure all fields of the COVID-19 Virus Test Requisition are completed (either paper requisition or computer
requisition depending on your agency), include: the patient’s full name, date of birth, Health Card Number (must
match the specimen label), source of specimen, date of onset, date of collection, physician name and address,
and clinical diagnosis.
16. Insert the completed requisition (or extra labels) in the outside pocket on the outside of the biohazard bag.
17. Remove gloves then gown. Discard PPE into appropriate container. Perform hand hygiene.
18. Remove eye protection then mask. Discard PPE into appropriate container. Perform hand hygiene
19. NURSE IS TO HAND DELIVER IMMEDIATELY TO THE LAB (apply new clean gloves to carry specimen to the
lab). Some agency’s request for optimum viability that the specimen be stored and transported at 2-8°C or on wet
ice to the laboratory – check with agency’s policy about this. If transport of specimen to testing laboratory will be
delayed more than 72 hours, specimens should be frozen at -70°C or below and shipped on dry ice.
**Do not aim up towards the patient’s eye’s
NP Swab: