REGISTERED NURSING
REGISTERED NURSING PROGRAM
NE 103:
OPEN NURSING SKILLS LAB
Review Course for Students Beginning the 2nd Year of the
College of Marin RN Program
FALL 2012
College of Marin
Registered Nursing Program
NE 103 Open Skills Lab
Course Number and Title:
NE 103: Open Skills Lab, 81062, Section 020 for Second Year Students
Student Units:
0.5 units (7 hours/day x 4 days during the week before the Fall 2012 semester begins)
Class Meeting Dates and Hours:
Meets four days:
Monday, 8/13/12, 8:10AM-12 Noon and 1:10-4:00 PM
Tuesday, 814/12, 8:10AM-12 Noon and 1:10-4:00 PM
Wednesday 8/15/12, 8:10AM-12 Noon and 1:10-4:00 PM
Thursday, 8/16/12, 8:10AM-12 Noon and 1:10-4:00 PM
Instructor Information:
Instructor:
Office:
Phone:
Email:
Diane Ridley, RN, MSN
Harlan Center 213
Office: 415-485-9383
Cell:
415-990-2040
diane.ridley@marin.edu
Course Description:
This course provides opportunities for RN students who have completed the required first-year skills labs
(NE 101 and NE 102) to have additional supervised practice integrating theory and implementing
assessment and technical skills that were taught in the previous nursing skills labs and theory courses.
Emphasis is placed on integration of the nursing process, communication and documentation skills, client
care management skills, and critical thinking and problem solving skills when carrying out nursing skills
and interventions. Students role play patient teaching situations to educate patients concerning procedures,
demonstrate increasing proficiency in manipulation of equipment, and implement pediatric, adult, geriatric,
and home health variations of nursing interventions.
Limitations on Enrollment:
Students must be enrolled in the RN program and have completed the first year skills lab (NE 101 and NE
102.) This is a “refresher” course for students in the College of Marin RN program who are entering their
second year. The course meets 4 days during the week before the Fall 2012 semester begins for 7 hours
each day, and to receive credit students must participate in 75% of class hours. Students who are unable to
take the entire course for credit but would like to refresh specific skills may attend class on a no-credit
drop-in basis as space permits; check with instructor.
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Proposed Schedule of Topics
Monday, August 13th, 2012: 0810-1200; Vital Signs and Assessment; Assessing vitals signs and
documentation
• Head to toe assessment
• Review of care planning and documentation
Monday, August 13th, 2012: 1310-1600: Managing IV Therapy
• Calculating IV rates
• Reconstituting, mixing, and hanging primary and secondary IVs using gravity tubing and
infusion devices
Tuesday, August 14th, 2012: 0810-1200: PCAs and TPN
• Setting up and programming PCA
• Documenting patient’s use of the PCA
• Administering TPN
Tuesday, August 14th, 2012: 1310-1600: Blood Administration; Caring for Diabetic Patients
• Administering blood products; documentation
• Review of principles of care of diabetes
• Fingerstick/capillary blood sugars using glucometers; documentation
• Administering SQ insulin using new insulin protocols; documentation
Wednesday, August 15th, 2012: 0810-1200: Administration of Immunizations: Preparation for Fall
2012 Flu Clinic
• Homework:
o Go to CDC website to answer questions about the 2012-2013 flu vaccine
o Read the handout on the College of Marin Health Center 2012-2013 flu clinic
• Class:
o View immunization video
o Practice administering a flu shot to a “client” (classmate) including drawing up the
correct dose, patient assessment and teaching, IM administration of the vaccine, and
documentation
Wednesday, August 15th, 2012: 1310-1600: Transferring and Positioning; Inserting Foley Catheters
and NG Tubes
• Transferring and positioning patients
• Setting up suction and inserting NG tubes for gastric decompression documentation
• Checking NG feeding tube placement and administering enteral feedings; documentation
• Inserting foley catheters
Thursday, August 16th, 2012: 0810-1200: Simulation and Wound Care/Dressing Changes and/or
Students’
Choice
• Group 1: Simulation in the Sim Lab
• Group 2: Wound care and central line dressing change
Thursday, August 16th, 2012: 1310-1600: Simulation and Wound Care/Dressing Changes and/or
Students’ Choice
• Group 1: Wound care and central line dressing change/
• Group 2: Simulation in the Sim Lab
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Methods of Instruction:
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Skills demonstrations
Guided and independent skills practice
PowerPoint Presentations
Videos and DVDs
Case studies and problem solving activities
Clinical simulations
Math for calculation of medication dosages and IV fluid administration
Critical Thinking:
Students learn to:
 Select appropriate nursing interventions for clinical problems and evaluate their effectiveness
 Find solutions to clinical problems through research, discussion, case studies and clinical
simulations
 Adapt skills to clients of various ages (adult, pediatric and geriatric), with various cultural
backgrounds and in various settings, including acute care and home care settings.
NE 103 Nursing Skills Lab Expected Learning Outcomes for Students:
Upon completion of this course, the student will be able to:
1.
2.
3.
4.
5.
Describe essential steps in performance of selected skills.
Identify and assemble required equipment for selected skills.
Demonstrate competency in selected skills that have been taught in pre-requisite and co-requisite
skills lab courses.
Demonstrate increased ability to apply these skills in co-requisite clinical courses.
Apply the nursing process to skill performance by assessing, diagnosing, planning, implementing
and evaluating nursing interventions.
Methods of Evaluation:
In order to receive credit for the class, students must participate in a minimum of 50% of scheduled
open skills lab classes. Participation includes active involvement in individual or group skill practice,
group discussions, simulations, case studies and guided self-study activities.
It is the student’s responsibility to sign in for each open skills lab class attended.
Students will be evaluated on their competency in performing skills specific to the RN role, including
patient assessment, patient teaching and documentation, and on their ability to demonstrate their knowledge
in responding to questions correctly. Students may do self-evaluations, and evaluate other students.
Student Responsibilities:



Students are responsible for signing in and actively participating in a minimum of 50% of scheduled
classes.
Students need to identify their own individual learning needs; the list of skills taught during previous
skills labs listed in this syllabus and the skills that are occurring during clinical experiences can serve
as a guide.
Students need to communicate their learning needs and/or requests for specific skills practice to the
instructor via email prior to class so that the instructor can obtain the appropriate supplies and
equipment and develop skills practice sessions, case studies, and simulations that are appropriate to the
student learning needs.
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Syllabi and References:
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College of Marin NE 103 Open Nursing Skills Lab syllabus
Wilkinson, Judith M. and Treas, Leslie S. Fundamentals of Nursing, second edition. Volumes 1 and
2. F.A.Davis Company, 2011.
The nursing drug handbook of the student’s choice
College of Marin NE 101 Nursing Skills Lab Syllabus
College of Marin NE 102 Nursing Skills Lab Syllabus
Nursing Skills Lab Philosophy:
Skills Lab courses are provided to assist students to learn and practice the skills and procedures used in
everyday nursing practice with accuracy and increasing speed and confidence in a mock-hospital
environment. These courses are intended to provide an opportunity to integrate theory, clinical judgment
and technical skills prior to their application in the clinical setting, and thereby assist the student in
transitioning from the classroom to the clinical setting. The Skills Lab is intended to provide a nonthreatening learning environment where mistakes may safely be made and corrected, professional attitudes
and behaviors modeled and adopted, and critical thinking and decision-making skills developed. It is also
intended to be a place where students may receive the encouragement and support that they need to grow
into competent, compassionate nurses. The goal is for the student to learn the basic purpose, indications,
principles and concepts involved in performing a skill while acquiring the required psychomotor abilities,
rather than having the student just memorize and perform the steps in a procedure.
Experience has shown distinct advantage obtained by students who spend time in the Lab practicing their
skills. Students who achieve proficiency in skills develop a sense of mastery and begin to integrate the
nursing role and identity into their clinical practice more easily. This subsequently helps them to be more
confident and independent and to enjoy greater participation in clinical assignments.
Because the only way to achieve competency in psychomotor skills and create “muscle memory” is
practice, attendance and participation in the lab, as well as preparation and practice outside of the lab, are
required of each student. Everyone learns and develops psychomotor skills at a different rate but the time
available for practice in each lab is limited. Therefore student preparation through reading, viewing
assigned media, and reviewing the theory related to the skills being presented in the lab prior to class, and
practice outside of class, is essential to achieve competency and proficiency in skills.
While the content of each level of the skills lab courses offered during the College of Marin Registered
Nursing Program differ, the overall course objectives remain the same. Upon completion of the selected
skills lab course, the student will be able to:
1.
2.
3.
4.
5.
Perform selected nursing skills at a competent level as evaluated by the instructor using
predetermined criteria.
Identify biological, humanistic, and behavioral principles that substantiate nursing actions
performed in nursing skills.
Act out patient teaching situations that serve to educate patients concerning procedures.
Demonstrate increasing proficiency in manipulation of equipment.
Implement pediatric, geriatric, and home health variations of nursing interventions.
Nursing Skills Lab Course Progression:
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NE 101:
NE 102:
NE 103:
NE 203:
Level I Nursing Skills Lab (For students in first year, first semester)
Level II Nursing Skills Lab (For students in first year, second semester)
Open Skills Lab (elective course, strongly recommended but not required)
Level III Nursing Skills Lab (For students in second year, third semester)
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
NE 205: Open Skills Lab for 3rd and 4th semester nursing students (elective course, strongly
recommended but not required)
OSHA Requirements:
The Occupational Safety and Health Administration mandates that all persons working in healthcare
institutions (including students and instructors) receive information regarding any possible exposure to
blood and blood-borne pathogens. You will be required to annually attend a class that describes the
important blood-borne pathogens, how to prevent exposure using Universal Precautions, and the steps to
take in the event of an exposure. Students are responsible for protecting themselves against exposure in
both the hospital and the lab by learning and using Standard and Universal Precautions and other CDC and
OSHA guidelines for the prevention of transmission of disease. Sharps containers, red bio-hazard waste
bags, disposable gloves and covered trash bins are provided for your safety in the lab, and OSHA
requirements are enforced. Due to possible contamination, drinking and eating, putting on lip balm or other
cosmetics, or putting in/removing contact lenses is not allowed in the Skills Lab.
Guidelines and Miscellaneous:

STUDENTS ARE EXPECTED TO PURCHASE (or download and print), READ, AND BRING TO
CLASS THE COURSE SYLLABUS (which contains articles, hospital chart forms, skill check-offs,
waivers, course evaluation forms, etc.) AND APPROPRIATE REFERENCES, SUCH AS NURSING
DRUG REFERENCE BOOKS AND THE SKILLS LAB TEXTBOOK.

EATING IS NOT ALLOWED in the lab, as ants, garbage and clutter are a problem. (Also, IV
solutions containing dextrose are generally not available in the Lab for this reason.) Further, eating in
the Lab is prohibited by OSHA, which forbids eating where blood exposure is possible. BEVERAGE
CONTAINERS WITH CLOSED TOPS (e.g., water bottles with screw-on tops, cups with lids) ARE
ALLOWED in class when skills/procedures that might involve blood exposure are not being
conducted.

PERFORMANCE OF ANY SKILL THAT INVOLVES POTENTIAL EXPOSURE TO
BLOOD/BODILY FLUIDS MUST ALWAYS BE PERFORMED USING
UNIVERSAL/STANDARD PRECAUTIONS ACCORDING TO OSHA GUIDELINES, USING
STERILE EQUIPMENT/SUPPLIES/MATERIALS WHOSE SHELF-LIFE HAS NOT EXPIRED
(ALWAYS CHECK EXPIRATION DATES!)

DO NOT RECAP NEEDLES! DO NOT SAVE OPEN (SEAL BROKEN) OR UNCAPPED
NEEDLES anywhere, including skill boxes. Syringes that have not had contact with blood/bodily
fluids may be saved from one lab to another for practice, but needles must be disposed of in a Sharps
container immediately.

UTILIZE SHARPS CONTAINERS APPROPRIATELY. Medical waste is expensive to process and
dispose of. Do not put items other than sharps (e.g., gloves, dressings) into the sharps containers. To
prevent injury, make sure sharps drop down into the container, and do not overfill the container.
Notify the instructor or the Lab Tech when a sharps container is becoming full so it can be changed
and injuries can be avoided. (Note: In the hospital, students and nurses should notify whomever is in
charge of changing the sharps containers on the unit whenever they find that a sharps container is
greater than ¾ full.)

TEACHING STUDENTS TO PRACTICE NURSING IN A COST EFFECTIVE MANNER IS A
GOAL OF THE COLLEGE OF MARIN NURSING REGISTERED PROGRAM. Standards of
medical and surgical asepsis require the use of significant amounts of single-use supplies in the clinical
setting, and the use of these single-use products impacts direct health care costs and creates significant
amounts of medical waste. WHILE NO COMPROMISE IN INFECTION CONTROL
MEASURES/ASEPSIS MAY BE USED IN THE CLINICAL SETTING, WHEN STUDENTS ARE
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PRACTICING SKILLS IN THE SKILLS LAB ON THE MANNEQUINS THEY MAY BE ASKED
TO RE-USE VARIOUS SUPPLIES WHEN DOING SO WILL NOT COMPROMISE THE HEALTH
AND SAFETY OF THE STUDENTS.

THE SKILLS LAB STRIVES TO PROVIDE A SIMULATED CLINICAL SETTING. THEREFORE,
STUDENTS ARE EXPECTED TO BEHAVE IN THE SAME COURTEOUS AND POFESSIONAL
MANNER AS THEY WOULD IN THE CLINICAL SETTING. The mannequins should be treated
respectfully (as though they were “real” patients), and equipment and patient care areas should be kept
neat, clean, and in working order just as they would be expected to be maintained in a clinical setting.

Students are expected to assist the instructor during the first and last ten minutes of each skills lab class
to set-up for skills practice and clean up and return supplies to their appropriate storage areas after
skills practice. STUDENTS MAY NOT LEAVE THE LAB UNTIL SUPPLIES AND EQUIPMENT
HAVE BEEN RETURNED TO THEIR PROPER STORAGE AREAS AND THE LABS HAS BEEN
CLEANED UP!

COLLABORATION AND TEAM WORK ARE ENCOURAGED—EXCEPT DURING TESTING!
But please work together quietly; when several groups are working at once, unmonitored voice levels
can become so loud that it becomes difficult to concentrate and communicate.

PLEASE CONCENTRATE ON THE WORK AT HAND, AND UTILIZE SKILLS LAB TIME
PRODUCTIVELY. Class time is for learning and practicing skills with the instructor and classmates,
not for socializing, completing tutoring sessions, studying for exams, or doing work for other classes.

ROOM 161, OUR LAB ASSISTANT’S OFFICE AND SUPPLY ROOM, IS NOT OPEN TO
STUDENTS EXCEPT WITH SPECIFIC PERMISSION. Constant traffic through this area is
disruptive and compromises the security of supplies. we expect that students will not enter this room
without specific permission, nor use it as a passageway between the hallway or Room 174 (the lab) and
Room 163.
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Review Outline of Course Content Taught in
Level I, Level II, and Level III Skills Labs
Course content of the NE 103 Open Skills Lab includes demonstration, review, and practice of skills
presented in previous skills labs (NE 101, NE 102) and may introduce some principles of skills that will be
presented in depth in the Level III skills lab (NE 103). It will also provide preparation for student
participation in the College of Marin Flu Clinics. Below is a summary of the course content presented in
the Level I, II, and III skills labs.
Clinical Nursing Skills Taught in NE 101
I.
Applying Principles of Asepsis and Infection Control:
A. Mandatory OSHA training on blood borne pathogens, standard/universal precautions
B. Hand washing
C. Contact, airborne, respiratory, and other transmission prevention
precautions/isolation
techniques
D. Management of the care of the patient with TB
II. Providing for Basic Human Needs:
A. Hygiene/Comfort: bathing, oral care, positioning
B. Nutrition: feeding clients, recording intake
C. Elimination: toileting patients, applying adult briefs and condom catheters, I&O, daily
weights, bowel care
D. Activity/mobility: ROM, moving and transferring patients, use of crutches, canes, walkers
III. Safety:
A. Fall risk assessment and prevention
B. Use of restraints
C. Aspiration precautions
D. Management/prevention of assaultive behavior
IV. Performing Physical Assessment:
A. Vital signs, including pain rating and O2 sat
B. Head to toe general survey/shift assessment (LOC, heart, lung, abdomen,
extremities,
peripheral, and circulation)
V. Oxygenation:
A. administering oxygen via various delivery devices
B. Peak flow meters
C. incentive spirometer
VI. Glucometer Checks
VII. Foley Catheter:
A. Insertion, irrigation, removal
B. Emptying/measurement, obtaining specimens
VIII. Medication Administration:
A. Calculating dosages
B. Administering medications by PO, topical, inhaled (nebulizers, MDIs/spacers),
SQ
(insulin and heparin/enoxaparin) and IM (immunizations, Imferon using Ztrack technique) routes
IX. Providing Perioperative Care:
A. Pre-op teaching, TC&DB, ICS, pain assessment, DVT prevention exercises, SCDs, TED hose,
mobilization, transferring
B. Informed consent
X. Sterile Technique and Wound and Skin Care:
A. Wound care
B. Central line dressing change
XI. Client Care Management Skills:
A. Use of the nursing process in planning, providing and documenting care
B. Communication: therapeutic communication, assertive communication,
conflict
management
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C. SBAR communication
D. Documentation, transcription of MD orders, nursing admission and discharge,
notes
nursing
Clinical Nursing Skills taught in NE 102
I.
Application of Principles of Infection Control:
A. Medical asepsis
B. Use of universal precautions
II. Providing Intravenous Therapy:
A. Indications for and management of patients requiring intravenous therapy
B. Care and maintenance of peripheral and central venous access devices
C. Hanging primary and secondary intravenous solutions
D. Priming intravenous tubing
E. Regulating intravenous flow rates via gravity and intravenous infusions pumps
F. Discontinuing a peripheral intravenous access device
III. Advanced Pain Management:
A. Setting up, programming, and assessing the patient receiving PCA therapy (Patient
Controlled Analgesia)
B. Epidural catheter management
IV. Providing Transfusion Therapy:
A. Informed consent
B. Interpreting orders for transfusions
C. Priming blood tubing
D. Identification of the patient
E. Assessment and management of the patient receiving blood transfusions and blood products
with focus on the management of transfusion reactions
V. Parenteral Nutrition:
A. Indications for parenteral nutrition
B. Following standard protocol for TPN administration
C. Priming tubing and filters and setting infusion rates
D. Monitoring patients receiving parenteral nutrition
VI. Providing Gastric Decompression and Enteral Feedings:
A. Placement of and management of nasogastric tubes for gastric decompression
B. Administration of and management of enteral feedings and medications via nasogastric and
PEG gastrostomy/jejunostomy tubes
VII. Providing Airway Management:
A. Oropharyngeal and nasotracheal suctioning
B. Closed/inline suctioning via endotracheal and tracheostomy tubes
C. Endotracheal tube care
D. Tracheostomy care
E. management of the cuff on an endotracheal or tracheostomy tube
VIII. Providing Ostomy Care:
A. Colostomy care
B. Urostomy care
IX. Client Care Management Skills:
A. Patient care organization
B. Patient care problem/needs prioritization
C. Time management
D. Clinical documentation/giving report
Clinical Skills Taught in NE 203
I. Annual OSHA review: Principles of Infection Control and Universal Precautions
A. Blood borne pathogens and use of universal precautions
B. Infection Control and Indications for and types of isolation
II. Oxygenation/Ventilation: Ventilators
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A. Indications for and management of patients requiring ventilators
B. Care of patients on ventilators
C. Principles of ventilator weaning
D. Tracheostomy care
E. Management of the cuff on an endotracheal or tracheostomy tube
III. Oxygenation/Ventilation: Chest Tubes
A. Indications for and management of patients requiring chest tubes
B. Setting up a chest tube
C. Monitoring and documenting chest tube drainage
D. Intervening for problems associated with chest tubes
IV. Intravenous Therapy: Central Venous Catheters and Vascular Access Devices
A. Definition of and indications for vascular access devices
B. Differences between vascular access devices: PICC, triple lumen, CVC, Groshong, Hickman,
ports, dialysis catheters
C. Documentation
V. Intravenous Therapy: Starting and Maintaining IVs
A. Virtual IV practice (computer simulation)
VI. Drawing Blood
A. Venipuncture equipment and lab tubes
B. Techniques for drawing blood while starting an IV
C. Techniques for drawing blood from a central line
VII. Performing a 3 lead EKG and using an AED
VIII Communication and Leadership/Management: Calling MDs and Using the Chain of Command
A. Recognizing when to call
B. Recognizing whom to call
C. Organizing data for the call: Information to provide, questions to anticipate, requests to make,
organization of call
D. Documentation
IX. Client Care Management Skills
A. Patient care organization
B. Patient care problem/needs prioritization
C. Time management
D. Clinical documentation
E. Giving report
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NE 103 Proposed Schedule of Topics
Monday, August 13th, 2012: 0810-1200; Vital Signs and Assessment;
• Assessing vitals signs and documentation
• Head to toe assessment
• Review of care planning and documentation
Monday, August 13th, 2012: 1310-1600: Managing IV Therapy
• Calculating IV rates
• Reconstituting, mixing, and hanging primary and secondary IVs using gravity tubing and
infusion devices
Tuesday, August 14th, 2012: 0810-1200: PCAs and TPN
• Setting up and programming PCA
• Documenting patient’s use of the PCA
• Administering TPN
Tuesday, August 14th, 2012: 1310-1600: Blood Administration; Caring for Diabetic Patients
• Administering blood products; documentation
• Review of principles of care of diabetes
• Fingerstick/capillary blood sugars using glucometers; documentation
• Administering SQ insulin using new insulin protocols; documentation
Wednesday, August 15th, 2012: 0810-1200: Administration of Immunizations: Preparation for Fall
2012 Flu Clinic
• Homework:
o Go to CDC website to answer questions about the 2012-2013 flu vaccine
o Read the handout on the College of Marin Health Center 2012-2013 flu clinic
• Class:
o View immunization video
o Practice administering a flu shot to a “client” (classmate) including drawing up the
correct dose, patient assessment and teaching, IM administration of the vaccine, and
documentation
Wednesday, August 15th, 2012: 1310-1600: Transferring and Positioning; Inserting Foley Catheters
and NG Tubes
• Transferring and positioning patients
• Setting up suction and inserting NG tubes for gastric decompression documentation
• Checking NG feeding tube placement and administering enteral feedings; documentation
• Inserting foley catheters
Thursday, August 16th, 2012: 0810-1200: Simulation and Wound Care/Dressing Changes and/or
Students’
Choice
• Group 1: Simulation in the Sim Lab
• Group 2: Wound care and central line dressing change
Thursday, August 16th, 2012: 1310-1600: Simulation and Wound Care/Dressing Changes and/or
Students’ Choice
• Group 1: Wound care and central line dressing change/
• Group 2: Simulation in the Sim Lab
10
Class
Schedule and
Student
Learning
Outcomes
11
Day #1 Monday, August 13th, 2012
Class #1: 8:10 AM-12:00 Noon
 Vital Signs and Assessment;
 Care Planning, Documentation, and
Reporting
Review of Vital Signs and Patient Assessment:
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory the student will:
• Describe the range of normal vital signs for adult and pediatric clients
• Demonstrate ability to assess and document vital signs, measure a pulse Oximetry, and
assess pain
• Perform and document a rapid, systematic head to toe assessment on a classmate or
manikin and document findings
Review of Care Planning and Documentation:
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory the student will:
• Identify normal and abnormal patient findings in a case study
• Based on case study findings, identify actual or potential nursing diagnoses and potential
complications
• Develop a plan of care for selected nursing diagnoses
• Use the plan of care to write a beginning of shift assessment note
• Use clinical findings and the plan of care to write and end of shift evaluation note.
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Guidelines for Performing a Basic Physical Assessment:
• NEUROLOGICAL/PSYCHOSOCIAL: Start by introducing yourself and asking how the patient
is feeling. Remember, “first talk then touch.” As appropriate and necessary, take care of any immediate
care needs that the patient requests or requires (e.g., toileting, repositioning). Note that as you talk to the
patient you are simultaneously beginning a basic assessment of the client’s neurological and
psychological function.
o Neuro: Observe whether the client is awake, alert, oriented to person (self and others) place,
time, and events. Be aware of language barriers. Note if patient responds appropriately to
gestures. Obtain translation cards or an interpreter (an interpreter phone is often used) as needed.
o Psychosocial: Observe whether the client seems calm/anxious/irritable/restless, cooperative or
uncooperative, smiling/optimistic or tearful/pessimistic, apathetic/withdrawn (e.g., flat
affect/showing no emotion, not speaking or speaking only in one or two word answers, avoiding
eye contact, keeping the room dark) or participating in conversation, and demonstrating interest
and participation in self-care and a readiness to learn. Note whether patient has social support,
e.g., family or friends visiting or calling.
• VITAL SIGNS: Next, assess the patient’s vital signs. Patients are familiar with and expect to have their
vital signs taken and this is an easy way to begin touching the patient. Note that as you assess the vital
signs, you are performing a basic assessment of the respiratory and cardiovascular systems.
o Get in the habit of taking VS in a specific order, e.g. TPR-BP-Pain-O2 Sat, writing the
assessment findings down immediately
o If you use an automatic vital sign machine (e.g., a Dynamap) you still need to assess the apical
pulse rate and rhythm for a full minute (noting if it is regular, regularly irregular or irregularly
irregular) and .assess the respiratory rate for 15 or 30 seconds.
o Note the condition of the skin.
• RESPIRATORY SYSTEM: Continue your assessment of the respiratory system by auscultating the
lungs.
o Listen to the anterior upper lobes of the lungs bilaterally.
o Ask the patient to sit up and lean forward, or to turn on their side, so you can listen to their lungs
(Right upper middle and lower lobes, and Left upper and lower lobes).
o Note the condition of the skin.
• ABDOMEN: Assess the patient’s abdomen. Note that as you assess the abdomen you are
performing a basic assessment of the gastrointestinal and genitourinary systems.
o Expose the abdomen, keeping the client’s genitalia and lower extremities covered as much as
possible.
o Look at the shape of the abdomen, note softness/firmness, and listen for bowel sounds in all 4
quadrants.
o Note the presence and condition of dressings, drains, catheters, ostomies.
o Note the condition of the skin.
• CIRCULATION, SENSATION, MOVEMENT: Assess the patient’s circulation, sensation, and
movement (CSM) in the lower extremities.
o Note the color and warmth of each extremity.
o Note the presence, location, and degree of any edema.
o Palpate for the presence of the Dorsalis Pedis and Posterior Tibialis pulses bilaterally,
o Assess the capillary refill,
o Ask the patient to wiggle their toes, dorsiflex and plantar flex their feet, and press down as if
pressing on a car’s gas pedal) against the resistance of your hand.
o Ask the patient to lift their leg off the bed without resistance and with resistance.
o Note the condition of the skin.
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Case Studies for
Practice Developing Care Plans
Patient #1
Mr. W. is a 45 year-old male admitted with a chief complaint of chest pain and shortenss of breath. He has
a history of hepatitis C and alcoholic cirrhosis, a GI Bleed, IV drug abuse. The patient is jaundiced and has
an enarlged liver, 3+ lower extremity edema, and decreased breath sounds, R > L. On CXR he is found to
have a right pleural effusion., Lab result show elevated liver function tests, abnormal coag panel. CBC
results: Hmg=9.8, Hct=29.6, WBC=7.0, platelets-125,000.
 List at least 6 actual or potential nursing diagnoses or collaborative problems.
 For each nursing diagnoses describe what would be observed and assessed for
 Describe independent and dependent nursing interventions for each diagnosis.
Patient #2
Ms. O is a 70 year-old female with an admitting diagnosis of nausea and vomiting, anorexia, hyperkalemia,
anemia, and diabetes. She has a history of a Right AKA and hypertension. Her lab results are as follows:
K=6.9; BUN=80; Creat=3.6, Hmg=8.9, Hct=27, plts=135,000, WBC=11,500.
•
•
•
List at least 6 actual or potential nursing diagnoses or collaborative problems
For each nursing diagnoses, describe what would be observed and assessed for
Describe independent and dependent nursing interventions for each diagnosis.
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Using SBAR for Patient Hand-off/Change of Shift Report
Use the information below to create an SBAR patient hand-off for your 78-year old
patient with a history of CAD, arthritis, and asthma who was admitted with a GI bleed
and is receiving blood transfusions.
Admission and recent patient care physician orders:
Admit to medicine, Dr. Sanger
Dx: GI Bleed; hx asthma, CAD, arthritis
Allergies: Sulfa
CBC with diff, coag panel, Chem 23 stat; call MD with results
Type and crossmatch 3 units PRBCs
Start IV of D51/2NS @ 100cc/hour
Diet: 2 gram NA, low cholesterol
Transfuse 3 units PRBCs each over 3 hours
Premedicate patient before first unit of PRBCs with Tylenol 650 mg PO and Benadryl 25 mg PO x 1
Re-check H/H 1 hour after transfusion complete and call MD with results
Additonal Meds:
Protonix 10mg IVPB q 12 hours
Albuterol MDI 1 puff s q 4 hours prn
Advair 1 inhalation bid
Stat CXR
Stat EKG
O2 @2 lpm np titrate to keep sat >93%
Lasix 20 mg IVP x 1 Stat
Significant events on your shift:
 Patient Admitted. Admission VS: 37.5, HR 116, RR 24, 105/63. The RA O2 sat =
90%.
 Admission lab results: Hmg = 7.9, WBC = 8,500; K+ = 3.3
 Pre-medications given, and one unit of blood has been completed.
 One hour after the second unit of PRBCs was started, the patient complained of SOB
and chest tightness, and was restless, apprehensive, diaphoretic and visibly SOB. VS
were T = 37.9 HR 128, BP 126/ 89, RR 36 and shallow, pulse oximetry = 89% on O2 a
2 lpm via np. Breath sounds decreased, bilateral rales up 1/3, + jugular venous
distention, + S3 gallop. Physician notified; Lasix 20mg IVP stat X 1 ordered and given.
 Patient now without SOB, skin warm and dry, patient calmer, voided 500 mL of clear
urine. VS: T 37.7, BP 118/77, HR 117, RR 24, O2 sat = 91% on O2 @ 2 lpm np.
Blood restarted.
SBAR
S: Situation
B: Background
A: Assessment
R: Recommendations: (Remember to address with the provider what you would like to
see done (e.g., what procedures, tests, meds to be given) and to ask the provider, “If the
patient does not get better who and when should they be called?”)
19
Day #1 Monday, August 13th, 2012
Class #2: 1:10 AM-4:00 PM
 Practice Dosage Calculations
 Managing IV Therapy
Review of Administration of Primary and Secondary Intravenous Therapy by Gravity and
Infusion Device
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory the student will:
• Apply principles of medical asepsis and universal precautions.
• Define the purpose of primary and secondary intravenous therapy.
• Describe procedure for assessment and maintenance of peripheral IV sites.
• Analyze evidence-based references to determine safe rate of administration for
selected medications given by secondary infusion.
• Calculate primary and secondary infusion rates.
• Select IV infusion solution and equipment based on analysis of client data.
• Demonstrate spiking primary large volume intravenous solutions and priming gravity
flow tubing.
• Calculate and regulate primary IV flow rates via gravity infusion.
• Demonstrate spiking, back priming, and infusing secondary infusions by gravity
• Calculate and regulate secondary IV flow rates via gravity infusion
• Demonstrate spiking primary large volume intravenous solutions and priming
infusion device tubing and use of infusion device.
• Demonstrate spiking, back priming, and infusing secondary infusions by infusion
device
• Document primary and secondary infusions in the medical record.
20
Medication Dosage Calculation Practice Problems
1. You have an order to given Heparin 12,000 units SQ bid. The pharmacy has sent you a vial
containing heparin 20,000/2ml. How many mls will you give?
2. A patient is to receive a total of 200 mg of doxycycline PO per day. Doxycycline can be
given once daily, or in divided doses q 12 hours. The physician orders doxycycline 100 mg
PO bid. The Pyxis contains Doxycycline capsules containing 0.05 g/capusule. How many
capsules will you administer per dose? How many capsules of Doxycycline will need to be
dispensed for the patient to have enough medication for 10 days?
3. The prescriber has ordered Vistaril (hydroxyzine HCl) 0.6 mg/kg IM for a child. If the child
weighs 42 kg, and the vial is labeled Vistaril 50mg/1ml, how many mls will you administer?
4. Digoxin comes in a vial containing 500 mcg/2 ml. How many mls will you prepare for a
patient who is ordered a maintenance dose of 0.0625 mg IV x qd?
5. The label on the vial reads Penicillin G 1,000,000 units. The instructions for reconstitution
are as follows: “ Add 19.6 mL of sterile water to vial. Resulting concentration: 1mL =
50,000 units.” How many mls contain 100,000 units?
6. A patient is 5 feet 3 inches tall and weighs 150 pounds. Use the adult nomogram to estimate
her BSA.
7. Doxycycline 60mg/m2 has been ordered for the patient. The medication comes in an oral
suspension containing 25mg/5 ml. How many milliliters will you administer to a patient who
is 160 cm and weighs 56 kg? (Use the formula BSA in m2 = square root of [ht in cm x wt in
kg/3600]
8. The prescriber ordered digoxin elixir 250mcg PO qd. The label reads 0.5mg/ml. How many
milliliters would you administer to the patient?
9. The physician has ordered erythromycin 0.5 gram PO q 8 hours for the treatment of Lyme
disease. The usual dosage is 6.75 mg/kg per dose. Is the MDs order appropriate for a patient
weighing 74 kg?
10. The patient is to receive Cipro 0.25g PO bid. Cipro comes in a concentration of 100mg/ml.
How many mLs will you administer per dose?
21
11. Dilantin 0.2 g PO tid is ordered for your patient. How many mLs will you administer per
dose if the drug label reads 100 mg/4 mL?
12. Lotensin 0.01g PO is ordered. The Pyxis contains Lotensin 5mg tablets. How many tablets
will you administer to your patient?
13. The MD orders the oral hypoglycemic drug Glucotrol (glipizide) 0.015 gram PO bid ac.
Each tablet contains 5mg of the drug. How many tablets will you need per day?
14. Your patient has been prescribed digoxin (Lanoxin) elixir 0.0625mg PO QD. The
concentration of the elixir is 0.05mg/ml. How many mLs will you administer to the patient?
15. A patient develops respiratory depression after receiving a dose of narcotic analgesic. The
prescriber orders 0.002gram of Narcan (naloxone HCl) a narcotic antagonist. You have a
10ml vial on hand containing 1mg/ml. How many ml will you administer?
16. You have an order for Solumedrol 60mg q 8 hours. You have a vial of Solumedrol
125mg/2mL. How many mLs will you give per dose?
17. Lasix 0.25mg/kg PO is ordered for your pediatric client. The child weighs 42kg. The
pharmacy sends you a vial of furosemide in a concentration of 2mg/ml. How many milliliters
will you give to the child?
18. Diuril, a thiazide diuretic, 0.005 gram/kg qd has been prescribed for a child. The label reads
50mg/5ml. How many mLs will you administer if the child’s weight is 74.8 lbs.?
19. Motrin 5mg/kg PO q 6 hours prn. Each 5 ml contains 100mg. If the child weighs 44 lbs.,
how many mLs per dose will you administer to this child?
20. The prescriber orders 1,200,000 units Penicillin G IM, a very viscous medication. The
5,000,000 unit vial of powder has these instructions: Add 8mls of sterile water to create a
concentration of 500,000 units/1 ml. How many mLs equals 1,200,000 units? Can this be
given in one injection? What size needle would you choose? What size syringe would you
select? What administration site would you choose?
21. Azithromycin 7.2mg/kg PO qd has been ordered for the patient. Azithromycin (Zithromax)
comes is capsules containing 250mg. How many capsules will you administer to a patient
weighing 154 pounds?
22
22. Codeine gr ¼ IM q 4 hours prn pain is ordered for Mr. D. The codeine on hand is in a Tubex
labeled gr ½ per milliliter. How many milliliters of the Codeine would you give? (Use
the conversion gr 1 = 60 mg.)
23. Your patient has a post-op analgesic order for morphine gr 1/10 IM q 3-4h prn abdominal
pain. The morphine on hand in the Pyxis is in a Tubex (a prefilled syringe) labeled 8 mg/mL
How many mLs will you give? (Use the conversion 1 grain = 60 mg.)
24. The physician writes an order to give acetylsalicylic acid (aspirin) 650 mg PO x 1 now. The
pharmacy sends you gr 5 caplets. How many caplets will you administer? (Use the
conversion gr 1 = 65mg aspirin.)
25. Your patient complains of pain. You have a medication order for codeine sulfate gr ½ PO q 4
hours prn pain. Each tablet contains gr ¼. How many tablets will you administer?
23
Calculating IV Drip Rates
To calculate the number of drops per minute that the IV should infuse, you need to know 3 pieces of
information:
The number of cc’s per hour you are trying to deliver to the patient
The drip factor of the tubing you are using.
The formula (or shortcut) for calculating drops per minute
1.
2.
3.
1.
The number of cc’s per hour
To calculate the number of cc’s hour that is to be delivered, take the total volume of the fluid to be given
and divide by the number of hours you want to deliver it in. IV rates are generally expressed in cc/hour.
Example: Infuse 1000cc D5 1/2NS over 8 hours:
2.
1000cc = 125cc
8 hours
1 hour
The drip factor.
IV tubing has 4 basic drip factors:
10 gtts/cc (blood tubing)
15 gtts/cc
20 gtts/cc
60 gtts/cc (Known universally as Micro-drip or Pedi-drip tubing. If you read that you are using Micro-drip
or Pedi-drip tubing, you know that it is 60 gtts/cc tubing; that is, 60 drops = 1 cc)
3.
The formula:
cc
hour
x
hour
minutes
x
drops
cc
=
drops
minute
Example:
You are to infuse 1000cc D5 1/2NS over 8 hours using 10 gtts/cc tubing. How many drops per minute will
be needed to infuse the IV in the prescribed amount of time? To calculate the IV rate in cc/hour (the rate),
and the rate in drops/minute, set up the following equation:
1000cc
8 hours
1000 x 1 x 10
8 x 60 x 1
x
1 hour
x
60 minutes
=
125 x 1
6
10 gtts
1 cc
=
=
20.8 or 21cc/hour
Example:
Infuse 1000cc D5 1/2NS over 8 hours using 15gtt/cc tubing. Calculate the drops/minute:
24
Example:
Infuse 1000cc D51/2NS over 8 hours using 20gtt/cc tubing. Calculate the drops/minute:
Example:
Infuse 1000cc D5 1/2NS over 8 hours using 60gtt/cc tubing. Calculate the drops/minute:
4. The Shortcut!




If using 10gtt/mL tubing, multiply mL/hour (rate) by 1/6 (or divide rate by 6)
If using 15gtt/mL tubing, multiply mL/hour (rate) by 1/4 (or divide rate by 4)
If using 20gtt/mL tubing, multiply mL/hour (rate) by 1/3 (or divide rate by 3)
If using 60gtt/mL tubing, multiply mL/hour (rate) by 1/1 (or divide rate by 1). (The number of
mL/hour will always equal drops/minute when using this kind of tubing.)
When calculating the IV drip rate, you can save time by determining the number of drops per minute
needed, and then dividing that number by 4 to determine the number of drops needed in 15 seconds. Do
your calculations, and then, at the bedside, get out your watch and count the number of drops that go by in
a 15 second period, adjusting the IV roller clamp up or down to increase or decrease the number of drops
until the correct rate is established
25
Setting up IV Equipment and Calculating IV Drip Rates
Goals:
• Calculating and setting IV infusion rates
• Understanding the differences between macro-drip and micro-drip and Buretrol/Volutrol
tubing
• Obtaining and utilizing information from various pharmacology sources
•
Safe, accurate IV and IVPB drug administration utilizing pharmacology resources and
recommendations
General Directions:
1. Look up the medications listed in the scenarios below in 2 different sources (nursing drug
books, nursing IV drug books, PDR, internet, palm pilot) to determine:
• the volume of solution in which you will mix the drug
• the type of solution in which you will mix the drug
• the rate at which you will infuse the drug
• whether the drug and the solution are compatible with the fluid running in the primary IV line
• any special considerations you need to be aware of
2. Note whether the information is the same in the various sources. Which source do you prefer
and why? If there are several choices about how to give the medication, give your rationale
for the choice you make.
3. Show your math work.
4. Set up the appropriate IV administration equipment. Be sure to label all IV bags and tubing.
IVPB labels must include the name the drug, the dosage, route, date, time, and your signature.
5. Calculate and set the correct IV infusion rate.
Scenarios:
A. Hannah is a 78-year-old patient admitted to the medical surgical unit following hip surgery.
Post-op orders include an IV of D5 ½ NS with 20 mEq KCL to run at 100cc/hour. Set up the IV
and set the correct rate. The MD has also ordered Kefzol 1 gram every 8 hours IVPB. Mix the
drug, hang the piggyback, calculate and set the correct infusion rate.
B. Jose, a 34-year-old diabetic, is admitted to the medical surgical unit with a diagnosis of
diabetic ketoacidosis. The MD orders an IV of 0.9 NS to infuse at 150mls/hour. Set up the IV and
calculate and set the infusion rate. When his chest x-ray reveals that Jose has pneumonia, the MD
orders Rocephin 1 gram IVPB q12 hours. Mix the drug, hang the piggyback, and calculate and set
the correct infusion rate.
C. Bertha, an 88-year-old woman, is admitted to the hospital with congestive heart failure,
dehydration, and failure to thrive. The MD orders an IV of 0.9NS to run at 75 ml/hour. Set up the
IV and calculate and set the correct infusion rate. When the lab work shows her potassium level is
26
low at 2.6, the MD orders potassium 10meq IVPB x 4 doses. Mix the drug, hang the piggyback,
calculate and set the correct infusion rate.
D. Johnny, a 10-year-old boy, is admitted to the pediatric floor post appendectomy. He weighs
60 pounds and is receiving an IV of D5NS at 50cc/ hour.
What kind of IV tubing do you need to use and why? Set up the IV and calculate and set the
correct infusion rate.
E. Maria, an 18-month-old baby, is admitted to the pediatric floor for gastroenteritis. She weighs
25 pounds and is on an IV of D5NS at 30cc/hour infusing into a #24 angiocath in her Right foot.
Set up this IV using microdrip tubing and a Buretrol/Volutrol, and calculate and set the correct
infusion rate.
F.
Tomas is a 77 year old patient admitted to the med surg floor S/P colostomy. He has an
IV of D5LR running at 150cc/hour into a #18 angiocath in his Right hand. He has an order for
famotidine/Pepcid 300 mg IVPB once a day. Mix the drug, hang the IV piggyback, calculate and
set the correct infusion rate.
G.
The nurse walks into Tomas’s room to administer the famotidine/Pepcid. First she
assesses the IV site and notes that the hand is swollen and pale in color. The radial pulse is strong.
Tomas c/o of mild pain at the site. The nurse checks for a blood return and finds none. The nurse
decides to discontinue Tomas’s IV and restart it in the opposite arm.

What complication of IV therapy do you think is occurring?

What is the significance of no blood return?

How do you check for a blood return?

Why does the nurse discontinue the IV?
H. Karin has osteomyelitis and is being treated with Vancomycin 1.5 grams IV every 12 hours.
Since osteomyelitis is a difficult infection to treat, she will be on IV antibiotic therapy for at least
6 weeks. She has a TKO IV line of 0.9NS @ 30cc/hr infusing into a #20 angiocath in the Right
forearm. Mix the drug, hang the piggyback, calculate and set the correct infusion rate.
27
Calculating and Programming the IV Pump
General Directions:
1. Answer the following questions.
2. Use dimensional analysis to calculate the rates in the examples and show your work.
3. Once you have answered the questions and done the calculations:
a. Determine which of the IV pumps in the lab you are going to use.
b. Select the appropriate IV tubing(s) for that pump
c. Select the appropriate volume of IVsolution
d. Correctly label the IV solution bag (all of the IV solutions in the lab are 0.9 NS) with
the name of the solution to be used.
e. Set the rate for the primary and/or secondary infusion(s) and the Volume To Be
Infused (VTBI) for the primary and/or secondary infusion(s) on the IV pump.
Scenarios
1. You have an order to give Protonix 40mg in 100 mLs NS IVPB over 15 minutes. You have
no IV pump.
a. Will you use a primary IV solution and tubing? Why or why not?
b. If you will use a primary IV solution and tubing, what solution will you select?
c. If you will use a primary IV solution and tubing, what are the possible drip factors?
d. What will you set the primary rate for, and considering the drip factor of the IV
tubing you selected, what will be the number of gtts/min?
e. Explain and demonstrate how you will prime the primary IV tubing
f. Explain and demonstrate how you will prime the secondary/IVPB tubing.
g. Explain and demonstrate where you will place the IVPB in relation to the primary
bag.
h. Which roller clamp, the one on the IVPB tubing or the one on the primary IV tubing,
controls the rate of the IVPB infusion?
i. What will you set the secondary rate for and, considering the drip factor, what will be
the number of gtts/min?
2. The MD orders D5 ½ NS 100 mLs/ hour. You are using an IV pump.
a. Explain and demonstrate the correct placement of the IV pump on the IV pole.
b. What tubing will you use for the infusion with this IV pump? What is the drip factor
of the pump IV tubing?
c. Explain and demonstrate how to prime the IV tubing.
d. Explain and demonstrate what will you set the primary IV pump rate for;
e. Explain and demonstrate what will you set the primary VTBI for.
3. The MD orders Kefzol 2 grams in 100 mLs of NS IVPB over 30 minutes. You are using an
IV pump.
a. Will you use a primary IV solution and tubing? Why or why not?
b. If you will use a primary IV solution and tubing, explain and demonstrate what
solution and tubing you will select. What is the drip factor of the tubing?
c. Label the selected primary solution and tubing correctly.
d. Determine and demonstrate what you will you set the primary rate and VTBI for.
e. Obtain the mixed IVPB medication and secondary tubing that is compatible with the
pump. Label the IVPB and tubing correctly.
f. Demonstrate hanging and superimposing the secondary IVPB and priming the
secondary tubing.
g. Determine and demonstrate what you will set the secondary rate for.
28
h. Determine and demonstrate what you will set the secondary VTBI for.
4. You are to give ranitidine/Zantac 300mg in 50 mls of D5W IVPB over 20 minutes. You are
using an IV pump.
a. Will you use a primary IV solution and tubing? Why or why not?
b. If you will use a primary IV solution and tubing, explain and demonstrate what
solution and tubing you will select. What is the drip factor of the tubing?
c. Label the selected primary solution and tubing correctly.
d. Determine and demonstrate setting the primary rate and VTBI.
e. Obtain the mixed IVPB medication and secondary tubing that is compatible with the
pump. Label the IVPB and tubing correctly.
f. Demonstrate hanging and superimposing the secondary IVPB.
g. Demonstrate priming the secondary tubing.
h. Determine and demonstrate setting the secondary rate and VTBI.
i. The pump malfunctions and there are no new pumps available from Central Supply.
Explain and demonstrate how you will continue the infusion at the correct rate
without the pump.
5. The patient has an IV of D5 /2 NS + 20 mEq KCl infusing on a pump at 125 mLs/hour. An
order on the patient’s medication administration record reads: Vancomycin 1 gram in 250
D5W IVPB every 12 hours; infuse over 2 hours.
a. Select and label the primary infusion and tubing
b. Correctly prime the tubing.
c. Demonstrate setting the primary rate and VTBI.
d. Is the ordered medication compatible with the ordered primary continuous infusion?
How will you proceed if they are not compatible?
e. Obtain the mixed IVPB medication and correct secondary tubing for use with this
pump. Label the IVPB and tubing correctly.
f. Demonstrate hanging and superimposing the secondary IVPB.
g. Demonstrate priming the secondary tubing.
h. Determine and demonstrate setting the secondary rate.
i. Determine and demonstrate setting the secondary VTBI.
6. Your patient is found to be hypovolemic. The patient is to receive a 500 mL bolus of 0.9NS
over 2 hours. There are only 250 mL and 1000 mL bags of 0.9 NS on the unit. You are using
an IV pump.
a. What are some signs and symptoms of hypovolemia?
b. What are some possible causes of hypovolemia?
c. Explain which size IV bag of NS you will select to use
d. Explain and demonstrate setting up the IV bolus for infusion, including selecting the
IV solution and tubing, labeling the IV solution and tubing, priming the tubing, and
setting the rate and VTBI
7. The patient is to receive a blood transfusion of 1 unit of PRBCs (approximately 250 mLs)
over 3 hours via an IV pump.
a. What are some major reasons for a blood transfusion?
b. What tubing will you use?
c. Do you need any other IV solution besides the PRBCs?
d. Will you use a pump? Why or why not?
e. If you will use a pump, will you use the primary or the secondary settings for the
PRBCs?
f. If you will use a pump, will you use a the primary or secondary settings for any other
IV solutions that you will infuse?
g. Demonstrate the primary or secondary pump rate and VTBI for the PRBCs.
h. Demonstrate the primary or secondary pump rate and VTBI for the other IV solution.
29
i.
Demonstrate what will you do when the PRBC infusion is complete?
30
Day 2: Tuesday, August 14th, 2012
Class #3: 8:10AM-12:00 Noon
 PCAs
 TPN
Review of PCA:
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory, the student will:
 Demonstrate pain assessment using a verbal and a nonverbal scale.
 Define Patient controlled Analgesia (PCA).
 List common medications used for PCA.
 Discuss advantages and disadvantages of PCA.
 Define epidural analgesia.
 Interpret PCA orders.
 Demonstrate priming PCA tubing and programming a PCA pump.
 Formulate a teaching plan for a patient with a PCA pump.
 Demonstrate ability to monitor and document PCA use and patient’s response in order to
assure good pain control and minimize risk potential for patients with a PCA
Review of Administration of TPN
After completing this Nursing Theory and Clinical Application Laboratory, the student will:
 Discuss indications for parenteral nutrition.
 Describe appropriate venous access devices for administering parenteral nutrition.
 Compare and contrast Total Parenteral Nutrition (TPN) and Peripheral Parenteral
Nutrition (PPN).
 Develop a generic care plan for a client receiving parenteral nutrition.
 Demonstrate correct procedures to safely provide parenteral nutrition for clients.
 Demonstrate correct procedure to safely provide intralipids for clients.
31
Pain Management
Definition of Pain
• “An unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage.”(International Association for the Study of Pain)
• Pain is inherently personal and subjective
Approach to the Treatment of Pain
• Treat underlying cause(s) when possible
• Relieve symptoms
• Symptoms can be relieved using both pharmacological and non-pharmacological interventions.
Definitions
• Opioid: Any drug, natural or synthetic, that has actions similar to morphine
• Opiate: Compounds present in opium (e.g., morphine, codeine)
• Narcotics: Legal context, used to designate opioids as well as cocaine, morphine, LSD
• Nociceptive Pain: Pain resulting from injury to tissues
– Visceral Pain: Results from injury to visceral organs (e.g., small intestine)
– Somatic Pain: Results from injury to somatic tissues (bones, joints, muscles)
• Neuropathic Pain: Results from injury to nerves
Endogenous Opioid Peptides
The body has 3 families of peptides that have opioid properties
• Enkephalins
• Endorphins
• Dymorphins
These peptides are found in the CNS and peripheral tissues.
• Opioid Receptors
Opioid Receptors
There are three main classes of opioid receptors:
• Mu
• Kappa
• Delta
Endogenous opioid peptides serve as:
• Neurotransmitters
• Neurohormones
• Neuromodulators
The endogenous opioid peptides (enkaphalins, endorphins, dymorhpins) act through all three types of
opioid receptors, including delta receptors.
• From a pharmacologic perspective the mu receptors are the most important because exogenous
opioids (opioid analgesics) seem to act primarily through activation of mu receptors.
• Exogenous opioids also produce weak activation of kappa receptors but do not seem to act on
delta receptors.
Response to Mu and Kappa Receptors
• Analgesia: mu, kappa
• Respiratory depression: mu
• Sedation: mu, kappa
• Euphoria: mu
• Physical dependence: mu
• Decreased GI motility: mu, kappa
Classification of Drugs that Act on Opioid Receptors
• Pure Opioid Agonists
32
•
•
– E.g., Morphine: mu agonist, kappa agonist
Agonist-Antagonist
– E.g., Pentazoncine, nalbuphin, butorphanol: mu antaonist, kappa agonist
Pure Opioid Antagonists
– E.g., Naloxone, naltrexone, nalmefene: mu antagonist, kappa antagonist
Opioid Prototype
• Prototype: Morphine (MSO4) (named after Morpheus, the God of dreams)
Other Opioid Analgesics
 Codeine--Tylenol #3, Tylenol #4
 Hydrocodone--Vicodin
 Oxycodone--Percocet, Percodan
 Propoxyphene--Darvocet
 Meperidine--Demerol
 Morphine--Roxanol, MS Contin, MSIR
 Hydromorphone—Dilaudid
 Fentanyl- -Duragesic
The WHO Analgesic Ladder for Pain Releif
• Non-opioid (NSAIDs)+/- Adjuvant
• Opioid for mild to moderate pain +/- Non-opioid +/- Adjuvant
• Opioid for moderate to severe pain +/- Non-opioid +/- Adjuvant
Pharmaceutical Actions of Morhpine
• Relieve pain
• Drowsiness
• Mental cloudiness
• Decrease anxiety
• Sense of well-being/euphoria
Other Effects of Opioids—Beneficial and Detrimental
• Respiratory depression
• Constipation
• Urinary retention
• Orthostatic hypotension
• Emesis
• Euphoria/dysphoria
• Sedation
• Miosis
• Cough suppression
• Biliary colic
Pharmacokinetics of Morhpine
• Various routes: Oral, IM, IV , SC, rectal, topical, mucosal, epidural, intrathecal
• Analgesia lasts up to 4-5 hours via IM, IV, and SC routes
• Analgesia last us to 24 hours with epidural and intrathecal route
• Depending upon the formulation, analgesia can last up to 24 hours with PO administration
Uses of Opioids
Pain relief:
• Acute pain
• Chronic non malignant pain
• Cancer pain
• Post-op pain
33
•
•
•
Labor and delivery
Chest pain/MI
Dyspnea with left ventricular failure and pulmonary edema
Routes of Administration
• Oral
• Parenteral: SC/SQ, IM, IV, spinal (epidural, intrathecal)
• Transmucosal
• Transdermal
Oral Route
• Inexpensive
• Noninvasive
• Easy for patients to self-administer
• First choice for managing both acute and chronic pain
• Inappropriate for severe, escalating pain because opioids administered orally don’t reach peak
effects for 90-120 minutes after ingestion
IV Route
• IV opioids have a rapid (10 minutes) onset
• IV opioids can be rapidly titrated to fit the patient’s analgesic/pain relief needs
• The IV route is best when patients need immediate relief from severe or escalating pain
• The IV route is also used for patients with chronic pain who can’t take oral opioids (e.g.,
terminally ill patients with intestinal obstruction)
Methods of IV administration include:
• Continuous infusion
• Intermittent IVP/bolus
• Patient controlled analgesia
 PCA only
 PCA + basal/background/continuous infusion
 basal/background/continuous infusion
Intraspinal Route
The intraspinal route includes:
• Epidural
• Intrathecal
• Medication can be delivered via bolus or continuous infusion or both.
• Intraspinal routes are recommended for major abdominal, thoracic, and joint surgeries when
severe, acute pain is anticipated.
Drugs commonly used by the intraspinal route include:
• Morphine (Astramorph PF, Duramorph)
• Fentanyl
• Hydromorphone
• Intraspinal Route
• Intraspinal opioids are being increasingly combined with low doses of local anesthetics, such as
bupivacaine.
• Combinations of opioids with local anesthetics provide analgesia (not complete anesthesia) and
allow administration of lower doses of opioids, which reduces opioid-induced adverse reactions.
Routes to Avoid
Intermittent IM
• Painful
• Potentially damaging to tissues
• Absorbed slowly and at an unpredictable rate, so pain control is unreliable
• Time consuming
• Poor choice for the elderly, who’ve lost muscle mass from aging, and for children, who dread
painful injections
• Inappropriate for postoperative pain because hypovolemia, hypothermia, and lack of muscle
activity further delay drug absorption
34
•
Slow absorption may result in administering additional doses, which can lead to more opioid
accumulation in the tissues. Then, as circulation and absorption improve, the patient may
experience adverse reactions such as sedation and respiratory depression.
• Unreliable absorption makes it difficult to predict peak effect and to know when to monitor for
respiratory depression.
• The risk of respiratory depression with the IM route is five times greater than for IV
administration.
Intermittent SQ
• Painful
• Slow onset of action
• Potentially damaging to tissues
• Time-consuming
Alternative Routes
• Transdermal
• Continuous SQ
• Rectal
• Stomal
• Vaginal
• Oral Transmucosal
• Nebulized
• Intranasal
Transdermal
• The system can release fentanyl at a nearly constant rate for up to 72 hours (some patients require
a new patch after 48 hours).
• Practitioners should also prescribe an immediate release opioid for breakthrough pain.
• A good option for patients with stable, moderate to severe chronic pain who are unable to take
opioids orally or who would benefit from the convenience of infrequent administration.
• The current formulation doesn’t substantially pain for 12 to 16 hours after a first dose.
• Titration to an effective dose may take days which requires the patient to take an opioid by another
route during this period.
• Can’t easily adjust the dose to manage adverse reactions, such as nausea and vomiting.
• After patch removal, a depot of fentanyl remains and serum concentration decline at the slow rate
of about 50% in approximately 17 hours.
• External or internal heat sources may increase transderaml fentanyl’s absorption (e.g., a fever of
104 F (40 C) can increase serum fentanyl concentration by one-third, increasing the risk of adverse
reactions and possibly requiring dosage decrease). Advise patients not to take excessively hot
showers, sleep on a heated water bed, or put a heating pad over the patch.
• Transdermal fentanyl isn’t safe for managing acute or postoperative pain, especially in the
outpatient setting, since these patients are usually opioid-naïve (not tolerant to the respiratoroy
depressant effect of opioids) and the smallest dose of transdermal fentanyl is 25mcg and can’t be
adjusted downward.
• In the outpatient setting, it’s dangerous to send patients home on opioid doses that haven’t yet
taken effect and may be too high.
Continuous SQ
• Used for continuously infusing opioids via PCA pump for patients with chronic cancer pain who
can’t take oral medications and who don’t have IV access.
• Hydromorphone and morphine are the most common opioid analgesics administered this way.
• Patients receive small volumes of highly concentrated fromulations. Most patients can absorb
between 2 and 5ml/hour.
• Patients receive rescue doses as SC boluses.
Rectal
• This route may be contraindicated in patients who are neutropenic or thrombocytopenic (platelet
count of <50,000) because of the risk of rectal bleeding from insertion.
35
•
•
•
•
The effective dose of opioids by the rectal route is approximately equal to oral dosing; however,
some researchers suggest reducing the starting dose by approximately 25%.
Drugs commercially available as rectal suppositories are morphine, methadone, hydromorphone,
and oxymorphone.
Oral tablets, oral solutions, and suspensions, and injectable products have been given rectally,
sometimes without altering the medication.
Studies show that the intact tablets of oral controlled-release opioids such as MS Contin can be
given rectally.
Stomal
• Opioids aren’t formulated for stomal administration, and no one knows how effective this route is.
• Temporary use of the stomal route may be an alternative when other routes are unavailable.
• Formulations used orally or rectally may be administered stomally.
• The starting dose is usually the same as for oral or rectal administration.
• Sigmoid colostomies (left-sided) which produce formed stool are more likely than other ostomies
to allow for absorption of opioids.
• Ostomies that are constructed in other areas of the colon and produce wet, liquid, or semisolid
effluent generally have more rapid transit times which pushes out the drug before it absorbs.
Vaginal
• Though no opioid is formulated for vaginal administration, the body can absorb drugs given by
this route.
• One study found controlled release morphine is safe an effective when administered every 23
hours by the vaginal route to patients with cancer pain. Patients reported no consistent changes
from the oral route in the frequency of adverse experiences, morphine requirements, or pain
intensity ratings.
Oral transmucosal
• Sublingual, buccal, gingival tissues are available for oral transmucosal administration.
• Research on these routes, except for administration of oral transmucosal fentanyl citrate, is
limited.
Intranasal
• Stadol is the only opioid formulated and available for intranasal administration.
• A small aerosol device delivers a set dose of the drug into a nostril.
• Alternative Routes
• Intranasal Stadol is easy for patients to use, has a consistent absorption pattern, and provides
adequate analgesia for some types of postoperative pain. However, because it is an agonistantagonist (not a mu agonist, or morphine-like drug) this drug may reverse the analgesia in
patients taking morphine-like drugs.
Nebulized
• Morphine administered by face mask is reportedly safe and effective for treating dyspnea
associated with end-stage chronic obstructive pulmonary disease, heart failure, and lung cancer.
• Morphine by face mask isn’t recommended for pain relief because current techniques provide
limited absorption of the drug.
• In addition to morphine, fentanyl, hydromorphone, and codeine can be nebulized.
• Although opioids are not formulated as nasal drops, you can instill the parenteral formulation of
sufentanil intranasally in droplet form or via a swab. But this can cause burning and sting,
especially in children, who often object to any form of nose drops which produce a sensation
similar to drowning.
Codeine
• Indicated for relief of mild to moderate pain
• Side effects are dose limiting.
36
•
•
•
•
•
Although codeine is a strong analgesic, the degree of pain relief that can be achieved safely is
quite low—much lower than can be achieved safely with morphine.
When taken in its usual analgesic dose, 30mg codeine produces as much pain relief as 325mg
aspirin or acetaminophen.
Codeine is classfied under Schedule II of the Controlled Substances Act.
The combination preparations (Tylenol with Codeine/APAP with Codeine), which can produce
greater pain relief than either agent alone, are classified under Schedule III.
Codeine is an extremely effective cough suppressant. The anti-tussive dose is 10 mg(lower than
the analgesic doses). Mixtures for cough suppression are classified under Schedule V.
Adjuvant Analgesics
Adjuvant analgesics are used for the treatment of specific pain syndromes, e.g. neuropathic pain, bone
pain, and muscle spasm, and can be helpful for preventing opioid tolerance.
Neuropathic Pain: Antidepressants
• Antidepressants: Antidepressants are used for the treatment of neuropathic pain, which
is described as lancinating, electrical, shooting pain.
• Antidepressants can relieve pain related to neuropathy such as post-herpetic neuralgia or
trigeminal neuralgia, regardless of whether patients are depressed.
• In addition to their analgesic effect, antidepressants can restore sleep cycles and may
improve mood
• Dosages of antidepressants used for pain are often lower than the typical antidepressant
dose.
Neuropathic Pain: Anticonvulsants
• Anticonvulsants such as phenytoin (Dilantin), carbamazepine (Tegretol), sodium
valproate, and clonazepam (Klonopin) may also relieve lancinating pain arising from
peripheral nerve syndromes such as trigeminal neuralgia and post-herpetic neuralgia.
Bone Pain: Corticosteroids and NSAIDS
• Corticosteroids (e.g., Prednisone) and non-steroidal anti-inflammatory drugs (e.g.,
Ibuprophen) may be very helpful in the relief of bone pain and pain that involves
inflammation (e.g., after orthopedic procedures, in the treatment of gout).
Visceral Pain
•
Visceral pain, such as spasms of bladder or rectum, colicky intestinal pain are often
treated with muscle relaxants.
Patient Assessment
• Pain Rating and Patients Rating of an Acceptable Level of Pain
• Level of Sedation
• Respiratory Rate
• Respiratory Depression
• Opioids depress respiration through activation of mu receptors, although activation of
kappa receptors also contributes
• Depressant effects begin about 7 minutes after IV injection, 30 minutes after IM
injection, and 90 minutes after SC injection. With all three routes, depressant effects may
persist for 4-5 hours. When given by spinal injection, onset of respiratory depression
maybe delayed for hours.
• With prolonged use, tolerance develops to respiratory depression. Large doses that
would be lethal to non-tolerant (“opioid naiive”) individuals can be taken by opioid
addicts and those who have long-term clinical use of opioids without noticeable effects
• At equianalgesic doses, all opioid analgesics depress respiration to the same extent.
• Significant respiratory depression is most likely when dosage is being titrated up.
• The best way to assess respiratory depression is to monitor opioid induced sedation,
because an increase in sedation generally precedes an increase in respiratory
depression.
37
•
If excessive sedation is observed, further dosing should be delayed.
Guidelines for Treatment of Pain
• Choose the appropriate drug:
• Chose the appropriate route
• Choose the appropriate dosage and titrate to pain control
• Schedule appropriately
• Anticipate side-effects
Appropriate Drug:
• Morphine is the standard. (Be aware of the danger of using meperidine/Demerol.)
• Reasons for using a drug other than MSO4:
• Allergy
• A favorable prior experience with another drug.
• Avoiding a limiting adverse effect of morphine. For example, while nausea is associated with
all of the opioids, some patients may be more sensitive to the emetic effects of morphine--and
vice-versa.
• To circumvent tolerance to morphine in a patient who is getting progressively less relief with
that drug. There is incomplete cross tolerance among the opioids, so switching to an
“equianalgesic dose” of another opioid may provide better analgesia.
• The need for rapid onset of action. Lipophilic drugs, such as meperidine, alfentanil, or
fentanyl, quickly penetrate the blood-brain barrier and therefore may occasionally be
desirable when pre-medicating a patient for a brief radiographic or surgical procedure.
Appropriate Route:
• PO or IV
• Avoid intermittent IM or SQ
Appropriate Dosage:
•
Start with ~2-10 mg morphine q 3-4 hours (consider severity of pain, age, height/weight, hepatic
function, renal function, etc.)
•
Patients in severe pain can have parenteral medication titrated every 15-30 minutes until pain is
relieved
•
If a previous dose of opioid is safe (sedation and respiratory rate WNL) increase the next dose by
25%-50%.
•
Breakthrough doses should be 10-15% of the total daily dosage.
•
Use equianalgesic dosing (there are schedules which tell you the pain relief equivalents between
different drugs and between different routes).
•
If switching routes of administration, pay careful attention to the relative analgesic potency of
each route. Use an equianalgesic table (a table that compares the relatively potency and pain
relieving ability of different analgesics).
•
When converting from parenteral morphine to oral morphine:
1. First calculate the total daily morphine requirement.
2. Since the relative potency ratio of parenteral to oral morphine is generally considered to be
1:3, multiply the total daily parenteral dose by 3 to get the equivalent oral dose.
•
When converting from parenteral morphine to oral morphine:
1. With controlled- release/continuous-release morphine (MS Contin) the total daily dose
remains the same but is divided into two, or sometimes three, evenly spaced doses (i.e., q 12
hours or q 8 hours)
• If switching from one opioid to another (because of tolerance or good pain control but
unacceptable side-effects):
1. The starting dose of the new drug should be reduced to 50-75% of the equianalgesic dose to
account for incomplete cross-tolerance
2. For persons with poor pain control and moderate, unacceptable side0-effects, the starting dose
of the new drug can usually be 75-100% of the equianalgesic dose
•
Caution is needed when the change is to methadone; a reduction of 66-75% of the equianalgesic
dose is recommended because methadone has a long half-life
38
Schedule appropriately:
• Schedule regularly (around-the-clock/ ATC) not PRN if pain is present most of the day, and have
a prn order for breakthrough pain
• Guidelines for Treatment of Pain
Anticipate and prevent side effects, including:
• Constipation
• Somnolence
• Nausea/vomiting
• Respiratory depression
Advocacy—Making a Difference One Patient at a Time
• The goal in advocacy, is to get affirmation and collaboration.
• Being a patient advocate is a fundamental nursing role. However, advocacy often means accepting
additional responsibility and work, and it may involve risk of reprisal and punishment.
• When a patient reports an unacceptable level of discomfort, a level of discomfort that the nurse
believes is beyond what the patient should live with, the nurse must consult the physician. But on
consultation with the physician, the nurse may be told that the problem “can wait until the next
day,” or similarly, be told, “I think the patient has become addicted,” or “I don’t think the pain is
real.”
• Be prepared for responses like this!
• To make communication more successful and the role as advocate easier, use specifics: provide
concrete measurable terms to describe the situation, supplying an objective, up-to-date pain
management history and assessment of the patient.
• Provide the prescriber with:
• Current pain management (drug, dosage, route, frequency, and time of last
administration)
• Pain rating
• Respiratory rate
• Level of sedation
• Emphasize what activities have been limited as a result of the patient’s unrelieved pain
(e.g., unable to turn, cough, and deep breath, unwilling/unable to get out of bed and/or
ambulate)
• Know the definition of pain (it is what the patient says it is)
• Know the definition of addiction (a pattern of compulsive drug use characterized by a continued
craving for a narcotic and the need to use the narcotic for effects other than pain relief).
• State the reasons why you feel the patient’s complaint of pain is legitimate (e.g., the patient is
normally cheerful, co-operative and stoic)
• Ask for the prescriber’s help in getting better pain control for the patient
• Speak quietly, slowly, in a non-emotional, monotone voice.
• Affirm your competence (e.g., don’t call the physician “Dr.—” and then refer to yourself as Mary
• Make a confident, professional presentation. Don’t whine or be apologetic.
• Use “I” statements--”I would prefer to have a PRN order so that I could titrate to keep Mr. A
breakthrough pain in the range of 1-3.”
Pro-Self Program—Guidelines for Patient and RN Communications about Pain with Prescribers
• At UCSF, Christine Miaskowski and associates have completed testing of the Pro Self Program, a
self-care intervention called ProSelf. They found that one of the most important interventions that
pain control nurses can use is to coach patients on how to speak with health care provider directly
about their pain. Guidelines includes the following statements:
o I have been having pain since____
o It is a ___ on a scale of 1-10.
o It disrupts/interferes with these activities:_____
o I have been taking (med, dosage, route, frequency).
o This does not relieve my pain/relieves my pain, but only partially or for ___time.
o I need your help to get better pain management.
39
PCA (Patient Controlled Analgesia) Machine
Whenever possible, employ the principle of patient controlled analgesia. The person who feels the pain is
the person who must have, to the extent possible, control of measures to relieve it. Patient controlled
analgesia may be defined, in the broadest sense, as the patient’s self-administration of all forms of pain
control by methods that consider safety, as well as the patient’s ability and willingness to exercise control.
A PCA (Patient Controlled Analgesia) machine is a computerized infusion device that allows the delivery
of continuous and on-demand doses of IV (intravenous) or SC (subcutaneous) narcotics/opioids. The
machine can be programmed to provide:
 continuous medication (continuous/basal/ background),
 intermittent patient-controlled/on-demand bolus dose of medication (PCA dose) or
 a combination of continuous medication plus a patient-controlled doses
(continuous/basal/background + PCA).
 a bolus dose
To prevent overdosing, the machine can be programmed for a delay time or “lock out” between patientinitiated doses and a maximal 4 hour dose.
Nursing responsibilities in caring for patient on PCA machines include:







Providing client teaching
Setting up the PCA machine with a continuous IV that is infusing on a pump.
Programming the PCA machine according to the prescriber’s order, and double-checking the order
and the PCA programming with another RN for accuracy
Periodically checking the syringe, infusion settings, tubing connections, and condition of the site
On-going client assessment and documentation of:
o Patient’s pain rating
o Patient’s respiratory rate
o Patient’s level of sedation
o Basal dosage/rate
o PCA dosage
o # of PCA attempts
o # of doses delivered.
o Total # of mg patient has received
o Amount of medication remaining in syringe
o When PCA syringe is changed
Evaluation of response to therapy
Notifying physician when patient is getting inadequate analgesia or experiencing intolerable side
effects.
Communicating Pain Assessment Findings to Members of the Health Care Team:
 Be objective in your presentation. Have the patient’s chart, MAR, pain flow sheet, nurse’s notes, etc.
with you.
 Give complete information: location, intensity, quality of pain
 Remind colleagues about the probable etiology of the pain, but do not rule out other potential causes
 Describe the effect of the pain on the patient’s function (ability to walk, eat, sleep, perform ADLs,
participate in plan of care)
 List the medication dosage, route, and frequency, including the last dose administered, given for pain,
the efficacy of the medication (e.g., reduction of pain rating from 8/10 to 5/10), and duration of relief.
 Ask for suggestions, and be prepared to make recommendations (requires you, the RN to be
knowledgeable about pain management!)
 When faced with unhelpful responses, reframe, educate and normalize. Examples:
o Statement: “I don’t think she has that much pain.”
o Response: “Mrs. Smith is generally very stoic.”
o Statement: “She has lung cancer. I don’t want to cause respiratory depression.”
40
Response: “Her respiratory rate is 24 and there is no change when she is given the morphine.
She has been on opioids for several days now, and has likely developed tolerance to the
respiratory depressant effect of the opioid.”
o Statement: “That’s a very high dose of narcotic.”
o Response: “That dose is really not unusual. Plus, we know that the correct dose of opioid is
the dose that relieves the patient’s pain to an acceptable level, without unacceptable sideeffects.”
(From Bednash, Geraldine and Ferrell, Betty R. “Pain and Symptom Management in End of Life Care.”
Course #732, Continuing Medical Education Resource, Sacramento, CA. See also Ferrell, . R. & Coyle,
N. (Eds.) Textbook of Palliative Nursing. New York, NY: Oxford University Press.)
o
41
42
43
TPN, PPN, and Intralipid Therapy
Definition:
Total parenteral nutrition (TPN), or hyperalimentation, is the intravenous administration of a
nutritionally complete formula that includes:
•
•
•
•
•
Amino acids
Glucose
Electrolytes
Vitamins
Trace elements.
TPN is often infused with intralipids (fat emulsion), either as two simultaneous infusions, or
mixed together in the same IV container.
Total parenteral nutrition (TPN) solutions are those that have dextrose concentrations of greater
than 10%. Since high concentrations of dextrose (>10%) can cause chemical phlebitis,
hyperalimentation solutions of >10% dextrose must be infused into a wide-diameter, high flow
central vein. The commonly used sites for vascular access of the central venous system are the
subclavian and internal jugular veins. The catheter tip location is usually in the superior vena
cava, although the innominate vein, the intrathoracic subclavian vein, and the right atrium (for
silastic catheters only) may be used.
Peripheral parenteral nutrition (PPN) solutions are hyperalimentation solutions that have a
dextrose concentration less than 10% glucose. Hyperalimentation solutions with lower dextrose
concentrations (<10%) have less tendency to cause phlebitis. Therefore, they may be infused into
the smaller-diameter, lower flow peripheral veins. Because hyperalimentation solutions of 10%
dextrose or less can be administered via peripheral veins, it is referred to as Peripheral Parenteral
Nutrition (PPN).
Purpose:
TPN and PPN are used to provide nutritional support for clients who:
• are unable to ingest food;
• are unable to ingest or absorb enough food to meet their caloric and nutritional requirements;
• have gastrointestinal conditions, persistent anorexia, severe burns, sepsis, cardiac conditions,
trauma, or liver failure;
• have cachexia (chronic protein calorie malnutrition) as a result of cancer, hepatic disease, or
chronic neurological disease;
• have protein malnutrition as a result of protein losses that occur with burns, albuminuria, and
autoimmune diseases like pemphigus.
Solution and Infusion Rate:
The solution and infusion schedule is individually designed for the client. The prescription is
reviewed daily, with adjustments made in response to the patient’s fluid and electrolyte balance
and nitrogen balance.
44
TPN may be infused continuously over 24 hours, or, especially for long-term therapy in the home,
it may be cycled, i.e., infused for only part of a day (e.g., 12 hours) so that the patient may engage
in normal activities. When TPN is infused for only part of the day, the infusion rate is tapered
over the last 2-4 hours of the infusion to avoid episodes of hypoglycemia. TPN is never stopped
abruptly. If TPN needs to be interrupted or stopped, the infusion rate should be tapered or
Dextrose 10% should be hung.
Complications Associated with Hyperalimentation:
Because of the high dextrose concentration, hyperalimentation solutions provide an excellent
culture media for microorganisms. That fact, in conjunction with the need for the patient
receiving TPN to have a central venous line, makes the risk for infection and sepsis a major
complication. Therefore, sterile technique is essential when preparing and infusing
hyperalimentation solutions. TPN is prepared in the pharmacy under a laminar flow hood. TPN
bottles come directly from the pharmacy and are numbered sequentially. Each TPN bottle label
includes clients name, room number, additives, IV number, start time, date, and stop time. Tubing
with a filter is generally used. The solution, tubing, and filter are changed every 24 hours.
The high osmolarity of solutions of 10% or greater dextrose makes hyper and hypoglycemia the
other major problems associated with hyperalimentation.
Composition of Total Parenteral Nutrition (hyperalimentation) Solution:
•
•
•
•
•
•
•
Amino acid (Freamine or Aminosol: 10% amino acid solution)
Carbohydrates--monohydrous glucose
Vitamins
Minerals and trace elements
Hypertonic glucose/dextrose (20-50%): Calories (1000-2000 Calories/Liter)
Electrolytes
Water
45

46
Day 2: Tuesday, August 14th, 2012
Class #4: 1:10 PM-4:00 PM
• Blood Administration
• Caring for Diabetic Patients
Review of Transfusion Therapy and Blood Administration
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory, the student will:
• Discuss indications for transfusion of blood products
• State the major blood groups.
• Discuss ethical and legal considerations when providing transfusion therapy.
• Formulate a teaching plan for a patient receiving a blood product transfusion.
• Analyze patient data in order to determine compatibility of blood products.
• Demonstrate correct procedure for priming blood tubing.
• Demonstrate correct procedure for initiating a blood product transfusion.
• Document transfusion of blood products in the medical record.
• List potential complications of administration of blood and blood products.
• Discuss five types of transfusion reactions.
• Demonstrate nursing assessments and interventions to be implemented in the event of a
transfusion reaction.
• Demonstrate SBAR communication to the physician or other members of the health care
team concerning a transfusion reaction within the context of selected case studies.
Review of Caring for Diabetic Patients
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory, the student will:
• Describe the basic pathophysiology of Type I and Type II diabetes
• State the range for normal blood glucose levels and target Hmg A1-C levels
• Explain the reason for use of various correctional insulin scales
• Define basal, correctional, and prandial insulin
• Perform a fingerstick/capillary blood sugars using glucometers; documentation
• Interpret physician orders for basal, correctional, and prandial insulin administration
• Accurately calculate, draw up, and administer SQ insulin based on client’s blood
sugar and insulin orders
• Document FSBS and insulin administration
47
Blood Transfusion Case Study
You receive the following orders:
Admit to medicine, Dr. Sanger
Dx: GI Bleed; hx asthma, CAD, arthritis
CBC with diff, coag panel, Chem 23 stat; call MD with results
Type and crossmatch 2 units PRBCs
Start IV of D51/2NS @ 100cc/hour
Diet: 2 gram NA, low cholesterol
Meds:
Protonix 10mg IVPB q 12 hours
Albuterol MDI 1 puff s q 4 hours prn
Advair 1 inhalation bid
You check the patient’s VS and perform the nursing admission history. The patient’s VS are: 37.5, HR
116, RR 24, 105/63. The RA O2 sat = 90%.
1.
2.
You have obtained VS and complete the nursing history. What will be your first nursing actions?
What do you suspect is the cause of the patient’s GI Bleed?
The labs come back as follows: Hmg = 7.9, WBC = 8,500; K+ = 3.3
3.
4.
In view of the patient’s Hmg, what is the probable Hct?
Do you think the MD will give you an order to transfuse this patient? Why or why not?
You contact the physician with the labs and he gives you the following telephone orders:
Transfuse 2 units PRBCs each over 3 hours
Re-check H/H 1 hour after transfusion complete and call MD with results
5.
What, if any, additional orders do you need for this patient?
The Blood Bank telephones you to say that the blood is ready.
6.
Prioritize and list your nursing actions.
The patient’s blood type is B, Rh +. The unit of blood you receive from the blood bank is O Rh -.
7.
Can you safely administer this unit of blood to the patient?
You find that in your absence, the patient’s IV has infiltrated.
8.
How much time do you have before you must begin infusing the blood?
You need to restart the IV.
9.
What size angiocath will you use?
10. Where will you store the blood while you are starting the IV?
48
11. If you can’t get the IV started, what will you do with the blood?
You get the IV re-started!
12.
13.
14.
15.
16.
Prime the IV tubing and begin infusing the NS via the pump.
Verify the patient’s identity and the unit of blood with another nurse classmate,
Hang the blood, set the rate
Document on the nursing documentation sheet.
Monitor the patient carefully after initiating the transfusion and re-check the patient’s VS
according to hospital policy and procedure.
One hour after the second unit of PRBCs is started, the patient calls you complaining of SOB and chest
tightness. Your assessment reveals a patient who is restless, apprehensive, diaphoretic and visibly SOB.
VS are T = 37.9 HR 128, BP 126/ 89, RR 36 and shallow. Her pulse oximetry is 89%. Breath sounds are
decreased with bilateral rales up 1/3. You note jugular venous distention and an S3 gallop.
17. What do you think is the problem?
18. How will you intervene? (List and prioritize your nursing actions, considering comfort measures
and orders for medications, treatments, and diagnostic tests)
19. What do you expect the CXR to show?
20. What do you expect the ABG to show (Is this a respiratory or metabolic/renal problem? Will the
pH be acidotic, alkalotic, or normal/compensated? Will the pO2 be elevated or decreased? Will
the CO2 be elevated or decreased?
21. What do you expect the EKG to show?
Thirty minutes after therapeutic interventions that patient states he/she is feeling much better. There is no
SOB, skin is warm and dry, patient feels calmer, and has voided 500 mL of clear urine. VS are: T 37.7,
BP 118/77, HR 117, RR 24. O2 sat = 91% on O2 @ 2 lpm np. You have orders to restart the blood
transfusion.
22. At what rate will you infuse the remainder of the PRBCs?
49
Optimal Management of Diabetic Patients
Definition
Diabetes is a group of disorders characterized by elevated levels of glucose in the blood—
hyperglycemia. It is a chronic disease that is a major cause of death and disability in the US and
it is reaching epidemic proportions. The number of deaths with diabetes as an underlying cause
increased 46% between 1980 and 1996.
Diagnosis
The World Health Organization diagnostic criteria for diabetes mellitus in non-pregnant adults is
(1985):
On at least two occasions:
1. Random plasma glucose > 200 mg/dl
2. Fasting plasma glucose > 140 mg/dl
3. 2 hour sample during oral glucose tolerance test >200 mg/dl.
Physiology/Pathophysiology:
Diabetes is a disease in which the body can’t use food as it should. In a healthy person, a
hormone called insulin, which is produced in the beta cells of the pancreas, helps to convert food
into energy. People with diabetes 1) lack insulin, 2) don’t make enough insulin, or 3) no longer
respond to insulin.
The body needs energy. It gets that energy from food. When food is consumed, the body
changes some of the food into sugar. Sugar enters the bloodstream and goes to all the cells in the
body. When the body doesn’t make enough insulin or can’t use insulin in the right way, sugar
can’t get from the bloodstream into the cells. Then sugar builds up in the blood. High blood
sugar can cause a variety of symptoms and make a person feel sick, though some people have
high blood sugar and still feel well. Long-term hyperglycemia contributes to macrovascular
(myocardial infarction, strokes, and peripheral vascular disease), microvascular (kidney and eye
disease) and neuropathic complications (diseases of the nerves).
Types of Diabetes
There are several different types of diabetes mellitus:
 Type I: Insulin dependent diabetes mellitus; an autoimmune-mediated destruction of the
beta cells of the pancreas usually with complete beta cell destruction and as a result, the
absence of endogenous insulin production. [Individuals with autoimmune mediated
destruction will likely have various antibodies present in the blood. Most specific are
antibodies to glutamic acid decarboxylase 65 (GAD65). 70-80% of individuals with type
1 diabetes will have these antibodies present, whereas the general population will have
the present at a rate of approximately 3%. Individuals with type 1 will also likely have
the presence of islet cell antibodies. When both these tests are used in combination, the
ability to differentiate and detect type 1diabetes increases to 90%. C-peptide is also very
helpful in diagnosis. It is often referred to as a pro-insulin and can be measured to detect
the presence of endogenous insulin. If C-peptide is normal or high, the individual is
producing insulin. If absent, beta cell failure has occurred and likely indicates type 1
50
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

diabetes. Thus clinicians should obtain GAD65, ICA, and C-peptide labs when trying to
distinguish between a patient with type 1 and type 2 diabetes. ] (Source:
www.medscape.com/viewarticle/503725?src=mp)
Type II Non-insulin dependent diabetes mellitus
Diabetes mellitus associated with other conditions or syndromes
Gestational diabetes mellitus.
Management
Management of diabetes includes:






Eating a well-balanced diet
Remaining physically active and getting exercise
Controlling stress
Monitoring blood sugar levels, both pre-prandial and post-prandial, and treating them
when too high or too low. (Post-prandial glucose level is a strong marker for
cardiovascular risk according to the Diabetes Intervention Study. And post-prandial
glucose levels have been found to be a better predictor for risk of death than fasting
levels.)
Administration of pills and/or insulin, if needed, to replace insulin, stimulate production
of insulin, improve/facilitate insulin’s action on peripheral receptor sites, decrease
gluconeogenesis, increase sensitivity/receptors to insulin
Controlling Hmg A1C levels (glucosylated hemoglobin). Normal glycosylated
hemoglobin is 6-7%. Glucose normally attaches itself to the hemoglobin molecules of
the red blood cell. Once attached it cannot dissociate. Therefore the higher the blood
glucose levels the higher the levels of glycosylated hemoglobin. The results of this test
show the average of the blood glucose level over the previous 3 months and it is therefore
useful for the evaluation of long-term glycemic control. Control of Hmg A1C decreases
the rate of complications and diseases (e.g., retinopathy, nephropathy, neuropathy)
associated with diabetes. In one study, for every 1% reduction in A1C, there was a
corresponding reduction in microvascular complications of up to 35%.
The American College of Endocrinology (ACE) Diabetes Guidelines
The American College of Endocrinology has recommended new diabetes guidelines:





Recommended A1C level: <6.5%
Fasting and pre-prandial blood glucose targets <110 mg/dl
Post-prandial blood glucose target: <180 mg/dl. (Normally blood glucose should return
to fasting levels within 2 hours.)
Frequent blood glucose testing. Blood glucose testing is alternately referred to as selfmonitoring blood glucose SFBG), fingerstick blood glucose (FSB), capillary blood
glucose (CBG) (as opposed to serum glucose that is done when the lab draws
blood).Frequent blood glucose testing leads to better glycemic control which empowers
patients to make changes in diet and exercise which leads to reduction in A1C.
o Type 1 patients: at least 3 times per day
o Type 2 patients at least 3 times per day
Check Hemoglobin A1C levels (reflects glucose levels over a period of 2-3 months):
o 2 times a year for those at goal
o At least 4 times per year for those above goal or changing therapy
51
Blood Sugar Values


Normal blood sugar range:
Critical blood sugar values:
70-110 (120)mg/dl
<60mg/dl
>400mg/dl
Insulin Therapy
The goal of insulin therapy is to simulate the body’s normal insulin response. This is why
intensive diabetes control regimens use both short and longer acting insulins.
In healthy people, the pancreatic beta cells synthesize insulin and secrete insulin in pulses every
1-2 hours. During the fasting state, the basal secretion rate is constant at about 1 unit/hour.
After a meal the amount of insulin secreted increases about five- to ten-fold to compensate for the
additional glucose burden. Because insulin has a half-life of only minutes, the body can maintain
normal blood glucose levels.
The correct insulin dosage is the amount required to keep serum glucose concentrations as close
to normal level as possible. The dose of insulin given prior to a meal generally tries to cover each
10-15 grams of carbohydrate with 1 unit of regular insulin.
Types of Insulin
Insulins differ in source (beef pancreas, pork pancreas, and recombinant DNA technology), time
from administration to onset, peak, and length of action. There are many types available, with
different generic and brand names, so both novice and experienced clinicians need to consult
references routinely to determine the unique characteristics of the insulin(s) they will be
administering, and they must use extreme care in reading orders and vial labels to ensure that the
insulin prescribed is the insulin being administered.
52
Route of Insulin Administration


The usual administration route is SC
Only Regular insulin can be given IV
Alternatives to Intermittent SC Injections
(Source: Richard A. Lehne. Pharmacology for Nursing Care. St. Louis: W.B. Saunders, 2004, p. 604.)






IV administration: Only Regular insulin may be administered IV. Regular insulin
administered IV is used in patients with circulatory collapse, diabetic ketoacidosis, or
hyperkalemia (intermediate- and long-acting or long-acting insulins are not used for coma or
other emergencies requiring rapid drug action). If given by continuous infusion, infuse drug
diluted in NS; intermittent infusion isn’t recommended.
Jet injectors: these devices use high pressure to shoot insulin directly through the skin into
the SC tissue. No needle is used
Pen Injectors: These devices look like a fountain pen but have a needle where the writing tip
would be and a disposable insulin cartridge inside. The dosage is adjusted by turning the
mechanism to the correct number of units to be delivered; clients with visual impairments can
count the number of clicks. Pen injectors that use disposable or refillable cartridges are
available. This method doesn’t permit mixed dosing.
Portable Insulin pumps: These small (about the size of a pager and weighing ~4 oz)
computerized devices are worn on a belt or in a pocket and administer insulin through a
flexible catheter placed in the subcutaneous layer in the abdomen. They .can be programmed
to deliver a continuous infusion of insulin (usually ~1 U/hour) and manual boluses dosages
can be administered during meals on the basis of caloric intake. The administration set and
site should be changed every 1-3 days.
Implantable Insulin Pumps: These still experimental devices are surgically implanted in the
abdomen and deliver insulin either intraperitoneally or intravenously. The insulin delivery is
adjusted by external telemetry. Research has shown that they can provide superior glycemic
control decrease less hypoglycemia and weight gain and improve quality of life.
Intranasal Insulin: Intranasal insulin administration is experimental. It has rapid onset and
short duration. It is suitable for delivery of mealtime insulin supplements but cannot meet
basal insulin needs so long-acting SC insulin is still required. Problems include discomfort
and expense. To aid absorption, the insulin must be administered with surfactants which
cause discomfort. This route may be more expensive than the SQ route because only 10 of
each dose is absorbed, which means that an intranasal dose must be ~10 times greater than a
SQ dose; on the other hand the client does not need to pay for the cost of syringes and
needles.
Insulin Dosage


The goal of therapy is to mimic the body’s normal production of insulin. Recall that:
o normally during the fasting state the pancreatic beta cells synthesize and secrete
insulin at a basal secretion rate of about 1 unit/hour
o after a meal the amount of insulin secreted increases about five- to ten-fold to
compensate for the additional glucose burden.
The dosage of insulin is individualized to the patient according to:
o blood glucose,
o diet
53




o exercise
o metabolism
o insulin resistance
Dosage of insulin is always expressed in USP Units.
Only insulin syringes should be used for administration of insulin. Use only the syringes
calibrated for the particular concentration of insulin administered, which is usually U100.
(Some people may develop insulin resistance and need large insulin doses to control
symptoms of diabetes; U-500 insulin is available. U-500 insulin must be administered with a
U-100 syringe because no syringes are made for this strength.)
Accuracy of measurement is important. Aids such as a insulin pens, magnifying sleeves, or
dose magnifiers may be necessary for clients with poor vision.
Most hospital policies require double-checking insulin dosages with another licensed person
prior to administration. It is best if the nurse administering the insulin shows the staff
member who is double-checking the insulin the vial containing the insulin, the syringe with
the drawn up dosage and the blood sugar and orders without prompting so that the person
double-checking truly checks each, and is able to draw a reasonable, unbiased conclusion
about the dosage accuracy and appropriateness.
Preferred Injection Sites for Insulin
Absorption varies from site to site:
 Insulin injected into an area that gets exercise will be absorbed more quickly
 If patient is overweight, absorption may be more consistent if the client uses only the
abdomen
 Young children and very lean or muscular adults may benefit from abdominal injections too
because their arms and legs have little subcutaneous fat
 The abdomen generally absorbs fastest, followed by the arms, thighs, and buttocks
 The abdomen is the recommended primary site for insulin SQ injections. It is recommended
for AM injections
 Arms may be used for PM insulin SQ injections
 Thighs may be used for HS insulin SQ injections
 Insulin injections should be given in the same body part at the same time each day (i.e., AM-abdomen, PM--left buttock). Using different areas for injection is acceptable so long as the
same area is used for corresponding doses each day. E.g., inject Regular and NPH insulin
into abdomen to speed action of regular insulin; in the evening inject NPH into thigh or
buttock to help prolong its action.
 Rotating sites is important for prevention of lipodystrophy (altered distribution of
subcutaneous fat). Two types of changes may be seen; lipoatrophy (loss of subcutaneous fat
and lipohypertrophy (accumulation of subcutaneous fat).
 Rotating sites within one area is better than using different areas without a plan. Some
diabetics achieve better control if sites are rotated in the same anatomic area, therefore intrasite rotation of injections sites is recommended: 12-3-6-9 o’clock
 Give injections one inch (2.5 cm) away from the previous site. (Note: Because automatic
injectors (needle-less injectors) use air pressure to propel insulin through the skin, the
absorption rate using this device differs from that of a needle injection because a micro-thin
stream of insulin penetrates the skin and is dispersed more widely in the subcutaneous tissue.
 Advise patients not to smoke, and especially not to smoke within 30 minutes after insulin
injection as smoking decreases amount of absorption of insulin SC (due to vasoconstriction).
Marijuana use may increase insulin requirements.
54
Mixing and Administering Insulins
The goal when mixing and administering insulin is to administer a compatible short-acting and a
longer-acting insulin in the prescribed amounts simultaneously into the subcutaneous tissues with
the least amount of discomfort and tissue damage.
There are many types of insulins currently available.: “natural” insulin (Regular insulin) and six
modified insulins. These insulins vary in onset, peak, and duration.
Two of the modified insulins—Lispro and Aspart—act more rapidly than “natural” insulin but
have a shorter duration of action.
Insulin Glargine is a modified human insulin with a prolonged duration of action of at least 24
hours. Glargine cannot be mixed with other insulins and may only be given SQ, never IV.
Only insulins that are compatible with each other should be combined/mixed. Compatibility of
short acting insulins with intermediate and long-acting insulins, and pre-mixed insulin
combinations are as follows (Richard A. Lehne. Pharmacology for Nursing Care. St. Louis: W.B.
Saunders, 2004, p. 603-604):
Short-Acting
Insulins
Regular
Lispro
Aspart
Description
70%NPH insulin/
30% Regular
50% NPH
insulin/50%
regular insulin
70% aspart
protamine/30%
insulin aspart
7%% insulin
lispro
protamine/25%
insulin lispro
Long-Acting Insulins
NPH
Yes
Yes
Yes
Lente
Yes
Yes
?
Ultralente
Yes
Yes
?
Glargine
No
No
No
Trade Name
Humulin 70/30
Novolin 70/30
Humulin 50/50
Time Course
Onset (min)
30-60
30-60
30-60
Peak (hr)
1.5-16
2-12
2-5.5
Duration (hr)
Up to 24
Up to 24
Up to 24
NovoLog Mix
70/30
Rapid
1-4
Up to 24
HumaLog Mix
75/25
Rapid
1-6.5
Up to 24
Summary of Guidelines for Mixing of Insulins



Lente, semilente, and ultralente insulins may be mixed in any proportion
Regular insulin may be mixed with NPH or lente insulins in any proportion.
When mixing regular insulin with intermediate or long-acting insulin, always draw up the
Regular insulin into the syringe first.
55



When NPH or Lente is mixed with regular insulin in the same syringe, give the injection
immediately to avoid loss of potency.
Lispro may be mixed with Humulin N or Humulin Ultralente within 15 minutes before a meal
to prevent a hypoglycemic reaction
Check expiration date; don’t give if there are color changes or the insulin becomes clumped
or granular in appearance. Store in a cool area. Refrigeration is desirable but not essential.
Source: Richard A. Lehne. Pharmacology for Nursing Care. St. Louis: W.B. Saunders, 2004, p. 603-604
Mixing of Insulins






Lente, semilente, and ultralente insulins may be mixed in any proportion
Regular insulin may be mixed with NPH or lente insulins in any proportion.
When mixing regular insulin with intermediate or long-acting insulin, always draw up the
Regular insulin into the syringe first.
When NPH or Lente is mixed with regular insulin in the same syringe, give the injection
immediately to avoid loss of potency.
Lispro may be mixed with Humulin N or Humulin Ultralente within 15 minutes before a meal
to prevent a hypoglycemic reaction
Check expiration date; don’t give if there are color changes or the insulin becomes clumped
or granular in appearance. Store in a cool area. Refrigeration is desirable but not essential.
Source: Richard A. Lehne. Pharmacology for Nursing Care. St. Louis: W.B. Saunders, 2004, p. 603-604
Short-Acting
Insulins
Regular
Lispro
Aspart
Description
70%NPH insulin/
30% Regular
50% NPH
insulin/50%
regular insulin
70% aspart
protamine/30%
insulin aspart
7%% insulin
lispro
protamine/25%
insulin lispro
Long-Acting Insulins
NPH
Yes
Yes
Yes
Lente
Yes
Yes
?
Ultralente
Yes
Yes
?
Glargine
No
No
No
Trade Name
Humulin 70/30
Novolin 70/30
Humulin 50/50
Time Course
Onset (min)
30-60
30-60
30-60
Peak (hr)
1.5-16
2-12
2-5.5
Duration (hr)
Up to 24
Up to 24
Up to 24
NovoLog Mix
70/30
Rapid
1-4
Up to 24
HumaLog Mix
75/25
Rapid
1-6.5
Up to 24
Storage of Insulin

Insulin in unopened vials should be stored under refrigeration until needed; it should not
56
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


be frozen.
When stored unopened in the refrigerator, insulin can be used up to the expiration date on
the vial
The vial in current use can be stored at room temperature for up to 1 month without
significant loss of activity. The date and time a vial of insulin is opened should be
recorded on the outside of the bottle.
Mixtures of insulin prepared in vials are stable for 1 month at room temperature and for 3
months under refrigeration.
Mixtures of insulin in pre-filled syringes should be stored in a refrigerator, where they
will be stable for at least 1 week. The syringe should be stored vertically with the needle
pointing up to prevent clogging of the needle.)
57
Oral Agents
Oral agents work one or more of 4 primary ways:
 Stimulate insulin release from beta cells of pancreas
 Decrease hepatic glucose production
 Decrease intestinal absorption of glucose,
 Improve insulin sensitivity (increases peripheral glucose uptake and utilization). Lower blood
glucose levels by decreasing insulin resistance and improving sensitivity of insulin in muscle
and adipose tissue. Stimulate release of insulin from the beta cells in the pancreas by closing
ATP dependent potassium channels in the beta cell membrane which causes opening of the
calcium channels. Increased calcium influx induces insulin secretion with the overall effect
to lower the blood glucose.
Common Types of Oral Agents





Sulfonylureas: secretagogues (stimulate release of insulin from beta cells of pancreas)
Meglitinide: secretagogue, designed to treat post-prandial hyperglycemia; e.g. Prandin
(repaglinide)
Biguanide: Metformin/Glucophage; enhances tissue response to insulin
Alpha glucosidase inhibitors: Precose/Acarbose and miglitol/Glyset work by limiting
absorption of glucose from the intestine. Appropriate for a patient who has a normal fasting
and elevated post-prandial readings.
Thiazolidinedioines: rosiglitazon: increase insulin sensitivity at insulin receptor sites;
appropriate for adults who produce insulin but can’t use it because the insulin receptors are
ineffective.
Medicines for Type 2 Diabetes – Benefits
Type of Medicine
Generic
Name
Brand Name
Benefits
Some of the combinations of medicine may come in a single pill, and are shown with a “/” symbol between
them. Others are taken together but are separate medicines, and are shown with a “+” symbol.
Biguanides: Block the liver from making sugar
Metformin
Glucophage®
Lowers A1C by about 1 point
Lowers “bad” cholesterol more than other types
Sulfonylureas Raise the amount of insulin in the body
Glimepiride
Amaryl®
Glipizide
Glucotrol®
Glyburide
Diabeta®; Glynase
Prestab®; Micronase®
Lowers A1C by about 1 point
Meglitinides Raise the amount of insulin in the body
Repaglinide
Prandin®
Lowers A1C by about 1 point
58
Medicines for Type 2 Diabetes – Benefits
Type of Medicine
Generic
Name
Brand Name
Nateglinide
Starlix®
Benefits
Thiazolidinediones (TZDs): Help the body use insulin better
Pioglitazone
Actos®
Lowers A1C by about 1 point
Lowers triglycerides (a kind of fat in your blood) more
than other types
Might protect kidney function
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: Raise the amount of insulin in the body after a meal
Sitagliptin
Januvia®
Saxagliptin
Onglyza®
Lowers A1C by less than 1 point
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists: Raise the amount of insulin in the body
Exenatide
Byetta®
Liraglutide
Victoza®
Less weight gain than other medicines
Less is known about how well this medicine lowers A1C
compared with other medicines
Combinations:
Glyburide/metformin
Metformin/pioglitazone
Metformin/sitagliptin
Lowers A1C by about 2 points
Metformin/pioglitazone lowers triglycerides
Metformin/saxagliptin
Metformin + GLP-1 receptor agonists
Metoformin + basal insulin
Metformin + GLP-1 receptor agonists may cause less
weight gain than other combinations of medicines
Metformin + premixed insulin
Source:
The information in this summary comes from the report Oral Diabetes Medications for Adults With Type 2 Diabetes:
An Update. It was produced by the Johns Hopkins University Evidence-based Practice Center through funding from
the Agency for Healthcare Research and Quality (AHRQ). For a copy of the report or for more information about
AHRQ and the Effective Health Care Program, go to
www.effectivehealthcare.ahrq.gov/diabetesmeds.cfm
This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at
Baylor College of Medicine, Houston, TX.It was written by Andrea Humphries, Thomas Workman, Ashok
Balasubramanyam, and Michael Fordis.
59
Medicines for Type 2 Diabetes – Possible Side Effects
Type of Medicine
Generic Name
Brand Name
Possible Side Effects
* NOTE: Your doctor has received an alert from the United States Food and Drug Administration (FDA)
that TZDs (pioglitazone or rosiglitazone) should not be taken by patients with serious or severe heart
failure. Rosiglitazone also increases the risk for heart attack and stroke. According to the FDA,
rosiglitazone is to be used only if other drugs do not work to lower your blood sugar. Talk with your
doctor.
Biguanides:Block the liver from making sugar
Metformin
Glucophage®
Some risk for low blood sugar
Less weight gain than other medicines
Higher risk for stomach problems (gas, diarrhea)
Sulfonylureas: Raise the amount of insulin in the body
Glimepiride
Amaryl®
Glipizide
Glucotrol®
Glyburide
Diabeta®; Glynase
Prestab®; Micronase®
May cause weight gain
3 to 5 times more likely to cause low blood sugar
May cause stomach problems
Meglitinides: Raise the amount of insulin in the body
Repaglinide
Prandin®
Nateglinide
Starlix®
May cause weight gain
Risk for low blood sugar
Thiazolidinediones (TZDs) *
Pioglitazone
Actos®
May cause weight gain
Some risk for low blood sugar
Can add to risk of heart failure or make it worse
Increases the risk for fracture, especially in women
May cause bladder cancer when used longer than 1
year
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: Raise the amount of insulin in the body after a meal
Sitagliptin
Januvia®
Saxagliptin
Onglyza®
Not enough is known about the side effects of these
medicines
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists: Raise the amount of insulin in the body
Exenatide
Byetta®
Liraglutide
Victoza®
Not enough is known about the side effects of these
medicines
Combinations
Glyburide/metformin
Metformin/pioglitazone
Metformin/sitagliptin
Metformin/saxagliptin
Some combinations with drugs such as sulfonylureas
may increase the risk of low blood sugar
Pioglitazone combinations may cause more weight
gain than other medicines
Pioglitazone combinations can add to the risk of hip
60
Medicines for Type 2 Diabetes – Possible Side Effects
Type of Medicine
Generic Name
Brand Name
Metformin + GLP-1 receptor agonists
Metformin + basal insulin
Metformin + premixed insulin
Possible Side Effects
and non-hip fractures, especially for women
Some combinations with metformin increase the risk
of stomach problems, but not as much as metformin
alone
Why is information about cholesterol and triglycerides listed in the chart?
Diabetes medicines are mainly for lowering blood sugar. Research shows that a few of them can also affect
cholesterol and triglycerides.
Cholesterol
Everyone should try to keep “bad” cholesterol (LDL cholesterol) as low as possible. Bad cholesterol can
clog your arteries and lead to a heart attack or stroke. People with diabetes have a greater risk for these
problems. Your doctor can tell if your LDL is too high.
Most diabetes medicines do not raise or lower your “good” cholesterol (HDL) enough to affect your health.
Good cholesterol helps your body and does not clog your arteries or cause heart problems.
Triglycerides
“Triglycerides” (try-GLIS-uh-rides) are a kind of fat in your blood. The body makes triglycerides. They are
also in food. Your body needs this kind of fat, but it is best to keep the level of your triglycerides low. Less
than 150 is usually the goal.
What else should I know about serious side effects?
The most common side effects of type 2 diabetes medicines are weight gain and stomach problems. The
chart titled "Medicines for Type 2 Diabetes – Possible Side Effects" lists other side effects that are not
common but can be serious. Here is more information about some of them so that you can talk with your
doctor about your concerns.
Low blood sugar
Sometimes, the medicines can lower your blood sugar too much. This is called “hypoglycemia” (high-pogly-SEE-mee-ah). Low blood sugar can cause you to feel dizzy, cold and sweaty, confused, shaky, and
weak.
Low blood sugar is more likely when you take two or more kinds of diabetes medicines.
Warning: If you think you may have low blood sugar, eat or drink something with sugar in it right away. If
you have symptoms while driving or using a machine, pull to the side of the road or turn off the machine.
You may wish to keep juice or candy with you until you are comfortable with your medicine. Ask your
doctor.
Lactic acidosis
Taking diabetes medicines can raise the chance of a rare condition called “lactic acidosis” (lak-tik a-suhDOE-sis). This condition is more likely for people who take diabetes medicines and have kidney or liver
problems. Each year, about 1 out of 10,000 people taking diabetes medicine will have lactic acidosis.
Common signs of lactic acidosis are:
 Trouble breathing.
 Vomiting or stomach pain.
 Weakness or unusual muscle pain.
 Chills or feeling light-headed.
The chance of having lactic acidosis is about the same for all diabetes medicines.
Warning: If you have any signs of lactic acidosis, call your doctor or nurse right away.
61
Heart failure
Congestive heart failure, or heart failure, is when the heart cannot pump enough blood to the rest of the
body. Pioglitazone (Actos®) might cause congestive heart failure or make it worse. Call your doctor or
nurse if you suddenly notice these symptoms of heart failure:
 Gain weight quickly.
 Tired and weak.
 Irregular heart beat.
 Swelling of your belly, ankles, or feet.
 Lose your appetite or are sick to your stomach.
 Shortness of breath when you exercise or lie down.
62
Diabetic Teaching
Basic diabetic teaching should include information about:
 The disease and it’s complications
 How to self-monitor blood glucose and urine ketone levels
 How to self-administer insulin and other medications
 Glycemic control through diet and exercise
 Stress reduction
 Recognition of hyperglycemic and hypoglycemic reactions/symptoms, and how to treat (e.g.,
have carbohydrates available for emergencies)
 Hygiene and foot care
 Infection control
 Sick day care
 Importance of wearing a medical alert bracelet at all times
 The need to carry insulin and syringes when away from home
Hyperglycemia
Signs and Symptoms of High Blood Sugar (Hyperglycemia):
 Headache
 Blurred vision
 Thirst
 Drinking a lot
 Urinating a lot
 Dry, itchy skin
Causes of High Blood Sugar:
 Too little insulin for food intake
 Stress/illness
Treatment: What to do when blood sugar is high:
 Test blood sugar
 Test for ketones in the urine
 Administer insulin as ordered
 Notify MD if blood sugar exceeds parameters
Mnemonic: Hot and dry—sugar high
Hypoglycemia
Signs and Symptoms of Low Blood Sugar (Hypoglycemia):
 Shaky
 Nervous
 Light-headed
 Sweaty
 Tired
 Angry
 Hungry
63


Confused
Sleepy
Causes of Low Blood Sugar:
 Skipping a meal or snack
 Not eating all of a meal or snack
 Not eating at the right time
 Exercising harder than usual
 Drinking alcohol
 Taking too much insulin
Treatment--What to do when blood sugar is low:
 Test blood sugar. If unable to test, treat as if you have low blood sugar.
 Treat by eating or drinking something with sugar. The following foods have 10-15 grams of
rapid acting carbohydrate to stabilize a client within 15 minutes (the 15/15 Rule):
o 4 oz/1/2 cup fruit juice;
o 4-6 oz. Regular soft drink;
o 4 tsp granulated sugar;
o 2 tablespoons raisins;
o 1 Tbsp honey or syrup;
o 2-3 glucose tablets or ½ tube glucose gel;
o 5-8 Lifesavers
o 6 jelly beans
o 3 graham cracker squares
o 6-8 oz 2% low fat or skim milk
 Have glucagon kit for emergencies
 Don’t go to sleep until testing blood sugar
Mnemonic: Cold, clammy—need some candy
Use of Glucagon for Treatment of Hypoglycemia
Glucagon is a hormone secreted by pancreatic alpha cells in response to hypoglycemia.
Glucagon stimulates glycogenolysis or gluconeogensis (the conversion of glycerol and amino
acids to glucose by inhibition of glycogen synthesis).
Glucagon is available by prescription as an emergency drug which is given as a shot to raise the
blood glucose level. It should be given in case of a severe insulin reaction or coma when the
client is unable to take sugar by mouth and there is no IV access.





Dosage: The dosage of glucagon is 1 mg SC/IM/IV, which may be repeated in 20 minutes
if needed. Reconstitute the glucagons with the diluent supplied by manufacturer when
preparing doses of 2mg or less. For larger doses, dilute with sterile water for injection.
Onset: The onset of SC glucagon is 30-45 minutes; the onset of IM glucagon is 15 minutes;
the onset of IV Glucagon is 5-20 minutes.
Duration: The duration of glucagon is ~1.5 hours.
Adverse reactions: Nausea and vomiting, decreased potassium levels, bronchospasm and
hypersensitivity reactions.
Nursing Considerations: IV glucose must be given if patient fails to respond. When the
patient responds, supplemental carbohydrates need to be given immediately.
64
Preparation and Administration of Glucagon
Glucagon comes in a kit or in box containing powder and diluting liquid to be mixed. If using the
kit, follow the package directions.
To prepare glucagon for injection if you have the box with the powder and diluent:
1. Remove the flip-off seal on bottles #1 and #2. Bottle #1 holds a diluting liquid, and bottle #2
holds a white powder.
2. Draw the plunger of an insulin syringe (U100) back to the 50 unit mark.
3. Steady the smaller bottle with the liquid in it (bottle #1) on the table. Push the needle of the
insulin syringe through the stopper.
4. Inject the air from the syringe into the bottle and then turn the bottle upside down.
5. Withdraw as much of the liquid as possible into the syringe.
6. Remove the needle and syringe from bottle #1 and insert this same needle into bottle #2 (the
bottle with the powder). Inject all of the liquid from the syringe into bottle #2.
7. Remove the needle and syringe. Shake the bottle gently until the glucagon powder dissolves
and the liquid becomes clear.
8. Withdraw the entire contents of bottle #2 (the mixed glucagon) into the syringe.
9. Inject the glucagon in the same way you would insulin, using the buttock, thigh, or arm.
10. Turn the person onto one side or stomach to prevent aspiration; vomiting is common after
administration of glucagon.
11. As soon as the person is alert and not feeling sick, he or she should eat something, as
glucagon acts only a short time. First give some juice or a regular soft drink, and then some
longer-acting carbohydrates and protein, such as half of a meat sandwich.
12. If the person does not wake up within 15 minutes, the dose may be repeated. Call an
ambulance.
13. Always call the doctor after an insulin reaction that results in coma or a seizure.
14. Check the package of glucagon periodically to be sure that it hasn’t passed the expiration
date. It’s a good idea to keep the syringe taped to the box so it will be ready.
1989 The University of Michigan
Sick Day Rules
Illness is associated with an increase in insulin resistance and an elevation of serum glucose. In
response to physical and emotional stresses, there is an increase in the level of stress hormones-glucagon, epinephrine, norepinephrine, cortisol, and growth hormone. These hormones raise the
serum glucose levels through the promotion of glucose production by the liver, and interfere with
glucose utilization by muscle and fat tissue which counteracts the effect of insulin. Thus insulin
needs may be increased during the times of illness and infection.
Sick Day Rules
 Take insulin or oral agent as usual
 Test blood glucose and urine ketones every 3-4 hours
 Report elevated gluocse levels and/or urine ketones to physician
 Patients requiring insulin may need supplemental doses of regular insulin every 3-4 hours.
 Substitute food 6-8 times a day if can’t follow usual meal plan
 If N/V, diarrhea, or fever persist, take liquids q 1 hour to prevent dehydration and provide
calories and report to MD
 Inability to retain oral fluids may warrant hospitalization to avoid diabetic ketoacidosis
65
Pre-op Care of Diabetic Patients
Specific orders regarding what diabetic medications diabetic patients should receive preoperatively are usually written by the surgeon or anesthesiologist. Blood glucose monitoring is
continued and results are reported to the physician. Since all pre-op patients are generally kept
NPO, most oral hypoglycemic agents are generally omitted on the morning of surgery but the
nurse should anticipate starting an IV containing D5W and administering small amounts of
insulin to prevent the possibility of hypoglycemia. The anesthesiologist will monitor the blood
glucose levels in the OR.
Post-Op Care of Diabetic Patients
Blood glucose monitoring 4 to six time daily is usually ordered, and IV infusions and regular
insulin are usually administered until the client is able to take oral nourishment. The client’s
prescribed pre-operative insulin type and dosage will usually be ordered once blood glucose
control is re-established and food is being consumed at adequate levels.
Complications of Diabetes: Diabetic Ketoacidosis (DKA) and Hyperglycemic
Hyperosmolar Non-ketotic Syndrome (HHNK)
Diabetic Ketoacidosis (DKA)
Diabetic ketoacidosis is caused by an absence or markedly inadequate amount of insulin. This
results in dehydration, electrolyte loss, and acidosis.
With decreased insulin production, the amount of glucose entering cells is reduced and serum
glucose remains high. When this is accompanied by the simultaneous unrestrained production of
glucose by the liver hyperglycemia also results. In an attempt to get rid of excess glucose, the
kidneys excrete the glucose along with water and electrolytes. This results in excessive fluid loss
leading to dehydration and electrolyte imbalance.
Treatment includes:

Monitoring of serum glucose

Re-hydration

Administration of insulin

Electrolyte replacement.
Example of medical treatment recommendations for diabetic ketoacidosis (students do not have
to learn this; it is provided for information only):
Hydration in Diabetic Ketoacidosis:
Hour 1: Provide 15-20ml/kg of isotonic NS (0.9% sodium chloride) or Ringers Lactate
Hour 2: Continue fluid as above at 15ml/kg. If client is hypernatremic, in CHF, or is a child,
consider 0.45% NS.
Hour 3: Reduce fluid intake to 7.5ml/kg in adults. Fluid should be 0.45% NS.
Hour 4: Adjust fluid intake to meet clinical needs. Consider output rate in calculation
Insulin Administration in Diabetic Ketoacidosis:
 Give 0.33 U/kg as an IV bolus, then 0.1 U/kg/hour by continuous infusion; continue infusion
until blood glucose level drops to 250mg/dl.
66

Then give insulin SC with dosage adjusted to patient’s blood glucose level. Or, 50-100 U IV
and 50-100 U SC immediately, then additional doses q 2-6 hours based on blood glucose
levels.
Treatment of Hypokalemia in Diabetic Ketoacidosis

Check for EKG changes.

In clients with adequate urine output, IV replacement of potassium is based on plasma K+
concentration:
o If K+ is <3, infuse >/= 0.6mEq/kg/hr
o If K+ is 3-4 mEq/L, infuse 0.6mEq/kg/hr
o If K+ is 4-5 mEq/L, infuse 0.2-0.4 mEq/kg/hr
o If K+ is 6 mEq/L, withold until K+ is <6.0 mEq/L
Hyperglycemic hyperosmolar non-ketotic syndrome (HHNK)
HHNS generally results from physiological and treatment related causes. Acute illness, the
ingestion of medications known to provoke insulin insufficiency (e.g., thizaide diuretics and
propranol), administration of TPN or procedures such as peritoneal dialysis can result in HHNS.
In hyperglycemic hyperosmolar non-ketotic syndrome hyperglycemia and hyperosmolarity
predominate. Persistent hyperglycemia causes osmotic diuresis, which results in losses of water
and electrolytes. Then, to maintain osmotic equilibrium, water shifts from the intracellular fluid to
the extra-cellular fluid space. There is glucosuria, dehydration, hypernatremia, and increased
osmolarity resulting in hypotension, tachycardia, and variable neurological signs including
seizures, hemiparesis, and alteration of sensorium. Ketosis and acidosis is minimal or absent.
In DKA there is virtually no insulin present, resulting in breakdown of stored glucose, protein,
and fat. However, in HHNK the level of insulin is not as low. Consequently, though there is not
enough insulin to prevent hyperglycemia, the small amount present is enough to prevent fat
breakdown. Often people with HHNK tolerate polyruia and polydipsia for weeks and only when
neurological changes occur or when an underlying illness worsens do they seek help.
67
Clinician’s Guide Premixed Insulin Analogues :
A comparison with other treatments for Type 2 diabetes
Agency for Healthcare Research and Quality
Premixed insulin analogues are an option for treating adults with type 2 diabetes. This guide
summarizes clinical evidence comparing the effectiveness and safety of premixed insulin
analogues with other insulin preparations and oral diabetes drugs. This guide does not address the
use of insulin in pumps. It does not address the effectiveness of insulin treatment for people with
type 1 diabetes, women with gestational diabetes, or people younger than 18 years old. It also
does not cover evidence about the effectiveness of dietary and other lifestyle modifications for
treatment of type 2 diabetes.
Clinical Issue
Type 2 diabetes is a complex metabolic disorder characterized by insulin resistance in peripheral
tissues and an inability of the pancreas to compensate by increasing insulin secretion. Medication
regimens to lower glucose levels are a primary component of type 2 diabetes treatment. Although
oral diabetes drugs are often effective, insulin is frequently required to achieve a desired level of
glucose control. Twenty-eight percent of people with type 2 diabetes use insulin alone or in
combination with an oral diabetes drug.Premixed insulin analogues combine rapid- and
intermediate-acting insulin analogues and were developed to provide more flexibility in treatment
regimens. They are among several treatment options when insulin is needed to treat type 2
diabetes. We do not have enough data to compare premixed insulin analogues with all treatment
options. However, there is sufficient evidence to compare them with premixed human insulin,
long-acting insulin analogues, and oral diabetes drugs.
Clinical Bottom Line
 Premixed insulin analogues and premixed human insulin have similar effects on
glycosylated hemoglobin (A1c), and rates of hypoglycemia are similar.level of
confidence . . .
 Premixed insulin analogues help achieve lower postprandial glucose levels than premixed
human insulin.level of confidence . . .
 Premixed insulin analogues help achieve lower A1c levels than long-acting insulin
analogues used alone, but rates of hypoglycemia are higher.level of confidence . . .
 Premixed insulin analogues are linked with more episodes of hypoglycemia than oral
diabetes drugs.level of confidence . . .
 Premixed insulin analogues help achieve lower A1c levels than oral diabetes drugs used
alone. level of confidence . . .
Confidence Scale
The confidence ratings in this guide are derived from a systematic review of the literature.
Thelevel of confidence is based on the overall quantity and quality of clinical evidence.
 High . . . There are consistent results from good quality studies. Further research is very
unlikely to change the conclusions.
 Medium . .. Findings are supported, but further research could change the conclusions.
 Low . . . There are very few studies, or existing studies are flawed.
March 2009 Source: The source material for this guide is a systematic review of 45 research
studies. The review, Comparative Effectiveness, Safety, and Indications of Insulin Analogues in
Premixed Formulations for Adults With Type 2 Diabetes (2008), was prepared by the Johns
68
Hopkins Evidence-based Practice Center. The Agency for Healthcare Research and Quality
(AHRQ) funded the systematic review and this guide. The guide was developed using feedback
from clinicians who reviewed preliminary drafts.
Insulin Preparations
Insulin preparations (Table 1) are distinguished by their pharmacokinetic properties, including
onset, peak, and duration of action (Figure 1).
Human Insulin
Recombinant human insulin is structurally identical to insulin produced by the human pancreas.
Human insulin is available in short-acting Regular insulin) and intermediate-acting NPH insulin
preparations.
 Regular insulin injected subcutaneously enters the bloodstream more slowly and over a
longer period of time than insulin secreted by the pancreas in response to a meal.
 NPH insulin enters the bloodstream more slowly than regular insulin, and its levels rise
and fall over a longer period of time.
Premixed Human Insulin
Premixed combinations of NPH and regular insulin are available. They provide basal
(continuous) insulin supplementation and short-term mealtime coverage.
Insulin Analogues
Insulin analogues are modified forms of human insulin. Amino acid substitutions alter their
pharmacokinetic properties.
 Lispro, aspart, and glulisine have a more rapid onset and shorter duration of action than
regular insulin. Like regular insulin, they are taken at mealtimes.
 Glargine and detemir have a longer duration of action and maintain more constant blood
levels than NPH insulin.
Premixed Insulin Analogues
Premixed insulin analogues combine a rapid-acting insulin analogue with its intermediate-acting
protamine suspension. They provide basal insulin supplementation and short-term mealtime
coverage.
Table 1. Insulin Preparations Drug Name Brand Name
Rapid-Acting Insulin Analogues
 Insulin aspart NovoLog®
 Insulin glulisine Apidra®
 Insulin lispro Humalog®
Short-Acting Insulin
 Regular insulin Humulin® R
 Novolin® R
Intermediate-Acting Insulin
 NPH insulin Humulin® N
 Novolin® N
Long-Acting Insulin Analogues
 Insulin detemir Levemir®
69
 Insulin glargine Lantus®
Premixed Human Insulin
 NPH/regular insulin Humulin® 70/30
 Novolin® 70/30
 Humulin® 50/50
Premixed Insulin Analogues
 Insulin aspart protamine suspension/ NovoLog® Mix 70/30 insulin aspart
 Insulin lispro protamine suspension/ Humalog® Mix75/25
 insulin lispro Humalog® Mix50/50
Comparing Effectiveness and Adverse Events
The evidence compiled for this guide (Table 2) comes primarily from clinical studies that
compare premixed insulin analogues with other insulin preparations or oral diabetes drugs. The
main outcomes in these studies were intermediate measures of clinical effectiveness, including
A1c, fasting glucose, and postprandial glucose. The studies were not designed to assess
cardiovascular outcomes or morbidity. There is not enough evidence to compare premixed insulin
analogues with rapid- acting insulin analogues alone, NPH insulin alone, or regimens using both
short-acting and long- or intermediate-acting insulin in other dosing ratios.
In general, premixed insulin analogues:
 Lead to lower postprandial glucose levels than premixed human insulin; other outcomes
are similar.
 Lead to lower A1c and postprandial glucose levels than long-acting insulin, but higher
fasting glucose.
 Lead to lower A1c and glucose levels than oral diabetes drugs.
Choosing Types of Insulin
Selecting the type of insulin preparation depends on many factors, including:
 an individual’s response to insulin
 meal patterns
 ability to self-inject
 diet
 exercise, and
 preferences.
Also, insulin preparations vary in their effectiveness to control fasting and postprandial glucose
levels. Controlling both fasting and postprandial glucose levels is necessary to achieve glycemic
control. At higher A1c levels, fasting glucose control is more beneficial in lowering A1c closer to
the desired target of about 7 percent.
When A1c is closer to 7 percent, postprandial glucose control becomes more important.
 For people who have not achieved adequate glucose control on oral diabetes drugs,
insulin therapy should be considered.
 Premixed insulin analogues and premixed human insulin have similar effects on A1c and
fasting glucose. However, premixed insulin analogues lead to lower postprandial glucose
levels.
70



Premixed insulin preparations are intended to simplify dosing and may permit a lower
number of daily insulin injections for people using more than one type of insulin.
Premixed insulin preparations are available in 70/30, 75/25, and 50/50 ratios for basal
supplementation and mealtime coverage.
Premixed insulin preparations are not as suitable as single insulin formulations for
adjusting daily doses to account for changes in activity levels and meal regimens.
Premixed Insulin Analogues: A Comparison With Other Treatments for Type 2 Diabetes
In comparing three diabetes treatments (Premixed Insulin Analogues with Oral Drugs, and
Premixed Insulin Analogues with Human Insulin Analogues) Pre-mixed Insulin Analogues were
more effective
 Better at lowering A1c . . Similar results
 Better at lowering . . fasting glucose. Similar results
 Better at lowering . . .postprandial glucose
 fewer adverse events
o Lower rates of hypoglycemia1 . . Similar results
o Less weight gain . . Similar results
Still Unknown
Evidence is insufficient to determine whether the effectiveness or adverse events of premixed
insulin analogues vary by age, gender, race, or ethnicity. Evidence is also insufficient to
determine if they vary for people with poor glycemic control or coexisting medical conditions.
There is also insufficient evidence on the long-term safety of premixed insulin analogues and
their impact on quality of life and treatment satisfaction.
Most studies of premixed insulin analogues last 1 year or less and focus on short-term outcomes.
Therefore, evidence is insufficient to determine the effects of premixed insulin analogues on
long-term outcomes, such as mortality, cardiovascular disease, kidney disease, neuropathy,
retinopathy, and long-term weight change, compared with other anti-diabetic medications.
On the Horizon
A retrospective observational study comparing the cardiovascular outcomes of people starting
insulin glargine compared with those starting premixed insulin analogues was completed in
January 2008. Two additional studies are in progress to evaluate quality of life and treatment
satisfaction with premixed insulin analogues and the long-acting insulin glargine with or without
rapid-acting glulisine.
Resource for Patients
Premixed Insulin for Type 2 Diabetes: A Guide for Adults is a companion to this Clinician’s
Guide. It can help people talk with their health care professional about insulin. It provides
information about:
 Types of insulin.
 Benefits, risks, and price of insulin preparations
 Seeking advice from a health care professional about insulin options.
For More Information
For electronic copies of the consumer’s guide, this clinician’s guide, and the full systematic
review, visit this Web site: www.effectivehealthcare.ahrq.gov
For free print copies, call:
 The AHRQ Publications Clearinghouse, (800) 358-9295
 Consumer’s Guide, AHRQ Pub. No. 08(09)-EHC017-A
71

Clinician’s Guide, AHRQ Pub. No. 08(09)-EHC017-3
AHRQ created the John M. Eisenberg Center at Oregon Health & Science University to make
research useful for decisionmakers. This guide was written by Monica Goei, M.D., David
Hickam, M.D., Joe Stewart, B.C.N.S.P., Martha Schechtel, R.N., Seth Meyer, M.A., Rachelle
Nicolai, B.A., and Valerie King, M.D., of the Eisenberg Center.
Price of Insulin
Rapid-Acting Insulin Analogues
 Insulin aspart NovoLog® $105 $200
 Insulin glulisine Apidra® $95 $180
 Insulin lispro Humalog® $105 $200
Short-Acting Insulin
 Regular insulin Humulin® R $45 NA
 Novolin® R $45 $135
 Intermediate-Acting Insulin
 NPH insulin Humulin® N $45 $135
 Novolin® N $45 $135
Long-Acting Insulin Analogues
 Insulin detemir Levemir® $95 $190
 Insulin glargine Lantus® $95 $190
Premixed Human Insulin
 70% NPH/30% regular insulin Humulin® 70/30 $45 $135
 Novolin® 70/30 $45 $135
 50% NPH/50% regular insulin Humulin® 50/50 $45 NA
Premixed Insulin Analogues
 70% insulin aspart protamine NovoLog® Mix 70/30 $105 $200
 suspension/30% insulin aspart
 75% insulin lispro protamine Humalog® Mix75/25 $105 $200
 suspension/25% insulin lispro
 50% insulin lispro protamine Humalog® Mix50/50 $105 $200
 suspension/50% insulin lispro
1 These drugs were evaluated in the systematic review.
2 Average Wholesale Price from Red Book, 2008. Price does not include cost of needles or syringes.
NA = not available in pens.
Image of the consumer guide brochure coverAHRQ Pub. No. 08(09)-EHC017-3 March 2009
72
http://www2.nurseweek.com/ce/self-study_modules/course.html?ID=626CE3781.0 hr
From Lizards and Laboratories: New Diabetes Options
Suzanne J. Pavolich-Danis, RN, ARNP-C, CDE, CRRN
Richard* has experienced a progressive decline in his control of Type 2 diabetes despite
increasing dosages of metformin (Glucophage) and glyburide (DiaBeta). With a body mass index
of 42, Richard is considered morbidly obese. He has chronic renal failure and requires a
continuous positive airway pressure (C-PAP) machine at night because of severe sleep apnea.
His primary health care provider has suggested insulin, but Richard is reluctant because he
remembers that after his mother began insulin, she continued to gain weight until her death. He
trusts you — his “nurse next door” — and at a family BBQ asks you what you know about the
new “lizard spit” drug for diabetes. Would you be able to answer his questions?
Sheila* has been using mealtime insulin for three years and desires better blood glucose control.
Despite her latest three-month blood glucose level being 7.5 (near the target), her readings after
meals often are above 300 mg/dL. (Most experts agree that at or below 150 mg/dL denotes good
control.) Since adding pramlintide acetate (Symlin) to her medication regimen last week, Sheila
has experienced nausea and has had several hypoglycemic episodes. She wants to quit the drug
because she is scared. If Sheila were your patient, could you provide the information she needs to
adjust to this new therapy?
Out of control
Only 37% of people with diabetes have well-controlled blood glucose levels — defined as a
three-month target blood glucose level [hemoglobin A1c] of less than 7%. Let’s restate that —
63% of patients with diabetes are walking around with poorly controlled blood glucose levels,
placing them at increased risk for a host of complications including blindness, renal failure,
amputation, stroke, and death.1 Sounds like it’s about time for a major breakthrough to get more
people with diabetes at or below the goal of 7%.
For some people with diabetes, help may already be here in the form of exenatide (Byetta, the
“lizard spit” drug), and pramlintide. The Food and Drug Administration approved both earlier this
year. Nurses may be asked about these new options and should be able to educate patients and
steer them to reliable sources of information. And many nurses who work with patients with
diabetes will have the responsibility of educating and monitoring patients who are using these
important new treatments.
Insulin’s new accomplices
These new treatments stem, in part, from our new understanding that insulin is not the only
hormone involved in poor blood glucose regulation. To think that all these years we’ve been
placing the blame for poor blood glucose regulation on a lack of insulin. We know that physical
activity, food intake, and hepatic glucose production play important roles, but from a hormonal
standpoint, insulin may have been getting a bad rap. Truth be told, two other hormones with
totally different origins and mechanisms of action have now been discovered to play significantly
important roles in blood glucose regulation.2,3
The first hormone, amylin, is a pancreatic beta-cell secreted hormone that regulates glucose
balance in conjunction with insulin and glucagon in response to food intake. It’s secreted with
73
insulin and contributes more significantly to glucose lowering after meals (the postprandial
period), especially during the three hours immediately after eating.2 Amylin slows the hepatic
production of glucose and also serves as a satiety signal, sending the message of fullness across
the blood-brain barrier to encourage us to stop eating.4
In people with Type 1 diabetes, amylin, like insulin, is not produced. With Type 2 diabetes,
secretion of both insulin and amylin are deficient. When beta cells are destroyed or improperly
functioning, supplementation with insulin injections can provide better, yet not physiologically
identical, glucose control because serum amylin levels are often deficient.2 Compound this with
the lack or reduction of insulin with an accelerated gastric emptying rate that often ensues, and
you have a formula for ever-rising and difficult-to-manage blood glucose levels.
The second hormone, the human incretin hormone glucagon-like-peptide-1 (GLP-1), is released
from the cells lining the ileum and the colon. GLP-1 is also called a “gut peptide” that promotes
pancreatic secretion of insulin and improves carbohydrate metabolism.4
Get tight … get right!
“Tight” control of blood glucose levels is desirable for people with either Type 1 or Type 2
diabetes to reduce the risk for long-term complications, including neuropathy, nephropathy,
retinopathy, amputations, and cardiovascular disease and stroke.5,6,7 Achieving tight control,
however, can be difficult despite a multitude of medication options and readily accessible, easyto-operate home glucose monitoring meters. Patients may fear episodes of hypoglycemia, may
dislike testing their blood glucose as often as necessary (or not have the time or resources to test),
and may not understand the benefits of tight control. In addition, achieving tight control using
insulin is associated with an increased risk of hypoglycemia and weight gain for most patients.6
Even as patients get closer to target HbA1c goals of 7%, the importance of controlling
postprandial glucose levels becomes more significant.8 Patients with hyperglycemia associated
with diabetes may be able to use exenatide and pramlintide when insulin or oral therapy alone is
insufficient for adequate blood glucose control.
Pramlintide — a copycat
Classified as an antihyperglycemic, pramlintide is a synthetic analog — a laboratory-created
compound that is structurally similar to human amylin. Clinical studies have shown that patients
with Type 1 or Type 2 diabetes who take pramlintide in addition to insulin have better
postprandial and long-term glucose control in addition to weight reduction. Pramlintide also
enables patients to reduce their mealtime insulin dosages necessary to achieve target blood
glucose levels.9
Pramlintide is not a replacement for insulin but an adjunctive medication to be administered at the
same time with mealtime insulin.9
Exenatide — lizard what?
Patients with Type 2 diabetes experiencing difficulty controlling blood sugar despite oral
antihyperglycemic therapy with metformin, a sulfonylurea such as glyburide, or a combination of
the two drugs may benefit from an addition of exenatide injections. Some patients may be taken
back when they discover exenatide was synthesized from the saliva of a large desert lizard, the
74
Gila monster. These large lizards typically eat only a few times each year, and extendin-4 (a
substance in their saliva similar to human GLP-1) allows nutrients to be stored and the pancreas
“turned off” until they eat again.10 Scientists studied extendin-4 and were able to synthesize a
compound in the lab that behaves in humans the way extendin-4 does in the Gila monster.
Patients administer exenatide subcutaneously in the thigh, abdomen, or upper arm twice daily,
within one hour before morning and evening meals. It’s only available in disposable prefilled
injection pens delivering 5 mcg and 10 mcg per dose and must never be placed in an insulin pump
device. The dose starts at 5 mcg twice daily before meals and may be increased to 10 mcg twice
daily after one month if necessary. Dosage adjustment is not necessary based on meal size or
physical activity levels.10 Exenatide, unlike other pen-delivered diabetes injectibles, must be kept
refrigerated.
The first drug in a new classification of medications known as incretin mimetics, exenatide
improves blood glucose control by significantly lowering postprandial blood glucose levels and
moderately lowering fasting blood glucose levels by closely regulating insulin secretion and
restoring first-phase secretion of insulin — the release of insulin the first 10 minutes after eating.
Its action is directly related to glucose levels: When exenatide is administered to a patient with
very high glucose levels, a significant amount of insulin secretion is stimulated. When glucose
levels are lower, less insulin secretion is stimulated.10 Incretin mimetics have glucose-regulating
actions on the stomach, liver, pancreas, and brain.
Research has shown that in addition to lowering HbA1c levels, exenatide in combination with
metformin and sulfolylureas can promote weight loss and help improve beta cell function and
restore normal Phase 1 and 2 insulin release.11,12,13
For exenatide to work, the pancreas must be able to secrete insulin; therefore, it is not indicated
for patients with Type 1 diabetes or for treatment of diabetic ketoacidosis. It’s approved for use in
conjunction with metformin and with the sulfonylureas glimepiride (Amaryl), glipizide
(Glucatrol, Glucatrol XR), glyburide (Micronase or DiaBeta), chlorpropamide (Diabinese), and
tolazamide (Tolinase).10
Researchers are investigating the use of exenatide with other medications. To date, however,
exenatide has not been approved to be used in combination therapy with insulin, the
thiazolidinediones pioglitazone (Actos) and rosiglitazone (Avandia), D-phenylalanine derivative
nateglinide (Starlix), the meglitinide repaglinide (Prandin), or the alpha-glucosidase inhibitors
acarbose (Precose) and miglitol (Glyset). Patients taking these medications who are also
prescribed exenatide off-label should be closely monitored for adverse effects, especially
hypoglycemia.10
The downside
Both pramlintide and exenatide have drawbacks. Since patients must be injecting insulin to be
prescribed pramlintide, the drawback to this dual injection therapy is that the medications may
not be combined in the same syringe, necessitating two injections for every meal. At the very
least, patients would expect to administer six individual injections and check their blood glucose
levels seven times daily. Those using basal insulin and consuming more frequent, smaller meals
would test and inject themselves even more. Pramlintide may not be administered through insulin
pump delivery devices.9
75
With pramlintide, patients may experience nausea and profound hypoglycemia, especially if
dosages are miscalculated proportionately to dietary intake and physical activity, making some
tasks unsafe. People with Type 1 diabetes tend to experience more adverse effects with
pramlintide than do people with Type 2 diabetes. Until patients determine whether they will
experience these adverse effects, encourage them not to drive or operate machinery. Patients
typically will be titrating their dose of pramlintide up while titrating their insulin dose down. 9
Patients transitioning to combination therapy with mealtime insulin and pramlintide benefit from
referral to a certified diabetes educator and a registered dietitian for guidance on dosing, titration,
and administration of the two medications in conjunction with balanced meals and periods of
physical activity. Meals covered with insulin and pramlintide must contain at least 250 calories or
30 grams of carbohydrates.9
When pramlintide therapy begins, the prescribing health care provider will set target goals for
blood glucose levels before and after meals. The initial recommended dose with Type 1 diabetes
is 2.5 units and with Type 2, 10 units before meals. The dosage of pramlintide is titrated upward
provided nausea has subsided for three days. The insulin dosage is titrated downward as needed
to achieve desired target blood glucose goals. Presently, pramlintide is not available in an
injectable pen and must be drawn up from a vial into a standard insulin syringe. Patients using
rapid-acting insulin in pen form may need instruction on proper technique with drawing up
medication from a vial with a syringe. They must also be reminded to select two sites that are at
least 2 inches apart.9
With exenatide, common adverse effects include vomiting, diarrhea, headache, jitteriness, and
acidic stomach. Nausea is especially common when exenatide therapy begins, but tends to
decrease with time in most patients. Up to 39% of patients receiving the 5 mcg dose and 49% of
patients receiving the 10 mcg dose experienced nausea when exenatide therapy was initiated.14
Additional points to remember about exenatide: Women who are breastfeeding, pregnant, or
planning conception should not take exenatide, nor should children.10 Exenatide is a clear
solution; if it appears cloudy, it must not be used. Missed doses should be skipped entirely as
exenatide should never be taken after a meal is completed.
Some like it … NOT!
While replacement of naturally occurring hormones may sound ideal, pramlintide and exenatide
are not intended for all patients with diabetes. Patients with gastroparesis, a condition that slows
down the absorption of food from the digestive tract; patients who have had gastric bypass
surgery; and those who have difficulty recognizing the warning signs of hypoglycemia are not
candidates for pramlintide or exenatide therapy.9,10
One major barrier in persuading patients to start exenatide or pramlintide therapy is the fact that
these medications must be injected to work. In addition, patients must be willing to intensively
monitor their blood glucose and follow up regularly with their prescribing professionals.
Intensive monitoring recommended for patients prescribed pramlintide includes testing blood
glucose levels before and after every meal and at bedtime. Patients also must understand how to
adjust insulin and pramlintide doses simultaneously.9
Patients tend to lose weight when prescribed exenatide and pramlintide, a desired effect for many
but not all patients with diabetes.10 The weight loss is slow and gradual, apparently unrelated to
76
the incidence of nausea — patients who do not experience nausea have been shown to experience
weight loss similar to those who do experience nausea that initially subsides with continued
therapy.11,12,13
Essential education, close monitoring
Exenatide and pramlintide require extensive education and close monitoring. Nurses caring for
patients who take exenatide and pramlintide should monitor for hypoglycemia, especially when
therapy begins or dosages are titrated upward. Because exenatide slows gastric emptying, it’s also
important to monitor for the effectiveness of medications that may depend on rapid GI
absorption, such as pain relief medications. Administration of medications may need to be
adjusted to times when exenatide is not used to cover a meal (such as at lunchtime or during a
snack). Medications dependent on specific threshold levels, such as contraceptives, should be
taken at least one hour before exenatide injection; in this instance, a backup contraceptive method
might be a good idea, especially if nausea and vomiting occur.
Remind patients that exenatide may cause hypoglycemia, especially when used in conjunction
with a sulfonylurea, requiring the dosage of the sulfonylurea to be decreased. Patients combining
insulin and pramlintide therapy may also experience profound hypoglycemia, typically within
three hours after dosing.9 Patients prescribed either of these new medications should always keep
their blood glucose meter nearby and carry a rapidly absorbing source of glucose. Convenient
tablets containing exactly 15 grams of carbohydrate are available at most drugstores and are
preferred to the indiscriminate use of hard candy or other sources of sugar. The “rule of 15” is
easy to remember for treating hypoglycemic episodes: Take 15 grams of carbohydrate, wait 15
minutes, and if still symptomatic, take 15 more. Advise patients not to drive, operate machinery,
or perform activities requiring their full attention until they see how they respond to the
medication.
Episodes of hypoglycemia and nausea may be less bothersome when patients become more
familiar with how their body responds and how to adjust the timing of medication. Often patients
experience a lack of desire to complete their meal, a real problem when medications are given at
the start of a meal. Remember that nausea may affect the amount of food consumed during a
meal, so the timing of fast-acting insulin and pramlintide may need to be delayed to avoid
hypoglycemia. It may be best delivered when the patient has nearly completed the meal and is
better able to calculate his or her actual carbohydrate intake and make necessary dosage
adjustments. Delivering mealtime insulin near the end of a meal may sound unorthodox, but since
gastric emptying will be delayed with pramlintide, this strategy may reduce the risk for
hypoglycemic episodes.
Often, patients focus on desirable medication benefits and grow discouraged when they are slow
to experience them. Remind patients that the weight loss associated with exenatide and
pramlintide is slow and gradual. Encourage them to endure nausea that often accompanies the
start of therapy.
On the horizon
Extended-release versions of pramlintide and exenatide are already undergoing research trials.
The extent to which nurses will see patients taking these two medications depends on many
factors, including patient acceptance and prescribing providers’ comfort levels in encouraging
aggressive and tight glucose control. Cost may also be a factor. However, the short-term expense
77
for medication most assuredly will be justified by the postponement or elimination of the
complications of poorly controlled diabetes.
*Not real patients.
78
Diabetes Case Study #1
John Armstrong, a 20 year-old, insulin-dependent diabetic, presents to the hospital ED with right
arm pain and impaired mobility after falling while skate-boarding. He is examined, has x-rays
performed, and is diagnosed with multiple compound fractures of his right lower arm.
John is admitted to your nursing unit from the ED and scheduled for an open reduction and
internal fixation (ORIF) of the right ulna and radius the next afternoon. His admitting vital signs
are T 99.6, P 124, R 20, BP 140/90. He is 6’ 2’’ and weighs 84 kg. His most recent FSBS is
120mg/dl.
He is made NPO for surgery, and his arm is immobilized in a splint and sling. He has a strong
radial pulse and is able to wiggle all his fingers. A saline lock is placed, and the physician has
written orders for pain medications and IV antibiotics. The physician has also initiated
Preprinted Subcutaneous Insulin Orders and capillary blood sugars/fingerstick blood sugars
(CBS/FSBS) as follows:
PREPRINTED SUBCUTANEOUS INSULIN ORDERS
DIET: NPO for surgery
FINGERSTICK BLOOD GLUCOSE SCHEDULE: Every 4 hours (recommended for
patients NPO, on tube feedings, or on TPN)
SUBCUTANEOUS INSULIN DOSING:
• Basal Insulin: Glaragine Insulin 21 units SQ QHS.
• Meal/Prandial Insulin: Aspart Insulin 7 units SQ tid ac. Hold scheduled
Meal/Prandial insulin doses when patient is NPO.
Correctional Insulin:
Moderate Dose Algorithm (for average size adult) [based on formula (BG – 100) divided by 40]
BG ac, hs, 0300 hours Additional Insulin
141-160
1 unit
161-200
2 units
201-240
3 units
241-280
4 units
281-320
5 units
If great than 320
Contact M.D.
Do not hold basal insulin or correction dose insulin when patient is NPO
Instructions:
You are the evening RN. At 2200 you check his CBS/FSBS.
1. (Perform a CBS on a colleague.) John’s CBS result is 275 mg/dl.
2. How many units of maintenance, correctional, and prandial insulin will you give?
3. Do you need any additional orders from the physician?
4. Draw up the insulin using aseptic technique and perform the double-check of the
insulin with a colleague. Use a U 50 syringe.
5. Administer the insulin to the phony fanny/phony tummy using correct technique.
6. Chart the CBS/FSBS, medication, dose, route, site, date, time, and your initials and
signature.
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At 7 AM, you wake John up and check his Vital Signs and CBS. His VS are: 99.6, 98, 18,
140/60.
7. (Perform a CBS on a colleague.) John’s CBS/FSBS result is 322 mg/dl
8. How many units of maintenance, correctional, and pre-prandial insulin will you give?
9. Draw up the insulin using aseptic technique and perform double-check of the insulin
with a colleague.
10. Administer the insulin to the phony fanny/phony tummy using correct technique.
11. Chart the CBS/FSBS, medication, dose, route, site, date time, and your initials and
signature.
You are the day shift RN. At 12 Noon, you check John’s VS and CBS. His VS are: 99.0, 88, 16,
128/64.
12. (Perform a CBS on a colleague.) John’s CBS result is 125mg/dl
13. How many units of maintenance, correctional, and pre-prandial insulin will you give?
14. Draw up the insulin using aseptic technique and double check the insulin with a
colleague.
15. Chart the CBS/FSBS, medication, dose, route, site, date time, and your initials and
signature.
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Diabetes Case Study #2
Mildred Jones a 38-year-old woman is admitted to the Med Surg unit for a non-healing foot ulcer
and Insulin Dependent Diabetes Mellitus.
The MD writes the following orders:
•
•
•
•
•
Wet-dry dressing changes TID. 2000 Calorie ADA diet.
Insulin:
o Humulin NPH 30 units and Humulin Regular Insulin 10 units qam.
o Humulin NPH 20 units and Humulin Regular Insulin 6 units qpm.
Finger Stick Blood sugars AC and HS. Call MD for FSBS >400 and < 60.
Ancef I gram IV q 6 hours.
Tylenol 0/650 po for temperature >101.5.
At Good Samaritan Hospital, AC and HS testing times are standardized at 0730, 1200, 1700 and
2200. Insulin administrations are standardized at 0730, 1200, 1700, and 2200. Meal times are
standardized at 8:00, 12:30, 17:30 and HS snack at 22:30.
At breakfast time, Mrs. Jones vital signs are as follows: BP 170/85 pulse 110 respirations 16
Temp 101.5. Her morning CBS is 353 mg/dl.
1. How many units will you give?
2. Draw it up using proper aseptic technique. Choose a site, and inject.
3. Chart the medication, dose, route, site, date, time, and FSBS.
At lunchtime, Mrs. Jones vital signs are as follows: 176/94 118 16. T102.0, CBS 246.
4. Does Mrs. Jones get Insulin?
5. Chart the FSBS in the proper place.
At dinnertime, Ms Jones vital signs are as follows: T 102.5. 150/90, 128, 22. CBS 375.
6. How many units will you give?
7. Draw it up using proper aseptic technique. Choose a site, and inject.
8. Chart the medication, dose, route, site, date, time, and FSBS.
At bedtime, Ms. Jones vital signs are as follows: T 103.5 BP 160/95 pulse 132 respirations 24.
CBS 475.
9. What action do you initiate?
10. Chart the FSBS in the proper place.
You call the MD and use SBAR to communicate. Plan your call to the MD and role play. He
orders a stat dose of Humulin Regular Insulin 14 units. He wants you to hang an IV of .9NS to
infuse at 200cc/hour. He orders a stat CBC, Blood Cultures x 2 and for the patient to be started
stat on Erythromycin 1 Gram IV q6 hours after the blood cultures are drawn.
11. How many units will you give?
12. Draw it up using proper aseptic technique.
13. Chart the insulin medication, dose, route, site, date, time, and FSBS.
At breakfast time the next morning, MS. Jones has Vital signs as follows: BP 120/60, pulse
100, and RR 16. T100.5 FSBS 52. MS. Jones is irritable, diaphoretic and slightly disoriented.
14. What action do you initiate?
81
You call the MD, and he asks if the patient has any nausea or vomiting and if the patient has an
appetite. You answer the patient has no nausea or vomiting and appears to be eating well. He
orders you to hold the Humulin Regular Insulin and give the patient 25 units of Humulin NPH.
15. Explain this order based on the insulin flow sheet.
Finish:
16. Document patient problems and nursing interventions and evaluation in a nurse’s note.
82
Skill Check-List Review: Administering Insulin
Assessment:
 Check the MAR with the physician’s written order for accuracy.
 *Compare the FSBS result with the med order to determine the correct dosage (Regular
insulin may be ordered according to a Sliding Scale—also called “Rainbow Coverage”—
with the amount of insulin determined by the result of the FSBS. NPH insulin and other
long- acting insulins are ordered as routine/scheduled doses once or twice a day).
 Review purpose(s) of medication, normal dosage range, onset of action, administration
routes, side-effects, contraindications, and nursing considerations.
o What is the primary reason this drug is prescribed?
o Why is my patient getting this drug?
o Is the dosage ordered within the normal range for this drug?
o Is the administration route ordered appropriate for this drug, and appropriate for
this patient?
o Are there any drug or food interactions to be aware of?
o What are the most important side effects and adverse reactions to be aware of?
o Are there any special considerations (e.g., labs to be monitored, medication to be
taken before meals, etc.) to be aware of?
 Assess for contraindications to administration of insulin (e.g., e.g., low serum glucose,
NPO status without a source of glucose).
 Assess the client’s medical record for age, allergies, and lab results (consider especially
serum glucose).
Planning:
 Check scheduling of medications for problems/conflicts.
 Check that medications are available. If not, order from pharmacy.
 Plan administration of routine insulin doses around meal times, allowing enough time to
check the client’s fingerstick glucose, prepare the injection and double-check it with
another nurse, and administer it far enough in advance to allow adequate time for the
insulin’s onset before a meal.
Implementation: Preparation and Administration of Meds
Preparation:
 Wash hands.
 Prepare insulin for one client at a time using the Five Rights.
 Obtain equipment: Insulin syringe 1/2cc or 1cc (100 units/cc) with 28 gauge 3/8-5/8 inch
needle; alcohol prep pad.
 Obtain the prescribed types of insulin . Mix protamine/long-acting insulin by rotating vial
between palms.
 Cleanse top of each vial with an alcohol swab. Pull back barrel of syringe to a volume of
air equal to the volume of both insulin dosages.*
 Remove needle cap. Insert needle into the long-acting insulin vial first and inject the
volume of air equal to the long-acting insulin dosage, without inverting vial and
contaminating needle.*
 Inject remaining air into rapid acting insulin vial, then invert vial, and withdraw desired
volume/correct dosage of rapid acting insulin, being careful to expel air bubbles whose
presence can affect the dosage. Have another nurse check the dosage*.
 Insert needle into long-acting vial and withdraw correct dose. Have another nurse check
the dosage.*
83

Cover needle with cap using scoop method.
Administration
 Identify the client: Ask the individual to state his/her name. Compare the name on MAR
with name on individual’s ID bracelet.
 Explain the procedure to the patient. Assess the client’s knowledge about the medication.
Do patient teaching as appropriate; explain the purpose of the drug and answer any
questions.
 Provide privacy.
 Put on clean gloves.
 Assist the client to a comfortable position, sitting or supine, and swab the administration
site with alcohol: Allow alcohol to dry. (Alcohol is optional at home). It is
recommended that the abdomen be the primary site for injections. Give injections one
inch away from the previous site. If the client is used to giving injections in other sites,
give them in the same body part at the same time of each day: e.g., AM abdomen, pm
left buttock.). To avoid too rapid absorption, it is recommended that limbs which may be
exercised be avoided. However, the arms can be used for PM doses, the legs for HS
doses. Remember:
o The abdomen generally absorbs fastest, followed by the arms, thighs, and
buttocks. The abdomen is the recommended primary site for insulin SQ
injections.
o The abdomen is recommended for AM injections
o Arms may be used for PM insulin SQ injections
o Thighs may be used for HS insulin SQ injections
o Insulin injections should be given in the same body part at the same time each
day (i.e., AM--abdomen, PM--left buttock). Using different areas for injection is
acceptable so long as the same area is used for corresponding doses each day.
E.g., inject Regular and NPH insulin into abdomen to speed action of regular
insulin; in the evening inject NPH into thigh or buttock to help prolong its action.
o Rotating sites is important for prevention of lipodystrophy (altered distribution of
subcutaneous fat). Two types of changes may be seen; lipoatrophy (loss of
subcutaneous fat and lipohypertrophy (accumulation of subcutaneous fat).
o Rotating sites within one area is better than using different areas without a plan.
Some diabetics achieve better control if sites are rotated in the same anatomic
area, therefore intra-site rotation of injections sites is recommended: 12-3-6-9
o’clock
o Give injections one inch (2.5 cm) away from the previous site. (Note: Because
automatic injectors (needle-less injectors) use air pressure to propel insulin
through the skin, the absorption rate using this device differs from that of a
needle injection because a micro-thin stream of insulin penetrates the skin and is
dispersed more widely in the subcutaneous tissue.
 Perform third check: Check to ensure that this is the correct patient, med, dosage, route,
and time.
 Gently accumulate a well-defined roll of skin without pinching—use bunch technique.
 Remove needle cap.
 Hold the syringe like a pencil. Using dart motion, inject at a 90 degree angle. Do not
aspirate. Push the plunger down and release the skin. Wait 1-2 seconds.
 Withdraw the needle quickly
 Apply gentle pressure with an alcohol prep pad, 2x2, or cotton ball. Do not rub area;
 Assist patient to return to a comfortable position.
84


Dispose of syringe and needle in Sharps container and wash hands.
Advise patients not to smoke, and especially not to smoke within 30 minutes after insulin
injection as smoking decreases amount of absorption of insulin SC (due to
vasoconstriction). Marijuana use may increase insulin requirements.
Documentation:
 Document administration of both of the insulins, recording the time and the
administration site on the MAR, as well as the FSBS, according to hospital policy. If
giving Correctional (or Sliding Scale/Rainbow Coverage insulin), record the FSBS and
the number of units given. Sign and initial.
 If the drug was withheld, enter and circle the time it was scheduled to be given on the
MAR and record the code indicating the reason it was withheld. Also note the reason the
medication was withheld in the nurse’s notes.
Evaluation:
 Make sure client has food or a source of glucose available after giving pre-meal/prandial
insulin.
 Observe clients who have received correctional insulin carefully. Return within 30
minutes (consider the onset of the particular type of insulin administered) to evaluate the
patient’s response to the medication. Observer for signs and symptoms of hypoglycemia
and hyperglycemia.
 Report any untoward effect, according to hospital policy, and document.
Grade: Pass/No Pass
Instructor’s Signature_____________________________________
85
Diabetes Critical Thinking Exercises
1. To combine two insulins in one syringe, inject air into the __________ insulin first, then into
the __________. Draw up the ____________________insulin and return to the __________ .
2. A newly diagnosed diabetic client is learning to self-administer insulin. On reviewing the
client’s chart, the nurse notes the following: weight 198 lbs., height 5’0”, age 37, speaks English,
fine motor skills within normal limits
The nurse will teach the client to:
a. Insert the needle into the abdominal tissue at a 90-degee angle
b. Include a small air space when drawing up the prescribed insulin dose
c. Instruct the client to use an insulin syringe with at least a 1 inch needle
d. Aspirate before injecting the insulin to ensure the needle is not in a vessel.
3. The nurse also includes in the client’s teaching:
a. “Once you take the regular insulin, you must eat because your blood sugar can drop quickly.”
b. “Be prepared for a possible rapid rise in your blood sugar about 2 hours after taking the rapidacting insulin.”
c. “Be aware that your blood sugar will drop about 15 minutes after you take the intermediateacting insulin.”
d. “Since the long-acting insulins have a duration of up to 36 hours, you can skip a dose once in a
while.”
4. T or F A syringe intended for insulin injection is measured in milliliters rather than units.
5. T or F When combining two insulins in one syringe, draw up the cloudy insulin first and
then the clear insulin.
6. The adolescent client states, “I can’t give myself insulin--it will hurt too much.” The nurse’s
response is based on the knowledge that:
a. Adolescents are not usually this resistant to becoming involved in their own care.
b. The insulin can be mixed with a small amount of a local anesthetic to decrease the pain
c. The physician can order an oral form of insulin for clients who are frightened of injections.
d. Even though the needles used for insulin are very small, some clients do experience pain with
injections.
7. List three factors that can alter the absorption of insulin:
i.____________________ii.____________________iii____________________
8. What concentrations of insulin are available and which concentration is most commonly used
in the US?______________________________
9. List three complications from insulin therapy:
i.____________________ii.____________________iii.____________________
10. List the six product types and sources of insulin:
i.____________________ii.____________________iii.____________________
iv.___________________v.____________________vi.____________________
11. How is the purity of insulin expressed?____________________
86
Name: ______________________________
Student Assignment
Below is a list of insulins currently available wit their generic name and their proprietary/trade
name in parentheses. Prior to class, students look up each of the following types of insulin and
determine: a) rapidity of onset of action, b) peak of action, and c) length of action. (The most
commonly used insulins are in bold.) In order for the student to participate in the lab on diabetes,
this assignment must be completed prior to class and submitted at the beginning of class.
1. Insulin Aspart
(NovoLog):_________________________________________________________________
___________________________________________________________________________
2. Insulin Glargine
(Lantus):___________________________________________________________________
___________________________________________________________________________
3. Insulin Regular (Humulin R, Novolin R, Regular Insulin, Pork Regular Iletin II, Regular
Purified Pork Insulin, Velosulin, Velosulin BR, Velosulin Human):____________________
__________________________________________________________________________
4. Insulin Injection Concentrated (Iletin II Regular [Concentrated]
U500:______________________________________________________________________
___________________________________________________________________________
5. Insulin, Isophane [NPH] (Humulin N, Novolin 70/30, Novolin, Iletin II (pork), Insulatard
NPH, Mixtard,)______________________________________________________________
___________________________________________________________________________
6. Insulin Lispro
(Humalog):_________________________________________________________________
___________________________________________________________________________
7. Insulin, Protamine Zinc (Iletin II):_____________________________________________
___________________________________________________________________________
8. Insulin Zinc Suspension [Lente] (Humulin L, Lente Iletin II (pork), Lente Purified Pork
Insulin,Novolin):_____________________________________________________________
___________________________________________________________________________
9. Insulin Zinc Suspension, extended [Ultralente] (Humulin U; Ultralente; Ultralente
Insulin):____________________________________________________________________
___________________________________________________________________________
__
10. Insulin Zinc Suspension Prompt [Semilente] (Semilente Insulin, Semilente Purified
Insulin):____________________________________________________________________
___________________________________________________________________________
87
88
Day #3: Wednesday, August 15th, 2012
Class # 5: 8:10 AM-12:00 Noon
• Preparation for Fall 2012 Flu Clinic
Administration of Immunizations
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory, the student will:
• Describe the cause of the flu and how it is spread:
• Explain why flu is a worldwide public health concern
• Describe the 3 viruses (two type A and one type B) included in the current 201-2013
influenza vaccine and how they were selected
• Explain the recommended immunization frequency
• Describe how long after immunization it takes for immunity to be conferred and efficacy
• Describe populations for whom the flu vaccine is recommended and those for whom it is
not recommended
• Describe isolation methods for limiting exposure to the flu
• Describe methods for preventing the flu
• List major signs and symptoms of the flu and how they differ from a cold or upper
respiratory infection
• Describe major complications associated with the flu
• Describe methods for positively diagnosing the flu and available treatment for infected
persons
• Create a teaching plan for educating clients about the flu and the flu vaccine
• State the usual dosage and route for the flu vaccine
• Demonstrate drawing up the correct dose of flu vaccine from a multi-dose vial Describe
and demonstrate an approach to the client receiving a flu vaccine that minimizes potential
risks
• Demonstrate correct administration of the flu vaccine using universal precautions and
appropriate landmarks
• Describe immediate interventions for someone having a reaction to the flu vaccine
Homework:
• Read the handout on the College of Marin Health Center 2012-2013 flu clinic
• Go to CDC website to answer questions about the 2012-2013 flu vaccine
Class:
• View immunization video
• Practice administering a flu shot to a “client” (classmate) including drawing up the
correct dose, patient assessment and teaching, IM administration of the vaccine, and
documentation
89
Information on Student Participation in the
College of Marin Flu Clinics
The College of Marin Flu Clinic
The annual College of Marin Flu Clinics are generally held during October and the first weeks of
November on both the Kentfield and Indian Valley Campuses. (The dates somewhat flexible from year to
year because of potential delays in the delivery of the vaccine.) Clinics are held on the Kentfield Campus
on Fridays mornings 9 AM to 12 Noon. June Lee, the RN in charge of the Student Health Center, and her
staff plan and coordinate the Flu Clinics. College of Marin second-year RN Program students are invited to
participate.
Student participation in the Flu Clinic is a great opportunity to do health promotion, health teaching, and
gain valuable practice giving IM injections. It also provides a service to the community, gives the College
of Marin Nursing Program increased visibility, and projects a positive image of the nursing program and
the nursing profession. It is also a lot of fun!
This is an external clinical experience that is linked with a RN program course that the student is currently
enrolled in, so malpractice insurance and our Workman’s Compensation policy cover the student. Students
who participate may be offered credit for this service learning experience through their instructors (e.g., as
a make-up for an absence day, as an external clinical experience, or as extra-credit in a theory course) but it
is up to the individual instructor to decide whether or not to do this. We encourage students to list their
participation in the clinics on their resume.
Student Preparation
Students who would like to participate will be required to prepare prior to the clinic. Preparations consists
of:
1) Viewing a brief video on administration of immunizations (available in the skills lab)
2) Reading about immunizations at http://www2.cdc.gov/nip/isd/immtoolkit/default.htm
3) Reading about influenza and the flu vaccine on the CDC website, http://www.cdc.gov/flu
and answering some questions (provided below).
There will also be a brief evaluation form for the student and the supervising RN to complete and sign at
the end of the clinic. These will be turned into the student’s instructor or placed in the student’s file.
Student Participation
Students participating in the clinics must come to the Student Health Center an hour before the clinic starts
(e.g., arrive at Student Health at 8 AM for a 9 AM clinic) in order to post directional signs outside, set up
stations with equipment, and pre-fill syringes with the vaccine. Students will also need to stay 30 minutes
to 1 hour after the clinic to clean up.
We can usually have six (6) students at each clinic. However, to accommodate more interested students, we
sometimes have students scheduled in shifts, e.g., 8 AM to 10:30 AM and 10:30 AM to 1:00 PM.
Students who sign up to participate have made a commitment to attend; you are our staff and we, and the
public, are counting on you! If you need to cancel, please do so 24 hours in advance, and let the instructor
and June Lee know. We would like the time to try to find another student to replace you.
Flow of the Clinic
90
When clients enter the Health Center, they are given a clipboard with information about the current Flu
Vaccine to read and a form to fill out. When they finish their paperwork they hand it to one of the Health
Center staff who accepts their payment. Clients may pay with cash or check. They are given a receipt with
their name on it to give to the RN who will be giving them their injection.
Though clients are given written information when they sign in, most of them don’t read it. But we still
have an opportunity to educate them as we give them their flu shot. We believe that it is important to make
people feel good about taking the time out for preventive care, and to help them feel individualized and
well cared for. This can be done in a variety of small ways: by introducing yourself, by calling the client
by name (their name is on the sheet they hand you), by being warm and cheerful, by answering questions
and providing information, and by being skillful and efficient yet unhurried. A flu clinic can be run like an
assembly line, but taking the extra time provides added value and promotes safety.
Approach to the Patient:
A basic approach can go something like this:
 Welcome the client, glancing at the registration sheet they hand you in order to positively identify
them and to call them by name.
 Introduce yourself as a Student Nurse in the College of Marin RN Program.
 Invite the client to sit down in the chair. (That way, if they have a vasovagal reaction they won’t
fall down!).
 Ask the client if they have ever had a flu shot before. If so, ask if they had any problems. If the
client has never had a flu shot before, explain that we would like him/her to stay for about 15-20
minutes after the shot just to monitor for any allergic or adverse reaction.
 Ask the client if he/she has any allergies (open ended). Then, just to be sure, ask specifically if
they have an allergy to eggs (used in the vaccine process) or to thimerosol (a preservative also
found in things like contac lens solution). People tend to answer initially without thinking and
then, as time passes, or as you probe, or just as you are putting the needle in their arm they say,
“Oh, yeah, well I am allergic to….”

Ask the client if he/she has an arm preference for the injection (open-ended question helps clients
who may have had a mastectomy not be forced to give details.) If the client has no preference I
say that I like to use their non-dominant side and ask whether they are right or left handed.

Ask the client to roll up the sleeve or have the client open their shirt and pull it down to expose
their shoulder/deltoid. (We have privacy screens for women who may have worn the wrong outfit
to get a shot.)
 Reassure the nervous client. I generally reassure all clients that I will tell them before I stick them.
IM Injection Procedure:
 Put on gloves.
 Find the site on the deltoid by asking the client to hold their arm out to their side and then look for
the center/biggest part of the deltoid. Then tell them to let their arm hang down at their side
relaxed because this seems to decrease the pain of the injection. Find your injection site again by
measuring 2-3 finger-breadths down from the acromium process. Swab the site vigorously (creates
some counter-irritation that is distracting) with alcohol; if you have time, let the alcohol dry
because that may decrease the stinging of the injection.
 It is an IM injection. The flu vaccine dose is 0.5 mLs. We use a 25 gauge, 1” needle (5/8” for very
skinny folks, 1 1/2” for hefty people). The information provided in our immunization video says
that it is not necessary to aspirate, but you can if you want to. (The reason that aspiration is
unnecessary is because there is apparently no danger if the vaccine goes directly into a blood
vessel.) However, if you hit a blood vessel it’s upsetting, so just pull out and say, “I’m so sorry,
there was something wrong with that syringe (or something like that) and I will need to stick you
again in another place. The vaccine is usually pre-drawn up so you have a lot sitting next to you.

Technique: I recommend that you do not bunch the muscle up, but rather spread it out—like
making fabric taut when you are sewing so the needle slips in easier. (One retired physician
91









client argued with me about technique so for the sake of public relations and his ego I did it
his way, but it is not my way.)
Say “little stick,” dart the needle in at a 90 degree angle, aspirate or not, and administer the
vaccine. As you withdraw the needle say, “Okay all done—you did great!” and put the
syringe and needle in the Sharps container. (The needles are so fine and small that most
people truly don’t feel it.)
Apply gentle pressure to the site with a 2x2 and apply a Band-Aid. You may need to ask the
client to hold the 2x2 while you open the Band-Aid. If there is no bleeding, you can ask the
client whether or not they would like a Band-Aid.
Take off your gloves and discard.
Initial the client’s form and indicate the site of the injection (RD or LD for Right or Left
Deltoid).
Explain that they may have some local soreness at the injection site for about 24 hours and
that they can take the “pain reliever of their choice” (you are a nurse and therefore aren’t
supposed to prescribe, and you wouldn’t want to tell a patient with cirrhosis to take Tylenol,
or a patient on Coumadin to take ASA. One man said to me, “Oh I’ll go right home and have
a shot of Jack Daniels!”
Explain that some people experience systemic flu like symptoms but they usually dissipate
within 48 hours. Assure the client that the virus is not alive so they have not been given the
flu and that it is probably coincidental, rather than cause and effect, when people report
getting the flu just after getting a flu shot; they were probably already been exposed.
Explain that true allergic reactions to flu shots are rare but that if they experience symptoms
such as SOB, tightening of the throat or chest etc. they should go to ED or call 911. (The flu
shot information sheet gives them this information.)
Encourage the client to take their information sheet with them, and thank them for coming in!
Document the flu vaccine lot number and injection site on the form and sign your name.
92
Student Preparation for the
College of Marin Flu Shot Clinics
Instructions:
The educational materials selected for students to read in preparation for participation in the flu clinic were
chosen to aid you in the major aspects of immunization administration: client assessment, dosage and
administration technique, provision of thorough, accurate patient education, and responding to adverse
effects. The Flu Clinic Preparation Questions attached were designed to help you key in on the important
information that you will need to provide quality care at the flu clinic.
1.
2.
3.
4.
5.
6.
Read the Centers for Disease Control materials on the flu and flu vaccines on-line at the CDC website
http://www.cdc.gov and answer the questions below. Note that at the College of Marin Flu Shot
Clinics we will be administering immunizations to adult clients only (over 18 years of age) , and will
only be administering the TIV (trivalent inactivated vaccine) not the LAIV (live attenuated intranasal
vaccine).
Read the materials about immunizations at http://www2.cdc.gov/nip/isd/immtoolkit/default.htm and
answer the questions below. On the left side of the web page you will see a menu with multiple topics.
The entire site is worthwhile so feel free to explore it. However, for our purposes you are most
interested in The Basics and Vaccine Administration.
a. From the vertical menu on the left side of the screen, click on The Basics. On the next screen
there will be a new vertical menu in blue; click on Competency Based Skills Check-list for
Immunizations. When the page opens there is a chart with very small, unreadable print.
However, next to it is a blue icon that says Skills Checklist PDF. Click on the small blue icon
to open the PDF file with a check-list that you can review and print.
b. From the vertical menu on the left side of the screen click on Vaccine Administration. When
the screen opens chose from the small vertical menu in blue How to Administer IM and SC
injections When the screen opens, click on the small blue icon that says How to Administer
IM and SC Injections-Adults.
c. Return to the Vaccine Administration menu and select Dose, Route, Site, Needle Size and
Preparation. When the page opens click on the small blue icon that says Dose, Route, Site,
Needle Size, and Preparation—Adults.
Watch the video on immunizations located in the Skills Lab.
Answer the Flu Vaccine Questions that are attached.
Bring your answers to the Questions with you to the flu clinic on the day you are assigned. The
materials are designed to aid you in assessment, provision of thorough, accurate patient education, and
responding to adverse effects. Students who do not bring a copy of their completed questions with
them to the flu clinic—as evidence that they have prepared—will not be allowed to give flu shots.
Bring a copy of the evaluation form with you to the flu clinic you are participating in and complete it at
the end of the experience. A copy will be placed in your file, and if you are receiving credit for this
activity for one of your nursing courses, another copy will be given to the appropriate nursing
instructor as proof of your participation.
93
Name ______________________________
Student Preparation for the College of Marin
Flu Shot Clinic
Questions
As you read the materials and watch the video, answer the following questions:
Contagion and spread:
1. How is the flu spread?
2.
What kind of isolation should a patient who is hospitalized with the flu be placed on?
3.
How long does it take after exposure to the flu for illness to develop?
4.
How long can the flu virus remain viable on inanimate objects?
5.
How long do people with the flu remain contagious?
6.
Besides getting a flu shot, what else can people do to prevent the flu?
Diagnosis and treatment:
7. What are signs and symptoms of the flu?
8.
How do signs and symptoms of the flu differ from a cold or URI?
9.
How is the flu positively diagnosed?
10. Is there any treatment available for the flu besides supportive care?
Complications:
11. What are the complications associated with the flu?
12. How many people die each year from the flu?
General Information:
13. What 3 viruses (two type A and one type B) are included in the current (2011-2012) influenza
vaccine?
94
Name ______________________________
14. How often does one need to get a flu shot (i.e., how long does immunity last, and why can’t
someone just be vaccinated once)?
Efficacy:
15. How long after immunization does it take for full immunity to be conferred?
16. How effective is the vaccine in healthy adults?
CDC Recommended Target Populations:
17. For whom is the flu vaccine recommended?
18. For whom is the flu vaccine not recommended?
19. What questions should you ask each client prior to administering the flu vaccine?
20. During which trimesters can pregnant women be vaccinated?
21. Can breastfeeding moms get the flu vaccine?
22. At what age can infants be vaccinated? (Note: We will not be giving vaccinations to anyone
under age 18 at the College of Marin Flu Clinic.)
23. It is recommended that international travelers (among others) get flu shots because of risk of
exposure on airplanes, as well as because of the fact that the flu season is different in the northern
and southern hemispheres and the tropics. When is the flu season in the northern hemisphere, the
southern hemisphere, and the tropics?
Vaccination technique:
24. What is the dosage and route of administration for the flu vaccine? (Note the addition of a new
route and dosage available for the first time for the 2011-2012 flu Season.)
25. What is the preferred injection site on adult and how can you best locate it?
26. Do you need to aspirate first when injecting the flu vaccine?
95
Name ______________________________
Flu vaccine reactions:
27. Can you get the flu from the flu vaccine injection?
28. How would you respond to someone who tells you that the last time they got a flu shot they got
the flu?
29. What mild side-effects might a client receiving the flu vaccine expect, and what anticipatory
guidance might you provide about minimizing these symptoms?
30. What are severe side-effects of the flu vaccine?
31. How will you recognize an anaphylactic reaction to a flu shot? (Note: Clients who have never
received a flu shot before, should be asked to sit out in the reception area of the Health Center for
15-20 minutes after their injection so that we can monitor them for a reaction.)
32. What actions will you take in the event of an anaphylactic reaction?
33. To what agency should any adverse reactions to the flu vaccine be reported?
34. Can people get other immunizations (e.g., Pneumovax) at the same time as the flu vaccine? (Note:
Pneumovax vaccine is not currently being offered at the College of Marin Health Centre during
the Flu Clinics, but can be obtained from private physicians, clinics, or the public health
department.)
96
Name_______________________________
College of Marin
Flu Clinic Evaluation
Purpose:
1. To assess the value to the student of the learning experience in this clinical agency.
2. To assess the student’s knowledge and skills to perform intake interviews/histories, obtain informed
consent, draw up medications, administer injections, provide client/ patient teaching, and work
cooperatively and effectively with agency staff and clients.
To be completed by the Student:
Evaluation Preparation Assignment and Experience: (Satisfactory/Unsatisfactory/Not Assessed)
_____1. Provided information on flu and flu vaccine for students to review.
_____2. Provided orientation to clinic and procedure for emergencies
_____3. Explained guidelines for immunizations
_____4. Explained patient selection and flow through clinic.
_____5. Provided demonstration of intake, informed consent, client teaching, and vaccine administration.
Student’s assessment/comments regarding the experience:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
To be completed by the Staff:
Evaluation of College of Marin RN Student: (Satisfactory/Unsatisfactory/Not Assessed)
_____1. Observed initial demonstration by staff of intake history, informed consent, client teaching, prefilling syringes, and administering vaccine.
_____2. Demonstrated safe, competent, accurate performance drawing up correct dosage of vaccine.
_____3. Demonstrated good communication skills and appropriate knowledge in performing intake
history, obtaining informed consent, and providing client teaching.
_____4. Demonstrated safe and competent administration of vaccine injections.
Registered Nurse’s comments/evaluation of the COM student:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Signature of Student/Date:__________________________________________________
Signature of Registered Nurse/Date:_____________________________________
97
Practice Flu Clinic
Flow of the Clinic:
When clients enter the Health Center, they are given a clipboard with information about the
current Flu Vaccine to read and a form to fill out. When they finish their paperwork they hand it
to one of the Health Center staff who accepts their payment. Clients may pay with cash or check.
They are given a receipt with their name on it to give to the RN who will be giving them their
injection.
Though clients are given written information when they sign in, most of them don’t read it. But
we still have an opportunity to educate them as we give them their flu shot. We believe that it is
important to make people feel good about taking the time out for preventive care, and to help
them feel individualized and well cared for. This can be done in a variety of small ways: by
introducing yourself, by calling the client by name (their name is on the sheet they hand you), by
being warm and cheerful, by answering questions and providing information, and by being
skillful and efficient yet unhurried. A flu clinic can be run like an assembly line, but taking the
extra time provides added value and promotes safety.
We will practice the flu clinic as follows:
Preparation
• Sign the liability waiver.
• Wearing gloves, clean the skills lab tables with antiseptic wipes or paper towels and soap
and water.
• Wash hands.
• Using asceptic technique, open package containing syringe and needle; tighten the needle
on the syringe
• Draw up 0.5 mL of sterile, unexpired NS (check the expiration date!) in a 3 mL syringe
with a 25 gauge, 1 mL needle. Do not inject air into the vial of NS as we will not being
doing so with the flu vaccine in the clinic. Tap syringe and expel any excess air and
bubbles.
• Double check dose with the instructor or another student.
• Write your name on a piece of paper that will serve as your flu shot
registration/permission sheet. You will present to the person administering your flu shot.
• Each student will administer 1 shot and get 1 shot, alternating roles of patient/client and
RN Student.
Student Role:
• Approach the RN and hand him/her your registration/permission sheet with your name.
• Be seated.
• Be prepared to answer the RN’s questions about allergies and your experience having a
flu shot.
• Ask any questions that you may have (but make it brief—we have a lot of injections to
give!)
RN Role
Approach to the Patient
A basic approach can go something like this:
98

Welcome the client, glancing at the registration sheet they hand you in order to positively
identify them and to call them by name.
 Introduce yourself as a Student Nurse in the College of Marin RN Program.
 Invite the client to sit down in the chair. (That way, if they have a vasovagal reaction they
won’t fall down!).
 Ask the client if they have ever had a flu shot before. If so, ask if they had any problems.
If the client has never had a flu shot before, explain that we would like him/her to stay for
about 15-20 minutes after the shot just to monitor for any allergic or adverse reaction.
 Ask the client if he/she has any allergies (open ended). Then, just to be sure, ask
specifically if they have an allergy to eggs (used in the vaccine process) or to thimerosol
(a preservative also found in things like contac lens solution). People tend to answer
initially without thinking and then, as time passes, or as you probe, or just as you are
putting the needle in their arm they say, “Oh, yeah, well I am allergic to….”
 Ask the client if he/she has an arm preference for the injection (open-ended question
helps clients who may have had a mastectomy not be forced to give details.) If the client
has no preference I say that I like to use their non-dominant side and ask whether they are
right or left handed.
 Ask the client to roll up the sleeve or have the client open their shirt and pull it down to
expose their shoulder/deltoid. (We have privacy screens for women who may have worn
the wrong outfit to get a shot.)
 Reassure the nervous client. I generally reassure all clients that I will tell them before I
stick them.
IM Injection Procedure:
 Put on gloves.
 Find the site on the deltoid by asking the client to hold their arm out to their side and then
look for the center/biggest part of the deltoid. (Alternatively, find the axillary line and
then find the site on the deltoid above it.) Then tell them to let their arm hang down at
their side relaxed because this seems to decrease the pain of the injection. Find your
injection site again by measuring 2-3 finger-breadths down from the acromium process.
Swab the site vigorously (creates some counter-irritation that is distracting) with alcohol;
if you have time, let the alcohol dry because that may decrease the stinging of the
injection.
 It is an IM injection. The flu vaccine dose is 0.5 mLs. We use a 25 gauge, 1” needle
(5/8” for very skinny folks, 1 1/2” for hefty people). The information provided in our
immunization video says that it is not necessary to aspirate, but you can if you want to.
(The reason that aspiration is unnecessary is because there is apparently no danger if the
vaccine goes directly into a blood vessel.) However, if you hit a blood vessel it’s
upsetting, so just pull out and say, “I’m so sorry, there was something wrong with that
syringe (or something like that) and I will need to stick you again in another place. The
vaccine is usually pre-drawn up so you have a lot sitting next to you.


Technique: I recommend that you do not bunch the muscle up, but rather spread it
out—like making fabric taut when you are sewing so the needle slips in easier. (One
retired physician client argued with me about technique so for the sake of public
relations and his ego I did it his way, but it is not my way.)
Say “little stick,” dart the needle in at a 90 degree angle, aspirate or not, and
administer the vaccine. As you withdraw the needle say, “Okay all done—you did
great!” and put the syringe and needle in the Sharps container. (The needles are so
fine and small that most people truly don’t feel it.)
99








Apply gentle pressure to the site with a 2x2 and apply a Band-Aid. You may need to
ask the client to hold the 2x2 while you open the Band-Aid. If there is no bleeding,
you can ask the client whether or not they would like a Band-Aid.
Take off your gloves and discard.
Initial the client’s form and indicate the site of the injection (RD or LD for Right or
Left Deltoid).
Explain that they may have some local soreness at the injection site for about 24
hours and that they can take the “pain reliever of their choice” (you are a nurse and
therefore aren’t supposed to prescribe, and you wouldn’t want to tell a patient with
cirrhosis to take Tylenol, or a patient on Coumadin to take ASA. One man said to
me, “Oh I’ll go right home and have a shot of Jack Daniels!”
Explain that some people experience systemic flu like symptoms but they usually
dissipate within 48 hours. Assure the client that the virus is not alive so they have not
been given the flu and that it is probably coincidental, rather than cause and effect,
when people report getting the flu just after getting a flu shot; they were probably
already been exposed.
Explain that true allergic reactions to flu shots are rare but that if they experience
symptoms such as SOB, tightening of the throat or chest etc. they should go to ED or
call 911. (The flu shot information sheet gives them this information.)
Encourage the client to take their information sheet with them, and thank them for
coming in!
Document the flu vaccine lot number and injection site on the form and sign your
name.
100
Day #3: Wednesday, August 15th, 2012
Class #6: 1:10 PM-4:00 PM
• Inserting and Maintaining NG Tubes
• Inserting and Maintaining Foley Catheters
Review of Indications for, Placement, and Management of NG Tubes for Gastric
Decompression and Enteral Feedings
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory, the student will:
• Apply principles of medical asepsis and universal precautions.
• List four major purposes for placement of an NG tube.
• Correctly set up suction for use with an NG tube
• Demonstrate the correct procedure for inserting a NG tube
• Describe methods for assessing the correct placement of an NG tube.
• Demonstrate the correct procedure for maintaining a nasogastric decompression tube.
• Demonstrate the correct procedure for discontinuing a nasogastric tube.
• State the most reliable methods for confirming correct placement of decompression and
feeding nasogastric tubes .
• Demonstrate the correct procedure for initiating and monitoring enteral nutrition.
• Describe interventions for enteral feeding complications such as diarrhea and delayed
gastric emptying
• Demonstrate the correct procedure for administering medications through a nasogastric or
gastrostomy tube.
101
FindArticles > Nursing > Oct 2001 > Article > Print friendly
What's behind intestinal obstruction?
McConnell, Edwina A
Learn the causes and effects and help your patient maneuver the detour.
CE ANCC/AACN 1.5 Contact Hours
PICTURE YOURSELF driving along a highway and suddenly coming to a roadblock. You look for
a way around it and discover that there's no escape. Other cars gang up behind you and honk
their horns. Traffic is at a standstill.
An intestinal obstruction is a lot like that roadblock. It impairs the forward flow of digestive
juices through the small or large intestine and impedes digestion. (See How a Blockage
Impedes Absorption.) Let's review how the problem develops and how you can help a patient
who's affected by the backup.
Where and why
Most intestinal obstructions occur in the small bowel, especially in its narrowest segmen--the
ileum. Obstructions in the large bowel generally affect the sigmoid colon. The mortality rate
for acute obstruction is 10% for the small bowel and 30% for the large bowel. These rates
double when blood flow to a bowel segment stops, causing infarction.
The causes of intestinal obstruction can be neurogenic, mechanical, or vascular.
Neurogenic factors are responsible for ileus, the most common type of intestinal obstruction.
Adynamic (paralytic) ileus, a stoppage of intestinal peristalsis for more than 72 hours, is the
sympathetic nervous system's response to peritoneal insult. The severity and duration depend
in part on the type of insult.
To some degree, all patients who have abdominal surgery develop postoperative ileus because
being handled irritates the bowel. Blood, colon contents, or urine may also irritate the
peritoneum during surgery. Other causes of adynamic ileus include trauma, hypokalemia,
myocardial infarction, and vascular insufficiency.
Mechanical causes of intestinal obstruction include adhesions, hernias, diverticulitis, tumors,
gallstones, and intussusception. Adhesions and hernias account for up to 75% of small-bowel
obstructions, with adhesions posing the greater risk in adults and hernias occurring more in
children.
102
Cancer accounts for about 80% of mechanical large-bowel obstructions and most commonly
affects the sigmoid colon. Sigmoid diverticulitis and volvulus (the bowel twisting in a loop)
may also obstruct the large bowel.
Vascular causes of intestinal obstruction include complete or partial occlusion of the celiac and
mesenteric arteries. When an embolus triggers an acute mesenteric obstruction, the mortality
rate is 75%; the patient requires emergency surgery. Atherosclerosis of the mesenteric
arteries commonly causes partial occlusion, which may be asymptomatic.
Ischemia in the intestine is the most serious consequence of intestinal obstruction because it
can pave the way for peritonitis, perforation, hemorrhage, and gangrene. Ischemia makes the
bowel more permeable, so normal bowel flora Escherichia coli and Klebsiella may penetrate
the bowel wall and enter the peritoneal cavity, causing peritonitis and septic shock.
Signs and symptoms point the way
Your patient's signs and symptoms will depend on the location, cause, duration, and other
characteristics of the intestinal obstruction. (For assessment tips, see Taking Stock of the
Problem.) Here's a review of potential problems.
* Abdominal discomfort or pain. Generally, the higher an intestinal obstruction, the more
severe the pain. A small-bowel obstruction typically causes intermittent colicky pain in the
midabdomen. With partial obstruction, pain may occur after the patient eats and resolve as
digestion progresses. Mechanical obstruction of the large bowel can cause colicky pain in the
lower abdomen, but it's typically much less intense than with a small-bowel obstruction.
Adynamic ileus may cause distension and discomfort without colicky pain.
Steady, severe, localized pain may signal strangulation. If an acute ischemic obstruction isn't
treated, the patient will develop fever, leukocytosis, and shock as the ischemic bowel segment
develops gangrene.
With chronic ischemia, the patient may initially have pain 15 to 30 minutes after a large meal
if an occluded artery can't meet the body's increased oxygen needs for digestion. As occlusion
worsens, pain occurs even after small meals and eventually becomes almost continuous.
* Vomiting. An obstruction can trap up to 8 liters of gastrointestinal (GI) secretions in the
intestines. The higher the obstruction, the sooner in the disease process vomiting will occur
and the more profuse it will be. The characteristics of the vomitus provide clues about the
location of an obstruction:
• profuse clear gastric fluid, obstruction at the pylorus
• bile and mucus, a high smallbowel obstruction
• gastric contents and bile, paralytic ileus
• bile-stained,fluid with mild distension, obstruction in the proximal small intestine
• orange-brown feculent drainage, low deal obstruction.
103
• feculent vomitus indicates bacterial overgrowth proximal to the obstruction and is a poor
prognostic sign.
Distension. A hallmark of intestinal obstruction, abdominal distension becomes more
pronounced the farther down the GI tract the obstruction occurs. A small-bowel obstruction
distends the upper quadrants, and a large-bowel obstruction distends the lower abdomen.
Untreated intestinal distension is self-perpetuating: Increased pressure compromises blood
flow and impedes venous drainage; tissue edema and decreased blood flow prevent normal
re-absorption so gas builds up. Intestinal bacteria act on the stagnant bowel contents, gas
production increases, and distension worsens.
As distension worsens, intraluminal pressure exceeds abdominal pressure. Increased capillary
permeability lets large amounts of isotonic fluid move from the plasma to the distended bowel,
and trapped fluid leaks into the peritoneum. The bowel can rupture if the pressure becomes
too great.
• Altered bowel sounds. In mechanical small-bowel obstruction, intensified peristalsis causes
hyperactive bowel sounds proximal to the obstruction. If obstruction is complete, sounds
distal to the obstruction are hypoactive, quiet, or absent because the intestine is empty.
• Stool changes. The location of an obstruction affects stool size, consistency, and amount. For
example, a patient with a partial small-bowel obstruction may have normal stool and normal
output or he may have diarrhea. If obstruction is complete, he may not pass any stool at all.
Thin, ribbonlike stools may signal large-bowel obstruction, which causes progressive
constipation until finally the patient can't pass any stool. However, he may have a watery
discharge as increased proximal peristalsis forces accumulated fluid past the obstruction.
Bloody stool is rare with smallbowel obstruction but does occur with intussusception. Bloody
stool is more common in large-bowel obstructions caused by ulcerative colitis, cancer, or
diverticulitis.
Problems beyond the GI tract
Aside from the local effects of intestinal obstruction, your patient is at risk for alterations in
fluid and electrolyte levels and blood pH.
Fluid and electrolyte imbalances can occur if copious vomiting or sequestration of fluids in the
intestine prevents reabsorption of electrolyte-rich digestive fluids into the bloodstream. As a
result, extracellular fluid and plasma volume decrease, causing dehydration and
hypernatremia. Signs of dehydration include an increased hematocrit level, decreased central
venous pressure, tachycardia, and hypotension. If dehydration is severe, the patient may
develop renal insufficiency or hypovolemic shock and die.
104
Metabolic alkalosis or acidosis is another risk. Alkalosis can occur if hydrogen ions in the
gastric juices aren't reabsorbed because of obstruction high in the small bowel or if the patient
has been vomiting.
In the later stages of obstruction or when an obstruction affects the large bowel, the risk of
metabolic acidosis is greater. One reason is that the obstruction may prevent absorption of
bicarbonate in pancreatic secretions. If the patient's nutritional reserves are depleted, he may
develop ketosis that worsens the acidosis. Finally, if distension pressing on the abdominal
arteries causes bowel ischemia, anaerobic metabolism increases lactic acid production, which
worsens acidosis.
Medical or surgical intervention?
A patient's history and physical findings typically indicate the type and extent of intestinal
obstruction. (For diagnostic tests that can help shed light on his condition, see Testing for
Obstruction.) Once the type of obstruction is identified, the physician initiates medical or
surgical interventions to eliminate the obstruction, decompress the GI tract, correct systemic
fluid and electrolyte imbalances, and prevent infection.
Medical interventions, such as discontinuing oral intake, instituting nasogastric (NG) suction,
or passing an intestinal tube, are best used for an incomplete nonmechanical obstruction. For
example, adynamic ileus responds to continuous GI decompression and treatment of the
primary disease. An NG tube attached to suction can help remove fluid and gas, prevent
vomiting, and reduce the risk of aspiration, atelectasis, and pneumonia. However, for a
mechanical obstruction caused by adhesions, a hernia, or a tumor, an intestinal tube alone is
ineffective because it would stop at the point of obstruction and decompress only the proximal
portion.
Surgery is indicated to remove most vascular and mechanically caused obstructions and any
ischemic bowel tissue. For example, adhesions completely obstructing the small bowel must
be surgically removed. A complete colon obstruction also calls for surgery: A colostomy
followed by resection of the primary lesion is the procedure of choice for a left-sided
obstruction. Primary resection and anastomosis is appropriate for a lesion in the right or
transverse colon.
Before surgery, provide your patient with fluid and electrolyte replacement and insert an NG
tube for decompression. Administer broad-spectrum antibiotics as ordered if strangulation is
suspected.
Managing your patient's care
Whether your patient's intestinal obstruction is managed medically or surgically, perform the
following measures:
105
• Assess him at least every 4 hours. Document vital signs, pain assessment, mental status,
and fluid intake and output, including output from his NG tube. Weigh the patient daily. Be
vigilant for signs of early shock, such as an increased pulse rate.
• Replace fluids and electrolytes as ordered. He may require additional sodium chloride,
bicarbonate, and potassium to replace lost electrolytes and restore fluid balance. A urine
output of at least 30 ml/hour indicates adequate hydration.
• Administer medications as ordered, such as antiemetics to control vomiting and antibiotics to
reduce bacterial overgrowth in the bowel. The physician will order analgesics at a dosage
sufficient to control abdominal pain without masking signs of increasing obstruction. (He may
not order opioids because they slow peristalsis.) Offer your patient alternative pain relief
strategies, such as massage and repositioning, and relaxation techniques, such as music
therapy.
• If the patient has an NG tube, make sure it's positioned properly and the suction is
adequate. To maintain patency and drainage, irrigate the tube with 0.9% sodium chloride
solution and reposition it as needed. Monitor and document the volume, odor, and
consistency of the drainage and note changes in the degree of your patient's nausea and
abdominal distension.
• Position your patient with the head of his bed elevated to relieve abdominal pressure and
allow frequent position changes.
• Provide oral and nasal care every 2 to 4 hours to help alleviate dryness and irritation from
being N.P.O. and having an NG tube.
• Third-space fluid shifts are common with intestinal obstruction, so assess for edema.
Measure your patient's abdominal girth every 2 to 4 hours, placing the tape at the same
location each time.
• Assess your patient's level of knowledge and desire for information. Explain his tests,
procedures, and planned care. If he receives a cancer diagnosis or needs a colostomy,
provide emotional support and contact the appropriate services, such as an ostomy nurse or
the social service department.
• As soon as your patient's condition stabilizes, help him out of bed. An upright position
relieves abdominal pressure and eases breathing. Activity also helps reestablish peristalsis
and hastens recovery.
• Keep the physician informed of your patient's status. Immediately report signs and
symptoms of bowel strangulation, such as vomiting, increasing distension, temperature
elevation, or pain that changes from cramping to constant. Report blood levels of sodium,
potassium, bicarbonate, and blood pH, as well as changes in mental status, vital signs, urine
output, and the amount of NG tube output.
• Tailor discharge teaching to your patient's needs. If he's had surgery, teach him about
wound healing and reestablishing a normal diet. Tell him how to prevent constipation with
fiber-rich foods, adequate fluids, and exercise.
Road to recovery
When an intestinal obstruction detours your patient's digestion, you can help him avoid
problems while he's on the road to recovery.
106
SELECTED REFERENCES
• Phipps, W., et al. (eds): Medical-Surgical Nursing: Concepts & Clinical Practice, 6th edition.
St. Louis, Mo., Mosby, 1999.
• Porth, C.: Pathophysiology: Concepts of Altered Health States, 5th edition. Philadelphia, Pa.,
Lippincott Williams & Wilkins, 1998.
• Shelton, B.: "Intestinal Obstruction," AACN Clinical Issues. 10(4):478-491, November 1999.
• Silen, W.: "Acute Intestinal Obstruction," in Harrison's Principles of Internal Medicine, 14th
edition, A. Fauci, et al. (eds). New York, N.Y., McGraw-Hill, 1998.
SELECTED WEB SITES
• Mayo Foundation for Medical Education and Research: http://www.mayohealth.org/home
• National Institute of Diabetes and Digestive and Kidney Diseases:
http://www.niddk.nih.gov/index.htm
BY EDWINA A. McCONNELL, RN, PHD, FRCNA, Independent Nurse Consultant, Gorham, ME
Copyright Springhouse Corporation Oct 2001
Provided by ProQuest Information and Learning Company. All rights Reserved
107
Preparation for Caring for Patients with NG Tubes
1. What is/are the major purpose(s) of an NG tube?
2. List the three major types of intestinal obstructions and give examples.
i.
ii.
iii.
3. Where do most obstructions in the small intestine and the large intestine occur
4. List major signs and symptoms of intestinal obstruction in the small intestine.
5. List major signs and symptoms of intestinal obstruction in the large intestine.
6. Why are patients at risk for metabolic acidosis and alkalosis, and what monitoring
and other patient care does the nurse need to provide.
7. What is the advantage of the use of a PEG tubing and for whom are they indicated?
108
NG Tube Practice
1. Demonstrate the procedure for placing an NG tube to suction:
a. Select and gather the equipment: towel; basin; stethoscope; flashlight;
tube (purpose and size); irrigation syringe set up; lubricant; tape; Tincture
of Benzoin (is it still used?!);safety pin and rubber band; cup and straw
with water;
b. Position the patient;
c. Explain the procedure;
d. Ask about nasal surgeries or problems and assess the nares with a
flashlight;
e. Measure (nose to ear lobe to below xyphoid) and mark tube for placement;
f. Lubricate the tube (consider Lidocaine gel);
g. Insert the tube gently and advance;
h. Assess to make sure the tube isn’t curling at the back of the throat
i. Ask the patient to drink from a glass of water and swallow as you try to
advance the tube
j. Assess for correct placement by aspiration and checking of pH, injecting
air, and/or getting a CXR;
k. Secure the tube with the special tapes or using ; connect the tube to suction
(or get CXR placement confirmation and then attach to a feeding that is
infusing on the pump).
2. Provide routine care for a patient with an NG, including assessing for placement,
flushing, giving oral care.
3. Demonstrate the procedure for setting up an NG feeding with ½ strength Jevity @
30 mls/hour
4. Reposition a patient who has an NG feeding tube.
5. Disconnect the NG tube to send the patient to radiology.
6. Set up a new suction canister
7. Mark and calculate NG output and/or empty the contents of the cylinder and
chart.
8. Calculate and replace NG output mLper mL via IV
109
NG Tube Case Study
You are an RN working on the day shift on the med/surg unit. You receive a new
admission, Mr. John Madison, 45 years old, from the ED. The physician has written the
following admitting orders:
3/7/11, 10:00 AM
Admit to Medicine, Hospitalist
Dx: R/O SBO
Physician Orders:
 NPO
 Insert Salem Sump NG tube and connect to LCWS
 On 3/8/11 clamp NG x 3 hours, then attach to suction X 1hour; repeat cycle.
Questions:
1.
2.
3.
4.
What are some of the possible causes for a SBO?
How is the diagnosis made?
What is the usual medical and surgical treatment for SBO?
What physician additional orders do you need?
 Labs
 Diagnostic studies
 Meds
 IVs
 Activity
5. What nursing diagnoses are associated with this diagnosis and what nursing interventions
will you perform?
110
Case Studies on Urinary Elimination
1. Your patient has had no urine output this shift. You are concerned about urinary retention.
 How you would assess the bladder?
 What signs/symptoms would indicate urinary retention?
 What signs/symptoms might indicate a pre-renal or intra-renal problem?
 What are some of the causes of urinary retention?
 What interventions do you anticipate performing if the patient is determined to have
urinary retention?
 What interventions do you anticipate performing if the patient has a pre-renal or intrarenal problem?
2. Your patient has had only 150cc of urine output in the past 8 hours.
 Is this within normal limits? What information do you need to determine this?
 What are some reasons for decreased urine output? (Consider pre-renal, renal, and postrenal causes.)
3. Your patient is a 58 year old male who has had surgery for prostate cancer. He will be
discharged home with a bladder catheter and a leg bag.
 Make a teaching plan for the patient regarding the continuing need for an indwelling
urinary catheter, care of a foley catheter drainage bag and a leg bag, and signs/symptoms
to notify the physician for. Role play the teaching plan.
4. Your patient is a 35 year-old female who has bladder dysfunction due to Multiple Sclerosis.
She has urinary retention and will be discharged with an order for intermittent bladder
catherization every 4-6 hours.
 Make a teaching plan.
 Role play the teaching plan.
 Consider why the health care provider did not order an indwelling catheter.
 Consider the similarities and differences between home and hospital intermittent
catherization.
111
Day #4: Thursday, August 16th, 2012
Class #7: 8:10 AM-12:00 Noon
 Simulation
 Wound Care/Dressing Changes
 Airways and Suctioning
Students will divide into two groups. One group of students will participate in a Sim during the
morning class, while the other half practices skills in the skills lab; the groups will reverse during
the afternoon class.
•
•
Group 1: Simulation in the Sim Lab (subject to availability)
Group 2: Wound care and central line dressing change
Wound Care/Dressing Changes
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory, the student will:
• Demonstrate open sterile gloving
• Describe and demonstrate the principles of maintaining a sterile field when performing a
sterile dressing change
• Demonstrate a central line dressing change using sterile technique
•
•
•
•
Identify various types of wound care products, dressings, and drains
Assess a hypothetical patient’s risk for skin breakdown utilizing the Braden scale
Measure, stage, and document a pressure ulcer
Perform a wet-to-moist dressing change
Artificial Airways (ET and Trach Tubes) and Suctioning
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory, the student will:
• Discuss indications for endotracheal and tracheostomy airways.
• Describe potential complications associated with endotracheal intubation.
• Describe evidence-based recommendations for preventing ventilator-associated
pneumonia (VAP).
• Demonstrate correct procedure for suctioning an endotracheal or tracheostomy airway
using open and closed systems.
• Discuss indications for chest tube insertion.
• State the purpose of a chest drainage system.
• Describe assessment of a patient with a chest tube.
• Demonstrate setting up a disposable chest drainage system.
• Document care in the medical record
112
Day #4: Thursday, August 16th, 2012
Class #8: 1:10 PM-4:10 PM
 Simulation
 Wound Care/Dressing Changes
 Airways and Suctioning
•
•
Group 1: Wound care and central line dressing change/
Group 2: Simulation in the Sim Lab (subject to availability)
Wound Care/Dressing Changes
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory, the student will:
• Demonstrate open sterile gloving
• Describe and demonstrate the principles of maintaining a sterile field when
performing a sterile dressing change
• Demonstrate a central line dressing change using sterile technique
•
•
•
•
Identify various types of wound care products, dressings, and drains
Assess a hypothetical patient’s risk for skin breakdown utilizing the Braden
scale
Measure, stage, and document a pressure ulcer
Perform a wet-to-moist dressing change
Artificial Airways (ET and Trach Tubes) and Suctioning
Student Learning Outcomes
After completing this Nursing Theory and Clinical Application Laboratory, the student will:
• Discuss indications for endotracheal and tracheostomy airways.
• Describe potential complications associated with endotracheal intubation.
• Describe evidence-based recommendations for preventing ventilator-associated
pneumonia (VAP).
• Demonstrate correct procedure for suctioning an endotracheal or tracheostomy airway
using open and closed systems.
• Discuss indications for chest tube insertion.
• State the purpose of a chest drainage system.
• Describe assessment of a patient with a chest tube.
• Demonstrate setting up a disposable chest drainage system.
• Document care in the medical record
• Discuss indications for tracheostomy care.
• Compare and contrast tracheostomy care using sterile technique and modified sterile
technique.
113
•
•
•
•
•
Discuss possible causes of acute dyspnea in a patient with a tracheostomy tube.
Discuss assessment of tracheostomy cuff pressure.
Demonstrate correct procedure for performing tracheostomy care on a mannequin.
Develop a generic teaching plan for a patient with a tracheostomy who will be discharged
to home.
Document tracheostomy care in the medical record.
114
Assessing and Promoting Skin Integrity
and Wound Healing
I. Principles of Medical and Surgical Asepsis:
(Adapted from Potter, Patricia A. and Perry, Anne Griffin. Fundamentals of Nursing, 5th edition. St.
Louis: Mosby, Inc., 2001.)
Definitions:
 Asepsis is defined as the absence of disease-producing (pathogenic) organisms. The two types of
aseptic technique the nurse utilizes are medical and surgical asepsis.


Medical asepsis, or clean technique, includes procedures used to reduce the number of and
prevent the spread of microorganisms. Hand washing, barrier techniques, and routine
environmental cleaning are examples of medical asepsis.
Surgical asepsis, or sterile technique, includes procedures use to eliminate all microorganisms
from an area. Sterilization destroys all microorganisms and their spores. Sterile technique is
practiced by nurses in the operating room, labor and delivery, and procedural areas where sterile
instruments and supplies are used.
Principles of Surgical Asepsis:
1. All items used within a sterile field must be sterile.
2. A sterile barrier that has been permeated by punctures, tears, or moisture must be considered
contaminated.
3. Once a sterile package is opened, a 2.5cm (1 inch border around the edges is considered unsterile.
4. Tables draped as part of a sterile field are considered sterile only at table level.
5. If there is any question or doubt of an item’s sterility, the item is considered to be unsterile.
6. Sterile person or items contact only sterile areas; unsterile persons or items contact only unsterile areas.
7. Movement around and in the sterile field must not compromise or contaminate the sterile field.
8. A sterile object or field out of the range of vision or an object held below a person’s waist is
contaminated.
9. A sterile object or field becomes contaminated by prolonged exposure to air; stay organized, and
complete any procedures as soon as possible.
II. Skin Integrity and Principles of Wound Healing
(Adapted from Potter, Patricia A. and Perry, Anne Griffin. Fundamentals of Nursing, 5th edition. St.
Louis: Mosby, Inc., 2001.)
Layers of the Integument:
 Stratum corneum
 Epidermis
 Dermis
Factors Affecting Pressure Ulcer Formation and Wound Healing:
 Shearing Force
 Friction
 Moisture
 Nutrition
 Infection
 Impaired Peripheral Circulation
 Age
Types of Wounds:

Abrasion
115
 Laceration
 Puncture
 Incision
Phases of Wound Healing:
 Inflammatory Stage/Reaction
 Proliferative Stage/Regeneration
 Maturation Phase/Remodeling
 Granulation/wound contraction
Types of Wound Healing:


Primary intention: No loss of tissue. Edges of a clean surgical incision remain close together
Secondary intention—Wound has some loss of tissue., e.g., burns, pressure ulcers, severe
lacerations. Wound edges do not approximate, but fill in with scar tissue.
 Tertiary intention—Wound healing is by delayed primary intention or closure. Healing by tertiary
intention occurs when surgical wounds are not closed immediately but left open for 3-5 days to
allow edema or infection to diminish. Wound edges are later sutured or stapled closed.
Complications of Wound Healing:
 Hemorrhage/bleeding
 Infection
 Evisceration
 Dehiscence
 Fistula
 Delayed wound healing
 Necrosis
Factors Influencing Wound Healing:
 Aging
 Prematurity
 Obesity
 Diabetes
 Compromised circulation
 Poor nutritional state
 Immunosuppressive drugs
 Irradiation in area around wound
 High levels of stress
 Steroids
III. Pressure Ulcers
Prevention of Pressure Ulcers:






Early identification of clients at risk: Norton Scale, Braden Scale
Pressure management
Hygiene and skin care
Positioning
Utilize appropriate support surfaces: pressure relieving and pressure reducing
Education
Management of Pressure Ulcers:
1. Assess and document (consider using “Pressure Sore Status Tool,” Ayello’s Assessment or simple
staging)
PSST: Pressure Sore Status Tool (c. 1990 Barbara Bates-Jensen)
116










Size
Depth
Edges
Undermining
Necrotic Tissue
Exudate/Drainage: Type and amount
Skin Color Surrounding Wound
Peripheral Tissue edema and induration
Granulation Tissue
Epithelization
Staging of Pressure Ulcers
 Stage I: Observable alteration of intact skin: skin temperature, tissue, sensation
 Stage II: Partial thickness skin loss involving epidermis and or dermis. The ulcer is superficial
and presents clinically as an abrasion, blister, or shallow crater.
 Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may
extend down to but not through underlying fascia. The ulcer presents as a deep crater or without
undermining adjacent tissue
 Stage IV: Full thickness skin loss with extensive destruction tissue necrosis, or damage to muscle
bone or supporting structure e.g., tendon, joint capsule.
2. Develop and Implement plan of care
3. Evaluate
4. Revise plan as necessary
Types of Wound Drainage:
 Serous: clear, watery plasma
 Sanguineous—indicates fresh bleeding
 Serosanguineous—paler, more watery drainage than sanguineous drainage
 Purulent—thick yellow, green, or brown drainage. (Collecting a specimen may be necessary.
Never collect a wound culture sample from old drainage. Clean wound first with NS to remove
skin flora.
IV. Drains:
Drains are used to evacuate drainage from wounds in order to avoid tension on sutures and keep wound
layers closed Common types of drains include:
 Penrose
 Jackson-Pratt
 Drainage evacuators, e.g. Hemovac
V. Wound Care
Cleansing Wounds
 Cleanse in the direction from the least contaminated area, such as the wound or incision, to the
surround skin, or from a drain site to the surrounding skin.
 Use gentle friction when applying solutions locally to the skin.
 Irrigation uses mechanical force of a stream of solution to loosen particulate matter on the wound
surface. Cleanse in direction from the least contaminated area to most contaminated area. Use a
35cc syringe with a 19 gauge angiocath with needle removed.
 The suture line is the least contaminated area and is always cleansed first. Start at center and work
toward one end. All other cleansing involves moving from one end to the other on each side of
the incision on the skin surrounding the incision, working in straight lines and moving away from
the suture line with each successive stroke.
117



Drains are cleansed using a circular stroke, starting with the area immediately next to the drain and
working outward.
Wounds should be cleansed initially and at each dressing change with non-cytotoxic solutions
using sterile gauze or by irrigation.
Pressure ulcers should be cleansed only with wound cleanser such as normal saline or some
commercial wound cleansers that are not cytotoxic (will not damage or kill cells such as
fibroblasts and healing tissue). Skin cleaners are not the same as wound cleansers. Infected or
necrotic ulcer wounds should not be cleaned with skin cleaners or antiseptic agents. (Some
commonly used solutions that are cytotoxic and therefore should not be used to clean granulating
wounds are Dakins solution (sodium hypochlorite solution), acetic acid, povidone iodine,
hydrogen peroxide.)
Products Used for Closure of Wounds:
 Staples
 Retention sutures--steel
 Sutures—silk, cotton, linen, nylon, Dacron
 Steri-Strips (sterile butterfly tapes)
 Adhesive
Purpose of Dressings:
 Protect wound from injury
 Maintain a moist environment to speed healing
 Prevent contamination
 Prevent spread of microorganisms
 Reduce physical and psychological discomfort
 Absorb drainage
 Control bleeding (pressure dressings)
 Fill dead space
 Support and splint the wound site
Dressing Materials:
The type of dressing used depends on whether the goal of wound care is debridement or wound healing.
Examples include:








Dry dressings: Used for abrasions and non-draining postoperative (primary intention) healing
incisions. Not appropriate for an open wound that is healing by secondary intention. If a dry
dressing adheres to a wound, the dressing should be moistened with sterile normal saline or sterile
water before removing the woven gauze.
Wet to moist/damp to damp/moist to moist dressings: Used in clean, granulating wounds to
maintain the moist environment needed for wound healing.
Wet to dry dressings: Used for wounds requiring mechanical debridement.
Telfa dressing: Used when dressing needs to be non-adherent.
Hydrocolloid dressings (DuoDERM, Comfeel, Restore, RepliCare): Hydrocolloid dressings
provide a moist environment for wound healing while facilitating the softening and subsequent
removal of wound debris. Provide an occlusive, protective barrier that absorbs drainage from the
wound into the dressing.
Hydrogel dressings (Vigilon, Biolex, NuGel IntraSite Gel, Saf Gel) have high moisture content
causing them to swell and retain fluid. Used over clean, moist, or macerated tissues. Provide a
non-adherent, protective barrier with the ability to absorb wound drainage.
Foam dressing (e.g., Allevyn, Lyofoam, Reston, EpiLock IOPATCH, CURAFORM) absorb light
to heavy amounts of exudates, are conformable/can be made to fit a wound.
Thin self-adhesive elastic film dressing (OpSite, Bioclusive, blisterfilm, Acu-derm, Tegaderm,
PROCLUDE, Polyskin): Provide protection of high-friction areas; serve as a synthetic permeable
118
membrane that acts a temporary second skin. Clear adherent non-absorptive, polymer-based
dressing that is permeable to oxygen and water vapor but not to water. Moisture retentive, nonabsorptive.
Products to Secure Dressings
 Tapes of various sizes and materials
 Montgomery straps
 Stockinet
 Kerlix wrap
 Binders
Vacuum Assisted Closure:
Vacuum assisted closure uses controlled negative pressure on wounds. Negative pressure stretches and
distorts the cells within the wound, pulling them close together. It is believed that this distortion causes the
epithelial cells to multiply rapidly and form granulation tissue. Biochemical mediators stimulate the
growth of new blood vessels to improve circulation to the region. Good results with VAC o chronic
wounds such as stasis ulcers and Stage III and Stage IV pressure ulcers.
Documentation:
After visual inspection and palpation of the wound, and completion of the wound care, the nurse
documents:
 Location of wound
 Measurement of wound (length, width, depth)
 Appearance of wound: wound edges (clean/well-approximated vs. open /poorly approximated),
color of wound bed, presence of swelling or inflammation
 Drainage characteristics: color, odor, amount, consistency
 Presence of drains and amount of drainage
 Presence of wound closure devices (e.g., retention sutures, Steri-Strips
 Epithelization, granulation, wound contraction
 Presence of pain and use of analgesics
 Tolerance of client to procedure
Photographic documentation is often used.
119
BRADEN SCALE
for Predicting Pressure Sore Risk
PATIENT’S NAME _________________________________DATE OF ASSESSMENT ____________
EVALUATOR’S NAME_____________________________________
Assessment of 7 areas
1. Sensory Perception (1-4) =
1. Moisture (1-4) =
2. Activity (1-4) =
3. Mobility (1-4) =
4. Nutrition (1-4) =
5. Friction and Shear (1-3) =
TOTAL SCORE:
_____
_____
_____
_____
_____
_____
_____ (Low score=High Risk; High Score=Low Risk
SENSORY PERCEPTION: Ability to respond meaningfully to pressure-related discomfort
_____1. Completely Limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to
diminished level of consciousness or sedation OR
Limited ability to feel pain over most of body
_____2. Very Limited: Responds only to painful stimuli. Cannot communicate discomfort except by
moaning or restlessness OR
Has a sensory impairment which limits the ability to feel pain or discomfort over 2 of body.
_____3. Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or
the need to be turned OR
Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
_____4. No Impairment: Responds to verbal commands. Has no sensory deficit which would limit ability
to feel or voice pain or discomfort..
MOISTURE: Degree to which skin is exposed to moisture
_____1. Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is
detected every time patient is moved or turned.
_____2. Very Moist: Skin is often, but not always moist. Linen must be changed at least once a shift.
_____3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately
once a day.
_____4. Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals.
ACTIVITY: Degree of physical activity
_____1. Bedfast: Confined to bed.
_____2. Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must
be assisted into chair or wheelchair.
_____3. Walks Occasionally: Walks occasionally during day, but for very short distances, with or without
assistance. Spends majority of each shift in bed or chair
_____4. Walks Frequently: Walks outside room at least twice a day and inside room at least once every
two hours during waking hours
MOBILITY: Ability to change and control body position
_____1. Completely Immobile: Does not make even slight changes in body or extremity position without
assistance
_____2. Very Limited: Makes occasional slight changes in body or extremity position but unable to make
frequent or significant changes independently.
_____3. Slightly Limited: Makes frequent though slight changes in body or extremity position
independently.
_____4. No Limitation: Makes major and frequent changes in position without assistance.
120
NUTRITION: Usual food intake pattern
_____1. Very Poor: Never eats a complete meal. Rarely eats more than a of any food offered. Eats 2
servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid
dietary supplement OR
Is NPO and/or maintained on clear liquids or IV=s for more than 5 days.
_____2. Probably Inadequate: Rarely eats a complete meal and generally eats only about 2 of any food
offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a
dietary supplement OR
Receives less than optimum amount of liquid diet or tube feeding
_____3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products
per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR
Is on a tube feeding or TPN regimen which probably meets most of nutritional needs
_____4. Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more
servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
FRICTION & SHEAR
_____1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding
against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with
maximum assistance. Spasticity, contractures or agitation leads to almost constant friction
_____2. Potential Problem: Moves feebly or requires minimum assistance. During a move skin
probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good
position in chair or bed most of the time but occasionally slides down.
_____3. No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle
strength to lift up completely during move. Maintains good position in bed or chair.
_____Total Score (maximum score 23=low risk; minimum score 7=high risk)
Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved
121
Institute for Healthcare Improvement
Prevention of Central Line-Associated Bloodstream Infection
Intervention–Central Line Bundle
The power of a “bundle” is that it brings together those scientifically grounded concepts that are
both necessary and sufficient to improve the clinical outcome of interest. The focus of
measurement is the completion of the entire bundle as a single intervention, rather than
completion of its individual components.
The “central line bundle” has five components:
1. Hand hygiene
2. Maximal barrier precautions upon insertion
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection with avoidance of the Femoral Vein for Central Venous
Access in Adults
5. Daily review of line necessity with prompt removal of unnecessary lines.
The various components of the central line bundle are all part of a broader guideline for the
prevention of CR-BSIs developed by the Centers for Disease Control and Prevention (CDC).
• O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of
intravascular catheter-related infections. MMWR Morb Mortal Wkly Rep. 2002;51(RR10):1-29.
ICUs that have implemented multifaceted interventions similar to the central line bundle have
nearly eliminated CR-BSIs.
• Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream
infections in the intensive care unit. Crit Care Med.2004;32:2014-2020.
Reference: Institute for Health Care Improvement
http://www.ihi.org/IHI/topics/criticalcare/intensivecare/changes/implementthecentrallinebundle.htm
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Open and Closed Suctioning,
Tracheostomy and Endotracheal Tubes, Cuff Pressure Measurement
and Prevention of Complications
Types of Suctioning
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•
Oropharyngeal suctioning (Yankaur suction catheter or regular suction catheter)
and deep suctioning
Deep nasotracheal/orotracheal/ suctioning
o Open suctioning for patients who are not intubated
o Closed suctioning/inline suctioning for patients who are intubated with
either an endotracheal tube (short-term, ~14 days) or a tracheostomy tube
General Guidelines
• There are portable suction equipment and. standard wall suction set ups. Both
require vaccum and a regulator, a suction catheter, tubing to connect the vacuum
to the suction canister, and tubing to connect the suction catheter to the canister
• Suction pressure for adults is usually between 80 and 120
• Suction should be constant not intermittent; intermittent cycles according to the
machine settings so the RN is not able to control the suctioning with their finger
over the hole in the catheter
• Suction catheters are sized by French; the larger the French, the larger the
catheter. There are adult, pediatric, neonatal sizes. Use a catheter large enough to
suction secretions but small enough to fit into the tracheostomy tube an allow
airflow during suctioning. To compute the largest safe catheter size, double the
tracheostomy size. For example, a #6 inner diameter tracheostomy tube can
accommodate up to a #12 French suction catheter.
• We caution you about suctioning, but don’t be so afraid of suctioning that you
ignore the patient’s needs; better to do something as best you can while
maintaining sterility as much as possible than to let the patient suffer. However,
also realize that the more you suction, the more you need to suction because the
catheter causes irritation to the mucous membranes which results in increased
sputum production.
• When patients are in CHF/pulmonary edema suctioning does not improve their
situation because fluid/secretions are in the alveoli, and suctioning clears only the
maintstem bronchi and trachea. Unfortunately, you cannot “vacuum” the alveoli
(even though you would like to!) Problems with CHF and pulmonary edema will
call for other interventions such as medications.
• Don’t rely on a timetable; suction when indicated and when secretions are most
likely to be in your patient’s upper airway such as after bronchodilator therapy or
chest PT
• Scopolamine or atropine rather than suctioning is appropriate for death rattle.
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Questions
1. What are the differences between endotracheal tubes and tracheostomy tubes?
Why is endotracheal tube only for short-term use?
2. How do you know when a patient needs to be suctioned?
Student Practice
1. Demonstrate setting up suction for a patient who needs nasotravheal suctioning:
• vaccum regulator
• connecting tubing from the vaccum regulator to the canister
• canister
• connecting tubing to the canister to the suction catheeter
• appropriate sized suction catheter set with container and glove
• water soluble lubricant
• NS
• Nasal trumpet
2. Demonstrate open suctioning
a) Gather equipment:
• Sterile NS to lubricate and rinse catheter: date/signature (good for 24 hours)
• Catheter kits with boat, gloves, and catheter.
• Ambu bag and O2 regulator and tubing
b) Have one student read the skill aloud to class as you demonstrate.
i) Begin by assessing need for suctioning: assess RR, work of breathing, breath
sounds, , O2 sat, etc.
ii) Identify patient and explain procedure
iii) Wash hands, put on gloves and protective eyewear and mask
iv) Pre-oxygenate patient—press button on ventilator to delivery 100% oxygen,
or administer 3 hyperinflation breaths using a manual resuscitation bag
connected to 10-15 liters/minute of oxygen
v) Turn on suction to continuous; set suction between 80 and 120 mm Hg; test by
putting finger over tubing
vi) Put on sterile gloves. Pick up suction catheter with dominant hand and free
end of connecting tubing with non-dominant hand and attach them
vii) Advance catheter without applying suction until you meet resistance or patient
coughs; then withdraw catheter about 1 cm.
viii) Apply suction intermittently (controversial) rotating the catheter while
withdrawing it (controversial). Suction for no more than 10 seconds. Flush
catheter and tubing with sterile saline.
ix) If patient needs additional suctioning, repeat process; suction only 2x with
same catheter then discard.
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x) Can such mouth with same suction catheter after completion of
nasotracheal/orotracheal/endotracheal/tracheal suctioning
3. Demonstrate closed/inline suctioning for a patient with a trach
a) Pre-oxygenate with 100% O2 by hitting switch on ventilator
b) Catheter is within sleeve so it remains sterile and is always available for frequent
suctioning, but RN should still wear gloves
c) Stabilize T-piece and advance catheter; be careful to avoid trauma to the carina.
When feel the carina, pull back ~1/2 inch and then press down on blue button of
suction catheter in order to suction; controversial whether to start/stop, twist
catheter as your remove it etc. Definitely suction for no more than 10-15 seconds-hold your own breath
d) Clean the catheter by ensuring that catheter is pulled all the way out and then
squeeze bullet of NS while you hold catheter button down. Can also fill a syringe
with sterile NS and attach that instead of a bullet.
e) Controversial about NS lavage: for patient it feels like aspirating; does stimulate
cough but doesn't truly break up mucous secretions; but sound makes us feel
good.
4. Describe the purpose of the endotracheal and tracheostomy tube cuffs, and
demonstrate inflating and deflating a cuff using the trach pilot line/”pillow”
a) What is the purpose of the cuff?
b) What is the purpose of the trach pilot line/”pillow”
c) When should cuff be inflated and when deflated?
d) Why do we check trach cuff pressure?
e) How much air should be in the cuff or how much pressure should be the cuff be
exerting
f) What is the normal range for trach cuff pressure?
g) What is the major complication we are trying to avoid?
h) The RN on the last shift documented that the patient’s trach cuff pressure was
20mm Hg. Demonstrate how you would measure the patient’s current trach cuff
pressure—find the minimal occluding volume, using the clear plastic model,
sphygmomanometer, and a 10 ml syringe with 3-way stopcock.
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