Custom Course Ware LANGARA COLLEGE NURSING PROGRAM HEALING II (N2251) NURSING SKILLS Section I TERM IV 200930 0 Revised August, 2009
INTRODUCTION LEARNING ACTIVITIES Table of Contents Caring for client with sutures, staples and/or steri strips... 6 Caring for clients with a surgical incision and a drain. 12 Caring for clients requiring Intravenous Medication Administration 17 Study Guide for clients Requiring Intravenous Medications 22 Administering an IV medication via a large (or primary) bag 26 Administering an IV medication via a piggy back system (mini or secondary bag) 29 Administering a medication push into an injection port of an infusing IV 33 Administering a medication piggy back into an intermittent IV device 36 Administering a medication push into an intermittent IV device.. 39 Caring for a client who requires a gastrointestinal intubation.. 41 Caring for a client who is receiving enteral nutrition... 47 Caring for clients who requires a urinary catheter. 51 Caring for clients who requires complex wound care... 56 Caring for clients with a chest tube... 60 Caring for clients with an artificial airway or a tracheotomy...64 Appendix.68 1
INTRODUCTION 2
CONSIDER THIS QUESTION... HOW WILL YOU PREPARE YOURSELF WHEN YOU ARE REQUIRED TO PERFORM A SKILL FOR THE FIRST TIME IN THE PRACTICE AREA? PERFECT PRACTICE MAKES PRACTICE PERFECT 3
Welcome to Nursing 2251 Healing II Nursing Skills Classes. This packet includes the learning activities for each Nursing Skills class. To maximize your time and learning, please read the learning activity before each class and complete all activities listed in the In Preparation portion. Let s all learn together while we are having fun! 4
LEARNING ACTIVITIES 5 Learning Activity Care of a client with Sutures, Staples or steri strips
- Asepsis, Therapeutic Agents/Modalities, Assessment- CONCEPTS: PAIN, ANXIETY/FEAR, UNPREDICTABILITY, VULNERABILITY, HEALING, TRUST, CONTROL, RESILIENCE OVERVIEW To promote wound healing and to reduce scar formation, skin and tissue edges are held together with sutures, staples or specialized tapes (steri strips). The client=s history of wound healing, the surgical site, the tissues involved and the purpose of the wound close determine the type of skin closures that are used (Perry & Potter, 2006). For example, an absorbable suture made from cat gut material is utilized when closing subcutaneous, fascia or dermal layers of tissues. Non - absorbable suture material sutures made from silk, polypropylene, nylon or Dacron are used for closure of the epidermal layer. For clients requiring additional support for their incisions, wire retention sutures are used. Staples are wide stainless steel clips that resemble an ordinary paper staple. This type of wound closure differs from sutures in that they do not encircle the wound edges. Instead they form a trough which keeps the wound edges together (Dugas, 1999). Staples may be inserted very quickly thereby reducing the surgical time and amount of anaesthetic required during surgery. Staples and non-absorbable sutures remain in place until the skin edges are healed. The time frame for healing varies with each person, however generally staples and sutures are removed within 7 10 days. Retention sutures are usually in place for a longer period to ensure adequate healing. When removing all types of sutures, caution must be taken to remove the entire suture. Should a piece of suture remain in the underlying tissues, the body will recognize it as a foreign object. Immediately an inflammatory response will be triggered and possible infection may result. Wound edges in small incisions or lacerations may be held together with a tape closure such as steri strips or butterfly bandages. These thin strips of sterile porous fabric tape promote healing and they offer additional support following the removal of sutures or staples from surgical incisions. 6 ENDS-IN-VIEW To complete a wound assessment. To be cognizant of the various types of suturing techniques.
To incorporate the Critical Elements of a skill when removing sutures/staples. To incorporate the Critical Elements of a skill when applying steri strips. To understand the purpose of applying steri strips. To provide discharge wound care teaching. To incorporate the principles of documentation. IN PREPARATION Review the various layers of tissues and skin. IN NERC In pairs complete the activities required in each scenario. Be prepared to share your learning with the large group. IN NURSING PRACTICE Review your agency=s Policy and Procedure Manual prior to removing sutures or staples or applying steri strips for your client. IN REFLECTION What steps can you take to reduce client stress during the suture/staple removal? What can you do to reduce the risk of complications associated with this nursing care? 7 What principles are involved in the removal of sutures or staples? REFERENCES Dugas, B., Esson, L., and Ronaldson, S. (1999). Nursing Foundations: A Canadian Perspective.
(2 nd ed.). Prentice Hall Canada Inc.: Scarborough, Ontario. Earnest, V. (1993). Clinical Skills in Nursing Practice. (2 nd edition). Philadelphia: Lippincott. Kozier, B., Erb, G., Berman, A., Burke, K., Bouchal, S., Hirst, S., (2004), Fundamentals of Nursing: The Nature of nursing Practice in Canada. Toronto: Prentice-Hall Health. Potter, B., Perry, A., Ross-Kerr, J., Wood, M. (2006). Canadian Fundamentals of Nursing (3 rd ed.) Elsevier Mosby: Toronto. 8 ADVANTAGES OF USING STAPLES FOR WOUND CLOSURES Staples reduce the surgical time and amount of anaesthetic required during surgery
Since the staple is inserted with a gun it reduces the amount of tissue handling, thus healing is faster The metal used in the staples rarely causes an immune response, therefore the risk of infection is reduced Staples are stronger, thereby giving more support to the wound edges Staples tend to cause less irritation to the tissues 9 Scenarios Scenario A You have been assigned to Mr. Dawson, a 60 year old man, who had a bowel resection eight
days ago. He has had no postoperative complications and is recovery well. His abdominal incision is healed and the skin edges are well approximated. Following the removal of his staples, Mr. Dawson will be discharged. Doctor=s Orders for Mr. Dawson Date Time Noted by Doctor s order Dr. Signature Today 0730 CCB Remove all abdominal staples. Apply steri strips to the wound Complete the activities: Acetaminophen plain I ii tabs, po, q4-6 h for pain Discharge home today Follow-up appt. in my office in 2 weeks 1. What factors would hinder or enhance incision healing. 2. What principles are involved in your care? 3. Document your nursing care? Dr. I Fall 10 4. What discharge teaching would you provide? Scenario B You are caring for Glen, an 18 year old who has had reconstructive and plastic surgery for his wounds from a bear attack. Glen=s wounds and the skin graph area have healed well and he is anxious to get home to his friends. The doctor has ordered that his interrupted sutures be removed. This is the first time that Glen has had stitches removed. He asks you ADoes it hurt
when you pull them out?@ Doctor=s Orders Date Time Noted By Dr. Orders Dr. Signature Today 0730 CCB Remove all sutures from the skin graph on the Rt. arm. Apply steri strips to the wound. Complete the activities: Acetaminophen plain i - ii tabs, po, q4-6h for pain. Discharge home today. Follow-up appt. in my office in 2 weeks 1. How would you help alleviate Glen s concerns? 2. What principles are involved in your care? 3. Document your nursing care? 4. What discharge teaching would you provide? Dr. B. Grizzly 11 Learning Activity Caring for a client with a surgical incision and a drain -Asepsis, Therapeutic agents/modalities, assessment, irrigation/drainage-
OVERVIEW CONCEPTS: Pain, transition, anxiety/fear,, healing, trust, resilience/hardiness, control The insertion of a drain into or near an incision line promotes wound healing in two ways. First, the removal of large amounts of secretions and/or debris through low suction allows the base of the wound to contract. This adhering of the wound edges promotes granulization and reepithelialization of the tissues. Secondly, the removal of fluids reduces or prevents the growth of microorganisms. There are two types of drains: open or closed. An example of an open drainage system is the penrose drain. One end of this flat rubber drain is located in the wound bed while the other end protrudes through either the incision or a separate small incision known as a stab wound. The drain acts as a wick, whereby it draws drainage through capillary action from the wound to a dressing. Although penrose drains are used sparingly, clients undergoing some types of plastic or ear/nose & throat surgeries may have this type of modality post operatively. A closed system relies on gentle suction to withdraw secretions and debris from the wound bed. Once the drainage is removed from the wound bed, it is collected in a reservoir. Common types of closed drainage systems include a Hemovac, Jackson-Pratt, Snyder or Davol drains. With a closed drainage system, it is important that the drain remains patent and that the suction mechanism is always engaged. This learning activity will focus on the assessment, cleaning, maintenance and removal of a closed system drainage unit. ENDS IN VIEW To complete a comprehensive assessment of a wound with a closed drain system. To apply nursing knowledge and critical thinking skills when caring for a client with a drain. To incorporate the critical components of a skill when performing an incisional and drain site dressing change. To incorporate the critical components of a skill when emptying or removing a closed system drain. 12 IN PREPARATION Read: your term III notes on Simple dressing change and aseptic technique.
the relevant information on open and closed drainage systems in your Perry & Potter textbook IN NERC Observe the drain dressing, emptying and removal demonstrations. In pairs, complete the learning activities in the scenarios. Be prepared to share your information with the large group. IN NURSING PRACTICE Review the Policy and Procedure manual in your agency prior to the care of a client with a drain. IN REFLECTION What would the psychological affects of a drainage device have on a client? REFERENCES Earnest, V. (1993). Clinical Skills in Nursing Practice. (2 nd edition). Philadelphia: Lippincott. Kozier, B., Erb, G., Berman, A., Burke, K., Bouchal, S., Hirst, S., (2004), Fundamentals of Nursing: The Nature of nursing Practice in Canada. Toronto: Prentice-Hall Health. Potter, B., Perry, A., Ross-Kerr, J., Wood, M. (2006). Canadian Fundamentals of Nursing (3 rd ed.) Elsevier Mosby: Toronto. 13 SCENARIO #1 Completing a dressing with a drain You are caring for Mrs. Green, a 42 year old lady, who has had an open cholecystectomy. She is recovering well. On the second post operative day, the doctor requests that you change Mrs.
Green s abdominal dressing. During the shift you will need to empty her drain. 1. What type of closed system drain does Mrs. Green have? 2. What assessment data would you gather? 3. What principles would you incorporate in your care of Mrs. Green s wound and drain? 4. Document your assessment and dressing change for Mrs. Green. 14 Scenario #2 Maintaining and emptying a closed system drain Throughout the shift you monitor Mrs. Green s output from her drain? At the end of the shift and prn, you must empty the drain and record the data on the appropriate sheets.
1. Where would you record the output from Mrs. Green s drain? 2. When would you notify a doctor of Mrs. Green s drainage? 3. What are the critical points to remember when emptying a closed system drain? 4. What would the drainage characteristics be on post op day 2? 15 Scenario #3 Removal of a closed system drain Mrs. Green is day 3 and the drainage from her closed system drain has been 10 cc in 24 hours. Her doctor has ordered the drain be removed. Please complete the care.
1. When would you anticipate that a drain would be removed? 2. What client teaching would you complete prior to the drain removal? 3. What principles would you incorporate during the removal of the drain? 4. Where would you place the used equipment? 5. When would you complete the follow up assessment after the drain is removed? 6. Document the procedure 16
Learning Activity Clients Requiring Intravenous Medication Administration - Asepsis, Therapeutic agents/modalities, Assessment - CONCEPTS: TRANSITION, ANXIETY/FEAR, UNPREDICTABILITY, VULNERABILITY, WELLNESS/HEALING, RESILIENCE/HARDINESS, TRUST, ENERGY OVERVIEW Medications are administered intravenously (IV) when a rapid therapeutic effect is required. Statistics estimate that up to 40% of hospitalized clients receive their medications by the IV route and IV medications administered in Out-Patient Departments, Ambulatory Clinics or at home are becoming increasingly popular. IV medications may be administered into a continuous intravenous infusion or into an intermittent IV device such as a saline or heparin lock. The five methods of administering an IV medication include: Infusing the medication via a large or primary bag of solution Infusing the medication via a piggy back system (ie. in a mini bag, a secondary bag or a controlled volume infuser) Injecting the medication directly push (or bolus) into an injection port of an infusing IV Injecting the medication directly push (or bolus) into an intermittent IV device Infusing the medication via a piggy back system into an intermittent IV device While best practice is to have medications added to an IV solution by a pharmacist, there are many medications prepared by nurses. This series of learning activity will focus on IV medications that are prepared and administered by nurses via the five different methods listed above. 17
Some advantages and disadvantages of IV medication administration are: ADVANTAGES Very effective when a rapid therapeutic effect is needed No absorption problems because the medication is administered directly into client's circulation Accurate titration due to accurate absorption More comfortable for client - the pain of IM/SC injection is avoided An alternative to the oral or intramuscular routes for clients who are unconscious, unable to swallow, NPO, or uncooperative Immediate discontinuation - if adverse reaction occurs, the infusion can be stopped immediately. DISADVANTAGES Due to immediate absorption and rapid onset of drug action, adverse reactions or errors may be serious and life threatening Potential incompatibilities when any two drugs are mixed together in a syringe or solution Large dosages of some medications may irritate the vein causing scarring, redness, tenderness at the IV site necessitating reestablishment of the IV In the event that the IV becomes interstitial, infusing medications may cause injury to the surrounding tissues The disadvantages listed above, can be prevented by careful and frequent assessment of the client and meticulous site to source IV assessments prior to and during the medication infusion. Accurate calculations and infusion rates is mandatory. Scrupulous checking of the client s allergies or sensitivities, as well as medication compatibilities with IV equipment and solutions must be completed prior to all IV medications being administrated. Most agencies have current compatibility charts available and the nurse may also contact the pharmacist to double check medication information. 18
ENDS-IN-VIEW Safely and knowledgeably prepare and administer an IV medication via a primary infusion by: being knowledgeable about the medication (classification, action, purpose, usual dosage, compatibilities, rate of administration, essential dilutions, adverse effects, nursing implication, client teaching) being knowledgeable of the advantages and disadvantages of administering medications via a large or primary IV bag critically thinking and using clinical judgment with respect to the appropriate IV medication administration method checking both the hospital and IV policies to ensure that you can administer the medication accurately calculating the amount of medication to be administered and the correct infusion rate being cognizant of the nursing measures that may be implemented to avoid potential complications of this modality gathering all the essential equipment to complete the medication administration implementing aseptic technique during all aspects of the preparation and administration of the medication completing a client assessment (including checking for allergies or any drug sensitivities, hydration status and IV site to source check) teaching the client about the medication documenting the medication and IV infusion assessing the client to determine if the expected outcomes have been achieved 19
IN PREPARATION Read: IV medication administration in your Perry & Potter textbook. Intravenous Policy for Langara Students located in the Appendix section of this course packet. Research: Research and make a medication card for the drugs, Potassium Chloride (KCL), Furosemide,. Gentamicin and Cefazolin. Please bring your calculator and a watch with a second hand to class. IN NERC With a partner, complete the activities required in the scenarios. Each student will prepare and administer the IV medication required in each scenario. During your practice be sure to incorporate the related theoretical knowledge and Critical Components of a skill. Think about any potential problems that may be encountered as you administer these medications intravenously. Consider possible solutions for these situations. IN NURSING PRACTICE Review the agency's Policy and Procedure Manual, as well as any relevant Pharmacy Manuals prior to the administration of any IV medication. Adhere to the, Nursing Department Student Guidelines and Policy with respect to the administration of medications via the intravenous route. IN REFLECTION What are the differences and/or similarities between administrating medications intravenously versus orally or via the intramuscular routes? When administering IV medications, what factors must you consider? What resources were most helpful to ensure the safe and competent administration of IV medications? 20 What Term IV concepts are incorporated in the administration of IV medications?
21 REFERENCES Buchholz. S. (2006). Henke s Med Math: Calculation, Preparation and Administration (5 th ed.). Philadelphia: Lippincott Kozier, B., Erb, G., Berman, A., Burke, K., Bouchal, S., Hirst, S., (2004). Fundamentals of Nursing: The Nature of nursing Practice in Canada. Toronto: Prentice-Hall Health. Potter, B., Perry, A., Ross-Kerr, J., Wood, M. (2006). Canadian fundamentals of Nursing (3 rd ed.) Elsevier Mosby: Toronto.
STUDY GUIDE FOR CLIENTS REQUIRING INTRAVENOUS MEDICATIONS Intravenous Infusion Rates (via Gravity) 1. The physician ordered the IV to infuse at 50 ml/hour. The drop factor is 10. How many drops/minute would you infuse? 2. The physician ordered 60 ml of IV solution to be infused in 30 minutes. The drop factor is 60. How many drops/minute would you infuse? 3. The physician ordered 2000 ml of IV solution to be infused over a period of 24 hours. The drop factor is 60. How many ml/hour is this? 22
Intravenous Infusion Rates (via an IV infusion pump) ** Note: Infusion pumps always have a drip factor of 60 drops/ml. Most pumps have a setting for the primary bag infusion rate and a different setting for a secondary (ie. mini bag) infusion rate. The primary setting is utilized to infuse the primary IV solution. For example, if the doctor ordered the primary bag of solution to run at 50 cc/hour, the primary setting would be set at 50 and the pump would infuse the IV solution at the desired rate. When you wish to infuse a medication, you would utilize the secondary setting. This will tell the IV pump to stop infusing the primary bag of solution and begin to infuse the medication at the desired flow rate. Once the medication is completely infused the pump will automatically start infusing the primary bag again at the original rate. 4. There is an order for Ranitidine 50 mg IV to be infused over 15 minutes. The medication is further diluted in 50 cc of normal saline (mini bag). What is the rate you would set to infuse the secondary line? 5. The physician has ordered Ampicillin 1 Gm. IV Q6H. The medication is to be further diluted in a 100 cc mini bag and it is to be infused over 20 minutes. What is the hourly rate for the pump? Reconstitution Calculations 6. The physician ordered 350 mg of an antibiotic IV. The vial contains power with a label that reads: Add 4.4 mls. of sterile water to obtain 200 mg/ml. How many mls. would you prepare? 23
24 7. The physician has ordered 500 mg of an antibiotic q6h IV. The antibiotic is stored as a powder. The vial reads: 1 gram/vial. The instructions on the vial tell you to add 3.8 mls of sterile water to yield 4 mls of solution. a. What is the concentration of the solution? b. What volume of the antibiotic would you add to the mini bag? c. The antibiotic is to be mixed in a 100 ml bag of D5W and to be infused over 30 minutes. At what rate would you set the IV if the drop factor is 10 drops/ml? 8 The doctor orders Heparin 850 U per hour by intravenous infusion. When preparing the Heparin infusion, 25,000 units of heparin is added to a 500 ml bag of D5W and is infused through mini drip (drip factor of 60 drops/ml) tubing. How many drops/minute would you infuse? a. What is the concentration of Heparin to IV fluid, once the med is added to the IV bag? b. How many mls. per hour would you infuse? c. At what rate would you set the IV pump at?
Critical Thinking Questions 9. What would you do if two IV medications via mini bag were ordered for your client at 1000 hours? 10. You are assigned to clients A, B and C who have one - 1200 IV mini-bag medication each. In addition, you are looking after Nurse Smith's client assignment while he is on a lunch break from 1130-1215. Lunches arrive at 1200. What would you do? Medication Calculations 11. The doctor ordered 5,000 Units of a medication. The drug is available as 1,000,000 Units in 10 cc. How much medication would you prepare? 12. The doctor ordered 200 mg of a medication. This medication is available as 125 mg/ml. How much medication would you prepare? 25
26 Administrating an IV medication via a large (or primary) bag into a continuous infusion SCENARIO #1 Mr. Bron Fieldwalker is post operative day 1 following surgery for colon cancer. He has an infusing intravenous of Normal Saline, a large abdominal dressing and a nasogastric tube attached to low intermittent suction. His am blood work results indicate that his potassium level is 2.4 meq/l. The doctor has written the following orders. Langara Hospital PHYSICIANS' ORDERS DATE TIME NOTED BY PHYSICIANS' ORDERS (today) 0900 WD NPO IV Normal Saline with 40 meq KCL /L @ 100 cc/hour Gentamicin 80 mg IV TID X 3 doses Cefazolin 750 mg IV q8h Morphine 1 2 mg. IV q2 h via PCA Dimenhydrinate 50 mg IV q 4hr prn. Acetaminophen with 30 mg codeine ii tabs po q 3-4 hr prn 983-469-257-0001 Mr. Bron Fieldwalker DOB January 28, 1950 M 50 yr Dr. Andrew Merrell PHYSICIANS' SIGNATURE Change abdominal dressing po day 2 Dr. Andrew Merrell
27 983-469-257-0001 Mr. Bron Fieldwalker DOB January 28, 1950 M 50 yr Dr. Andrew Merrell SCHEDULED MEDICATION ADMINISTRATION RECORD 24 HOURS FROM 0800 THRU 0800 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 01 02 03 04 05 06 07 KCL 20 meq/10cc KCL 40 meq/l of Normal Saline at prescribed rate. Cefazolin 1 g vial Cefazolin 750 mg IV q 8hr 08 16 24 Gentamicin 40 mg/1cc Gentamicin 80 mg times 3 doses 1000 1800 02 last dose Morphine 10 mg/1 ml injectable. Morphine 1 2 mg IV q 2hr prn Via PCA STAT & PRN MEDICATIONS Acetaminophen 325 mg with 30 mg codeine/tab Acetaminophen 325 mg with 30 mg codeine ii tabs po q 3-4 hr prn (crushed) DimenhyDRINATE 50 mg/1 ml injectable. Dimenhydrinate 50 mg IM q 4hr prn. 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 01 02 03 04 05 06 07
Complete the Activities Prepare and administer the KCL. 1. What factors would you consider prior to preparing and administering the KCL? 2. While gathering your supplies to administer the KCL you discover that there are no liter IV bags of Saline, what would you do? 3. What lab values would be important to check before and during the administration of KCL? 4. How would you document the infusion of the KCL? 28
29 Administration of an IV Medication (in a liquid form) via a piggy back system (mini bag or secondary bag) ENDS-IN-VIEW Safely and knowledgeably prepare and administer an IV medication via a piggy back system, mini bag or secondary intravenous bag into an infusing IV by: being knowledgeable about the medication (classification, action, purpose, usual dosage, compatibilities, rate of administration, essential dilutions, adverse effects, nursing implication, client teaching) being knowledgeable of the advantages and disadvantages of administering medications via a mini bag or piggy back system critically thinking and using clinical judgment with respect to the appropriate IV medication administration method checking both the hospital and IV policies to ensure that you can administer the medication accurately calculating the amount of medication to be administered and the correct infusion rate being cognizant of the nursing measures that may be implemented to avoid potential complications of this modality gathering all the essential equipment to complete the medication administration implementing aseptic technique during all aspects of the preparation and administration of the medication completing a client assessment (including checking for allergies or any drug sensitivities, hydration status and IV site to source check) teaching the client about the medication documenting the medication and IV infusion assessing the client to determine if the expected outcomes have been achieved
Scenario #2 It is now 1000, please administer Mr. Fieldwalker s IV medication. Discuss the scenario and answer the questions. 1. What factors would you consider prior to administering Gentamicin? 2. What is the major side effect of this medication? 3. What precautions would be implemented to prevent the major side effects of this medication? 30
31 Administrating an IV Medication ( in a powder form) via a piggy back system (mini bag or secondary bag) ENDS-IN-VIEW Safely and knowledgeably prepare and administer an IV medication via a piggy back system, mini bag or secondary intravenous bag into an infusing IV by: being knowledgeable about the medication (classification, action, purpose, usual dosage, compatibilities, rate of administration, essential dilutions, adverse effects, nursing implication, client teaching) being knowledgeable of the advantages and disadvantages of administering medications via a mini bag or piggy back system critically thinking and using clinical judgment with respect to the appropriate IV medication administration method checking both the hospital and IV policies to ensure that you can administer the medication accurately calculating the amount of medication to be administered and the correct infusion rate being cognizant of the nursing measures that may be implemented to avoid potential complications of this modality gathering all the essential equipment to complete the medication administration implementing aseptic technique during all aspects of the preparation and administration of the medication correctly reconstituting a powder medication completing a client assessment (including checking for allergies or any drug sensitivities, hydration status and IV site to source check) teaching the client about the medication documenting the medication and IV infusion assessing the client to determine if the expected outcomes have been achieved
Scenario #3 It is now 1600. Please administer Mr. Fieldwalker s 1600 dose of Cefazolin. 1. What additional information is required when giving an IV medication in a powder form? 2. After you have withdrawn the required amount of medication from the vial, you find that there is enough medication for a second dose. The medication is stable for 72 hours if it is stored in a fridge. What information would you write on the medication vial? 3. At the bedside, you find an empty mini bag from the 1000 Gentamicin. What would you do? 4. Practice back flushing the secondary tubing. 32
Administrating a Medication push (or bolus) into an injection port of an infusing IV ENDS IN VIEW Safely and knowledgeably prepare and administer an IV medication push or direct into an infusing intravenous by: being knowledgeable about the medication (classification, action, purpose, usual dosage, compatibilities, rate of administration, essential dilutions, adverse effects, nursing implication, client teaching) being knowledgeable about the advantages and disadvantages of administering medications push or direct being aware of the signs and symptoms of speed shock critically thinking and using clinical judgement with respect to the appropriate IV medication administration method checking both the hospital and Langara IV policies to ensure that you can administer the medication accurately calculating the amount of medication to be administered gathering all the essential equipment to complete the medication administration implementing aseptic technique during all aspects of the preparation and administration of the medication completing a client assessment (including checking for allergies or any drug sensitivities, hydration status and IV site to source check) administering the medication per the prescribed rate adequately flushing the medication into the circulatory system teaching the client about the medication documenting the medication and IV infusion assessing the client to determine if the expected outcomes have been achieved 33
SCENARIO #4 On post op day 2, Mr. Fieldwalker s has a diminished urinary output (60 ml over the past four hours) and his physician ordered Furosemide 40 mg IV STAT. 1. What factors would you consider in your selection of the most appropriate method of administering this medication? 2. What information do you need to know before you would administer the Furosemide? 3. What special precautions would you implement when administering a medication push? 4. What assessment information would you gather before and after you administered the Furosemide? 5. What information would you include in your client teaching about this medication? 34 6. Document your medication.
35 983-469-257-0001 Mr. Bron Fieldwalker DOB January 28, 1950 M. 50 yr. Dr. Andrew Merrell SCHEDULED MEDICATION ADMINISTRATION RECORD 24 HOURS FROM 0800 THRU 0800 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 01 02 03 04 05 06 07 KCL 20 meq/10cc KCL 40 meq/l of Normal Saline at prescribed rate. Cefazolin 1 g vial Cefazolin 750 mg IV q 8hr 08 16 24 Gentamicin 40 mg/1cc Gentamicin 80 mg times 3 doses 10 18 02 last dose STAT & PRN MEDICATIONS Acetaminophen 325 mg with 30 mg codeine/tab Acetaminophen 325 mg with 30 mg codeine ii tabs po q 3-4 hr prn (crushed) DimenHYDRINATE 50 mg/1 ml injectable. Dimenhydrinate 50 mg IM q 4hr prn. Furosemide 10 mg/ml. injectable Furosemide 40 mg IV stat 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 01 02 03 04 05 06 07
Administering a powder medication piggy back into an intermittent IV device ENDS IN VIEW Safely and knowledgeably prepare and administer an IV medication via a piggy back system, mini bag or secondary intravenous bag into an intermittent device by: being knowledgeable about the medication (classification, action, purpose, usual dosage, compatibilities, rate of administration, essential dilutions, adverse effects, nursing implication, client teaching) being knowledgeable about the advantages and disadvantages of administering medications push or direct critically thinking and using clinical judgment with respect to the appropriate IV medication administration method checking both the hospital and Langara IV policies to ensure that you can administer the medication accurately calculating the amount of medication to be administered and the correct infusion rate gathering all the essential equipment to complete the medication administration implementing aseptic technique during all aspects of the preparation and administration of the medication completing a client assessment (including checking for allergies or any drug sensitivities) completing the appropriate IV site assessments adequately flushing the medication teaching the client about the medication documenting the medication and IV infusion assessing the client to determine if the expected outcomes have been achieved 36
Scenario #5 Ms. Morrison developed an infection after having a total abdominal hysterectomy. She is drinking well and her doctor has ordered her intravenous to be saline locked. Please provide this nursing care and then administer Ms. Morrison s 1200 antibiotic. Langara Hospital PHYSICIANS' ORDERS DATE TIME NOTED BY Today 0500 COP PHYSICIAN S ORDERS Vital signs routine. DAT. AAT. IV NS at 100 cc/hr. Convert IV to saline lock when drinking well. Ampicillin 750 mg IV q6h Tylenol #3 or plain i-ii tabs q 4hr prn Colace 100 mg BID po 37 348-209-0001 Ms. Morrison, Jeannie DOB January 1, 1960 F 46 y Dr. Ken Warwick PHYSICIANS' SIGNATURE Dr. Ken Warwick Today 1300 CCB Diphenhydramine 50 mg IV stat Dr. D. Collin
38 348-209-0001 Ms. Morrison, Jeannie DOB January 1, 1960 F 46 y Dr. Ken Warwick SCHEDULED MEDICATION ADMINISTRATION RECORD 24 HOURS FROM 0800 THRU 0800 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 01 02 03 04 05 06 07 IV of Normal Saline at 100 cc/hr. Ampicillin IM/IV 1 Gram vial Ampicillin 750 mg IV q6h 12 18 24 06 Docusate Sodium (Colace) 50 mg capsule Docusate Sodium 100 mg po BID 08 20 STAT & PRN MEDICATIONS Acetaminophen 325 mg tablets with 30 mg Codeine Tylenol #3 i-ii tabs q 4hr prn Acetaminophen 325 mg Tylenol plain i-ii tabs q 4hr prn DiphenhydrAMINE vial 50 mg/1ml for IM/IV DiphenhydrAMINE 50 mg IV stat 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 01 02 03 04 05 06 07 ALLERGIES: ASPIRIN CHECKED BY: Laura Madison
39 Administering a Medication push (or bolus) into an intermittent IV device ENDS IN VIEW Safely and knowledgeably prepare and administer an IV medication push or direct into an intermittent device by: being knowledgeable about the medication (classification, action, purpose, usual dosage, compatibilities, rate of administration, essential dilutions, adverse effects, nursing implication, client teaching) being knowledgeable about the advantages and disadvantages of administering medications push or direct being aware of the signs and symptoms of speed shock critically thinking and using clinical judgment with respect to the appropriate IV medication administration method checking both the hospital and Langara IV policies to ensure that you can administer the medication accurately calculating the amount of medication to be administered gathering all the essential equipment to complete the medication administration implementing aseptic technique during all aspects of the preparation and administration of the medication completing a client assessment (including checking for allergies or any drug sensitivities) completing the appropriate IV site assessment administering the medication per the prescribed rate adequately flushing the medication teaching the client about the medication documenting the medication and IV infusion assessing the client to determine if the expected outcomes have been achieved
Scenario #6 Following the administration of the Ampicillin, Ms. Morrison has a headache, chills, she is itchy all over and she has developed a raised red rash all over her trunk. She states that her chest is feeling tight as if she can not breathe. 1. What do you suspect is happening to Ms. Morrison? 2. What would your priority nursing care include? 3. What medication would you administer now? 4. Compare the differences/similarities between administering IV medications through a continuous infusion versus an intermittent device. 40
Learning Activity Caring for clients who require Gastrointestinal Intubation -Asepsis, therapeutic agents/modalities, assessment, irrigation/drainage- CONCEPTS: TRANSITION, ANXIETY/FEAR, VULNERABILITY, HEALING, TRUST, RESILIENCE/HARDINESS, CONTROL OVERVIEW Gastrointestinal intubation refers to the insertion of a rubber, plastic or silicone tube through the mouth, nose or abdominal wall into the digestive tract. Tubes inserted through the nose or mouth are generally inserted by nurses and are utilized for a short period of time. These would include the single lumen, Levin tube or a double lumen, salem sump tube. Permanent gastrointestinal tubes including the gastrostomy (g-tube) or the jejunostomy (j-tube) are usually inserted by doctors either in the operating room or a GI clinic. Gastrointestinal tubes may be used to: Prevent nausea and vomiting by removing secretions from the stomach (decompression); prevent distention of the stomach by removing secretions (decompression) irrigate the stomach and/or remove toxins (lavage) administer nutrients and/or medications for those unable to orally ingest an adequate amount of food to maintain their nutritional status (gavage); apply compression via an inflated balloon to prevent bleeding of the esophagus; aspirate secretions for diagnostic purposes (aspiration). This learning activity will focus on the nursing care of a client with a salem sump tube inserted via the nose primarily for decompression or gavage purposes. ENDS-IN-VIEW To be cognizant of when a specific type of gastrointestinal intubation tube would be indicated. To be aware of the potential complications associated with each gastrointestinal intubation tube. 41 To be able to complete a detailed assessment of a client requiring a gastrointestinal intubation tube. To apply the nursing knowledge and skills involved in the insertion, maintenance and removal of a salem sump nasogastric tube. To appreciate personal meaning of clients who requires a gastrointestinal tube.
IN PREPARATION Review: Anatomy and physiology of the upper gastrointestinal system Read: Gastrointestinal intubation, nasogastric tubes, gastric sumps in your Perry & Potter and Lewis, S. et. al textbooks. IN NERC Working in pairs complete the learning activities required in each scenario. Be prepared to share your learning with the large group. IN NURSING PRACTICE Review the Policy and Procedure manual before caring for a client with any gastrointestinal intubation. IN REFLECTION How would you feel if you required a gastrointestinal tube? How would you reduce the stress for your client and their family when inserting a nasogastric tube? How will you avoid potential complications associated with gastrointestinal intubation? REFERENCES Day, R., Paul, P., Williams, B., Smeltzer, S., and Bare, B., (2007), Brunner & Suddarth s textbook of Medical Surgical Nursing, First Canadian Edition. Lippincott, Williams &Wilkins. 42 Kozier, B., Erb, G., Berman, A., Burke, K., Bouchal, S., Hirst, S., (2004), Fundamentals of Nursing: The Nature of nursing Practice in Canada. Toronto: Prentice-Hall Health. Lewis, S., Collier, L. and Heitkemper, M. (2004). Medical - surgical nursing: Assessment and management of clinical problems (6 th ed.). St. Louis: C. V. Mosby. Potter, B., Perry, A., Ross-Kerr, J., Wood, M. (2006). Canadian Fundamentals of Nursing (3 rd ed.) Elsevier Mosby: Toronto.
SCENARIO #1 Ms. Beales is post op day 1 following bowel surgery. Until her colostomy becomes active the Doctor ordered a gastrointestinal intubation. See the Doctor s orders sheet. 1. What type of tube would be inserted? 2. What is the purpose of this tube? 3. Why would Ms. Beales tube be connected to low continuous suction? 4. To establish low continuous suction the suction dial would be positioned at what setting? 5. Upon first meeting Ms. Beales what assessment data would you gather? 43
Physician=s Orders Langara Hospital PHYSICIANS= ORDERS 962-403-104-000 Ms. Kate Beales DOB February 14, 1941 F 59yrs Dr. Edward Mann Date Time Noted By Doctor s Orders Doctor s Signature Yesterday 1400 hours S.E.C. Post-op colostomy IV D5/NS @ 100 m./hr Daily dressing change NG connected to low continuous suction Vital signs q4h Intake and output NPO AAT Morphine 10 mg IM q4h prn Tylenol #3 i-ii tabs PO q4h prn Gravol 50 mg IM q4-6h prn Maalox 30 ml per NG tube q4h prn Dr. Edward Mann 44
Scenario #2 Later that Day Ms. Beales= NG tube is accidentally pulled out. Ms. Beales NG tube was originally inserted in the Operating Room. She is anxious about having the tube inserted while awake. 1. How would you support her? What client teaching would you provide? 2. In pairs, practice inserting the NG tube according to the Critical Components of a Skill. NOTE: PLEASE DO NOT USE LUBRICANT WHEN INSERTING THE NG TUBES, AS IT DAMAGES THE MANNEQUINS. 3. What safety checks would you complete to ensure the tube is in the stomach? 4. What complications can occur during the insertion of a NG tube? 5. Document the insertion of the NG tube. 45 6. What are the standards of care for a client with a NG tube?
46 Scenario #3 Over the Next Few Days Ms. Beales= NG drainage decreases. She has active bowel sounds and has not experienced any nausea or abdominal distention. The Doctor ordered her NG tube be clamped. If Ms. Beales can tolerate the clamping for 4 hours, remove the NG tube. 1. What would indicate that Mr. Beales is tolerating the NG being clamped? 2. Remove the NG tube according to the Critical Components of a Skill. 3. What assessment data would you collect during and following the removal of the NG tube? 4. Document the NG tube removal.
OVERVIEW Learning Activity Caring for a Client who is receiving enteral nutrition - asepsis, therapeutic agents/modalities, assessment CONCEPTS: TRANSITION, ANXIETY/FEAR, VULNERABILITY, HEALING, TRUST RESILIENCE/HARDINESS, CONTROL Enteral feeding refers to the administration of a nutritionally balanced liquefied food or formula through a tube inserted into the nose or mouth terminating in the stomach or a tube directly placed into the duodenum or jejunum (Brunner & Suddarths, 2006). This type of feeding may be ordered for clients who have a functioning gastrointestinal system but who are unable to meet their nutritional needs due to anorexia, facial fractures, paralysis of the mouth and/or throat, ineffective swallowing or extensive burns to the face, mouth and/or neck. Enteral feeding may be implemented on a short or long term basis. The length of time a client is to receive enteral feeds will determine the type of tube to be inserted. If a client requires enteral feeds for a short time, a nasogastric or enterflex tube will be inserted through the nose or mouth. For permanent nutrition, a client will have a gastrostomy tube placed into the stomach via percutaneous endoscopically or a surgically inserted jejunostomy tube. This learning activity will focus on the knowledge and skills required to care for a client receiving enteral nutrition. ENDS-IN-VIEW To be cognizant of the various type of feeding tubes. To be cognizant of various types of commercially prepared enteral formulas/solutions. To be able to prepare a client for a percutaneous endoscopically gastrostomy (PEG) tube insertion. To apply the nursing knowledge and skills required of a client receiving enteral nutrition. To be cognizant of the potential complications associated with enteral nutrition. To be able to complete an assessment of a client receiving enteral nutrition. To apply the nursing knowledge and skills require during the administration of medications via a gastrointestinal tube. To appreciate personal meaning of clients who are receiving enteral nutrition. 47
IN PREPARATION Read : enteral nutrition in your Perry & Potter textbook IN NERC Working in pairs, answer the questions in the scenario. Be prepared to share your answers with the large group. Watch the demonstration on how to use the Kangaroo pump. IN NURSING PRACTICE Review the Policy and Procedure manual before caring for a client receiving enteral nutrition or before administering medications via a gastrointestinal tube. IN REFLECTION What would it be like to receive your nutrition via a tube? REFERENCES Kozier, B., Erb, G., Berman, A., Burke, K., Bouchal, S., Hirst, S., (2004), Fundamentals of Nursing: The Nature of nursing Practice in Canada. Toronto: Prentice-Hall Health. Day, R., paul, P., Williams, B., Smeltzer, S., and Bare, R. (2007) Brunner & Saddarth s Textbook of Medical surgical Nursing. (1 st Canadian edition). Lippincott, Williams & Wilkins. Lewis, S., Collier, L., and Heitkemper, M. (2004). Medical - surgical nursing: Assessment and management of clinical problems (6 th ed.). St. Louis: C. V. Mosby. Potter, B., Perry, A., Ross-Kerr, J., Wood, M. (2006). Canadian Fundamentals of Nursing (3 rd ed.) Elsevier Mosby: Toronto. 48
Scenario #1 Enteral Nutrition Mr. Olsen has been admitted with multiple fracture of the face from an automobile accident. There is considerable edema and he is having difficulty swallowing. His doctor has ordered a enterflex tube be inserted for enteral nutrition. Doctor s orders for Mr. Olsen Insert an enterflex tube Start feedings of Ensure ½ strength, 50 cc/hr. 1. Besides Ensure, list some common commercially prepared enteral formulas. 2. What are the differences between continuous and intermittent enteral feeds? 3. What are the nursing responsibilities when infusing Mr. Olsen=s tube feed? -Assessment? - Positioning? -Flushing? 49 - Increasing the concentration and amount of the enteral feed -Testing for residual amounts?
-Preventing infections? -Documentation? 4. What assessment findings would indicate that Mr. Olsen is not tolerating this enteral feed? 5. Mr. Olsen requests Tylenol #3 tablets for his facial pain. How would you administer this medication? 6. What medications should not administer via an enteral tube? 7. What other members of the health team would you include in Mr. Olson s care? 50
Learning Activity Caring for Clients who require a Urinary Catheter - assessment, asepsis, irrigation/drainage, therapeutic agents/modalities CONCEPTS: TRANSITION, ANXIETY/FEAR, VULNERABILITY, HEALING, TRUST, CONTROL OVERVIEW Urinary catheterization is described as the introduction of a plastic or rubber catheter through the urethra into the urinary bladder (Perry & Potter, 2006). Urinary catheters facilitate the continuous flow of urine for clients that are unable to control micturation due to a neurological condition or spinal cord injury or for individuals with urinary retention, bladder distention, urinary tract obstructions or other urological conditions. This modality may also be utilized to: provide precise monitoring of the urinary output of hemodynamically unstable clients or critically ill patients (Perry & Potter, 2006) reduce the strain on the bladder for clients who have undergone urological surgery provide continuous bladder irrigations following urological surgeries instill medications into the bladder prevent urinary leakage in clients with extensive pressure wounds obtain a sterile urine specimen should the client be unable to provide one assess residual amounts of urine. There are several types of catheter tubes and external gravity collection bags. One of the most common types of catheter is the indwelling or foley catheter. This learning activity will focus on the insertion, maintenance and removal of a foley or indwelling catheter. ENDS-IN-VIEW To identify common client situations where a urinary catheter may be indicated. To identify the purposes of the different types of urinary catheters. 51 To identify potential complication and preventative nursing measures for clients with a foley (indwelling) urinary catheter. To incorporate the "critical components of a skill" when inserting, maintaining or removing an indwelling catheter. To incorporate the critical components of a skill when obtaining a urine specimen from a urinary catheter.
IN PREPARATION Read in your Perry and Potter text: or review the male and female urinary system in your Biology text measures to encourage voiding and prevention of urinary tract infections urinary catheterization IN NERC Working in pairs, complete all the learning activities in the scenarios. Be prepared to share your learning with the large group. IN NURSING PRACTICE Review the Policy and Procedures Manual before caring for a client who requires a urinary catheter. IN REFLECTION What teaching would you provide for a client who requires the insertion, maintenance and removal of a urinary catheter? How will you provide comfort and privacy for your client while inserting a urinary catheter? REFERENCES Kozier, B., Erb, G., Berman, A., Burke, K., Bouchal, S., Hirst, S., (2004), Fundamentals of Nursing: The Nature of nursing Practice in Canada. Toronto: Prentice-Hall Health. Potter, P., Perry, A., Ross-Kerr, J Wood, M. (2006), Canadian Fundamentals of Nursing.(3 rd edition). Elsevier Mosby: Toronto 52
SCENARIO Ms. Lee had an emergency appendectomy 10 hours ago. Ms. Lee tells you that she has been unable to void since her surgery and that she is beginning to feel uncomfortable in her lower abdomen. Doctor=s orders for Ms. Lee Insert a foley catheter prn and should the urine returns be more that 300 cc keep the catheter in for 24-48 hours 1. What are the possible reasons why Ms. Lee is unable to void? 2. What common nursing measures would you implement to encourage Ms. Lee to void? 3. As the measures outlined in the previous questions failed, you have decided to procedure with the insertion of a foley catheter. What essential information would you impart to Ms. Lee prior to the catheterization? 4. What assessment data would you gather prior to the insertion of the foley catheter? 53 5. What criteria would you consider in selecting the appropriate catheter for Ms. Lee?