Advanced Nursing Skills Day
Keith Rischer RN, MA, CEN
1
Today’s Objectives…
IV Meds
 In a simulated clinical situation, demonstrate hanging an IV
piggyback and calculate correct rate and set up on Horizon pump.
 In a simulated clinical situation, demonstrate calculation to safely
administer IV medication bolus per PDA and administer.
 In a simulated clinical situation, calculate correct dose of Heparin
bolus and drip rate per SCH policy and protocol.
Carb Counting-Insulin
 In a simulated clinical situation, calculate the correct dose of insulin
to administer based on CHO intake at meal.
 In a simulated clinical situation, based on sliding scale calculate the
correct dose to administer and demonstrate correct technique to mix
Regular and NPH or Lente.
 Demonstrate correct technique to administer insulin via insulin pen.
2
Today’s Objectives…
IV Insertion
 State the veins of the hands and arms that could be used for
intravenous insertion for all ages.
 Implement measures to promote venous distention.
 State potential complications when initiating IV therapy and measures
to prevent complications.
 Demonstrate IV insertion, dressing of the IV site and application of a
saline lock safely with the simulation arm.
Central-Arterial Lines
 Identify indications for placement of central/arterial lines.
 Identify significance of CVP and normal ranges
 Describe nursing responsibilities and priorities for the client with
central/arterial lines.
 State potential complications and measures to prevent complications
with central/arterial lines.
3
Today’s Objectives…
Chest Tubes
 Identify indications for placement of chest tubes.
 Describe the principles and patho that support the use of chest tubes.
 Describe nursing responsibilities and priorities for the client with chest
tubes.
 Identify significance of bubbling in the waterseal chamber and what
assessments are required by nurse.
ET-Ventilator
 Identify indications for placement of endotracheal tube/ventilator.
 Describe nursing responsibilities and priorities for the client during
intubation with ventilator.
 Identify principles of ABG interpretation and relevance to ventilator
management.
 Describe different modes of ventilation and significance of ventilator
settings.
 State potential complications and measures to prevent complications
with ventilator.
4
Insulin & Carb Counting

Time action profiles of…
•
•
•
•
Novolog
Regular
Lente
NPH
Mixing
 Insulin pen

5
IV Med Administration Principles
COMPATIBILITY
 Correctly calculate rate of IV push to q1530 seconds
 Label all syringes brought into room once
aspirated
 Assess site
 Aseptic technique w/port
 Knowledge of most common side effects

6
IV Meds

IV Push
•
•

IV Piggyback
•
•

Morphine 4mg/1cc
PDA 1mg per minute…how much volume q minute
Rocephin 1Gram in 50cc bag
Give over 30”-what do you set IV pump to infuse
IV Heparin
•
•
215 lbs.
70u/kg bolus….15u/kg hourly rate
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SAVE that Line!
S: Scrupulous hand hygiene
•
Before and after contact w/vascular access device and
prior to insertion
A: Aseptic technique
•
During catheter insertion & care
V: Vigorous friction to hubs
•
With alcohol whenever you make or break a connection
to give meds, flush
E: Ensure patency
•
Flush all lumens w/adequate amount of saline or
heparin to maintain patency per hospital policy
8
IV Insertion:Venous Selection

Start distally
•



LE not routinely used in
adults due to risk of
embolism/thromboplebitis
Visualize veins if possible
Avoid areas of flexion
Use smallest IV possible
•
•
22 ga. (blue) Standard
Ensure vein can handle
size of jelco
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Principles of IV Therapy
BP cuff-keep on opposite arm if
continuous IV infusion
 Do not use PIV same side as pt. who has
had axillary node dissection, dialysis shunt
 Hair removal if needed-use clippers or
scissors

10
IV Insertion
1.
2.
3.
4.
5.
6.
7.
8.
Chloroprep
1.
Prep for at least 10 seconds
2.
Allow to air dry before insertion
Distal/circumferential traction
Low approach angle…bevel up
directly on top of vein
Upon blood flash go level and
advance 1/8”
Slide jelco in slowly
Pressure on vein 1” distally once
removed stylette
Stabilize PIV securely with tape or
Stat-lock if available (preferred)
Transparent dressing
11
IV Therapy Complications: Infiltration

Progression
•
•
Skin blanched…edema<1” in any direction…cool to
touch…may or may not have pain
Edema 1-6” in any direction

•
•
At this level or greater requires incident report
Gross edema >6” in any direction…mild to moderate pain
Skin tight, leaking, discolored, bruised or swollen, deep
pitting edema, circulatory impairment
12
Infiltration/Extravasation: Nursing Priorities




DC infusion immediately
Document…notify MD
Ongoing assessment of CMS and appearance
Follow guidelines depending on if vesicant
medication
•

Dopamine & vasopressors most common
Extravasation injuries are a sentinel event
13
IV Therapy Complications: Phlebitis

Progression
•
•
•
•
Initially redness at site with
or without pain
Pain at access site site
w/redness
In addition red
streak…palpable venous
cord
Palpable venous cord >1”
and purulent drainage
At first sign of phlebitis IV
must be DC’d and event
documented
14
IV Therapy Complications:Infection

Prevention
•
•

Use aseptic technique when accessing ports and
upon insertion
Monitor site and integrity of dressing
Infection Present
•
•
Blood cultures from catheter and separate venous
site
Monitor for sepsis
15
Site Assessment
•
•
•
•
•
Assess tenderness by palpation
Redness
Moisture/leaking
Swelling distally if continous infusion
Dressing labeled
 Date
inserted
 Size of IV jelco
 Initials of nurse
•
If >4 days since inserted DC and restart
16
Nursing Responsibilities




Frequent IV site assessment
Be aware of medications that irritate vein
Vigilant with meds that can cause cellular
damage if infiltrate
Infiltrated?
•
•
•
•
Stop IV immediately
Elevate extremity
Warm packs
Check w/pharmacy if additional measures needed
17
Nursing Responsibilities

Primary/secondary tubing changed per
hospital policy
•
•
Q 4 days (ANW)
TPN/Lipids changed q day
Intermittent IVPB tubing changed q 24 hours
 When IV dc’d assess site and make sure
jelco tip intact
 If Heparin used to flush central access
device…assess for HIT

18
PIV Troubleshooting

Pain
•

Distal occlusion alarm on IV pump
•
•

AC site-extend arm
Flush site and assess for occlusion
Leakage
•

Assess site…always a red flag and IV should be DC’d
unless has irritating solution infusing
Make sure is not from loose attachment to jelco
? Infiltration
•
•
Flush IV slowly w/5-10cc NS
Assess for leakage/swelling/pain
19
Central Lines: PICC

Indications
•

Length of therapy
Complications
•
Phlebitis


Measure mid arm
circimference and
document
Nursing Priorities
•
•
•
Dressing intact
Site assessment
Note how many cm.
out to hub & validate
20
Central Lines: Implanted Port
Accessing ports
 Access needle/tubing changed q 7days
 Dressing changed q 7 days
 Site assessment

21
Central Lines: Non-Tunneled

Indications
•


Length of therapy
Complications
Nursing Priorities
•
Risk of Infection




Insertion
Accessing device
Systemic infection
Remove as soon as
possible
22
Arterial Lines



Locations
Indications
Nursing priorities
•
•
•
•
Site care
Pressure bag
CMS
Complications



Infection
Infiltration
Bleeding
23
Blood Product Administration
Minimum 22 g.(blue hub) IV-prefer 20g.
(pink) or 18g. (green)
 Informed consent obtained
 Administer within 30” once received from Blood Bank
 Blood tubing with filter-use NS to prime/flush

•
•
•
•
Validate pt., type of blood product, expiration date, blood tag #
VS before, 15” after initiation, end of each
Infuse PRBC’s over 2 hours (appx 300cc/unit)
Consider Lasix chaser if hx CHF
24
Complications Blood Products

Circulatory Overload
Acute Hemolytic Reaction
• Chills, fever, flushing, tachycardia, SOB,
hypotension, acute renal failure, shock,
cardiac arrest, death
Febrile-Nonhemolytic Reaction
• Sudden onset of chills, fever, temp elevation
>1 degree C. headache, anxiety
Mild Allergic Reaction
• Flushing, urticaria, hives
25
Nursing Responsibilities
STOP transfusion
 Maintain IV site-disconnect from IV and
flush with NS
 Notify blood bank/MD
 Recheck ID
 Monitor VS
 Treat sx per MD orders
 Save bag and tubing-send to blood bank

26
Chest Tube: Nursing Priorities




Assess resp. status
closely
Check water seal for
bubbling
Milk NOT strip every 2
hours
Assess color-amount
drainage
•

Call MD if >100cc/hr x2
hours first 24 hours
Sterile quaze/occlusive
dressing at bedside 27
Mechanical Ventilation


The use of an ET and POSITIVE pressure to deliver O2
at preset tidal volume
Modes
•
Assist Control (AC)


•
Synchronized Intermittent Mandatory Ventilation (SIMV)


•
•
TV & rate preset
Additional resp. receive preset TV
Additional resp. receive own TV
Used for weaning
Continuous Positive Airway Pressure (CPAP)
Bi-pap


Non-mechanical
receive both insp. & exp. Pressures w/facemask
28
Mechanical Ventilation

Terminology
•
•
Rate
Tidal volume

•
Fraction of inspired O2 concentration (FiO2)

•
•
Use lowest possible to maintain O2 sats
Positive End Expiratory Pressure (PEEP)
Minute volume


10-15cc/kg
RR x TV
AC12-TV 600-50%-+5
29
Mechanical Ventilation: Adverse
Effects

Complications
•
•
•
•
•
•
Aspiration
Infection-VAP
Stress ulcer of GI tract
Tracheal damage
Ventilator dependancy
Decreased cardiac output

•
Positive pressure decr. venous return & CO
Barotrauma

pneumothorax
30
Mechanical Ventilation:Nursing Priorities

Ventilator Alarm Troubleshooting
• High pressure
 Secretions-needs sx
 Tubing obstructed or kinked
 Biting ET
•
Low pressure
 Disconnection of tubing
 Follow tubing from ET to ventilator
31