Skills & Scenarios 81

Transcription

1 Skills & Scenarios 81

2 Psychomotor Skills Checklist Skill Lab Clinical Date Initial Date Initial 1. Change I.V. tubing 2. Change I.V solution 3. Regulate I.V. flow rate 4. Flush peripheral lock 5. Change peripheral I.V. dressing 6. Convert IV to peripheral lock 7. Convert peripheral lock to IV 8. Administer IVPB 9. PPN administration 10. Blood/blood products administration 11. Tracheostomy care and suctioning 12. Monitor and manage closed drainage chest tube 13. Orotracheal & Nasotracheal suctioning *Please place this in your clinical folder *Include 1 st semester skills checklist in your clinical folder 82

3 Napa Valley College ADN Program NURS 143 Category A Skills Scenario 1 Your patient has a peripheral saline lock in the lower forearm. The Doctor orders: 500ml 0.9%Saline to run at 100ml/hr. Convert the saline lock to the IV and calculate gtts/minute based on tubing gtt factor of 15. Scenario 2 Your patient has an IV running at 1000ml/8 hr. The tubing and bag is scheduled to be changed. After you hang the new tubing and IV, the doctor orders it to be discontinued and converted to a saline lock. Calculate flow rate in ml/hr. Scenario 3 The patient has a peripheral saline lock. The doctor has ordered: Transfuse 1 unit of packed RBC s (300ml) over 2 hours. Set up for the blood administration and calculate the flow rate in ml/hour. Scenario 4 The patient has a peripheral saline lock. You are to start PPN at 80ml/hr. You also need to identify at least 4 significant interventions when the patient is on PPN. Calculate flow rate in gtts/min based on tubing gtt factor of 15. Scenario 5 Your patient has a peripheral I.V. running at 100ml/hour. He is to receive Keflin 1 Gm IVPB. It is mixed in 100ml Sterile N.S. and is to be given over 30 minutes. The drop factor of the I.V tubing is 15. When this last dose is finished you are to change the I.V. to a saline lock. Category B Skills Scenario 6 Your patient has returned from surgery with a chest tube. Identify and describe the purpose of the individual chambers of the drainage set. Describe normal and abnormal findings. Describe and demonstrate three interventions/assessments you would do. Scenario 7 Your patient with a tracheostomy has upper airway rhonchi and retained pulmonary secretions. Describe and demonstrate tracheostomy suctioning. Scenario 8 He is also due for routine tracheostomy care. Describe and demonstrate tracheostomy care. 83

4 IV Guidelines Preparation a. Procedures must be checked off in campus lab within three weeks from date of lab skills day. b. Review hospital policies for IV s, blood transfusions, and PPN, and TKO rates c. Review in campus lab and keep notes regarding i. Hanging IV and priming tubing ii. Superimposing/Changing an IV solution bag iii. Changing a peripheral lock into a running IV iv. Changing a running IV into a peripheral lock v. Flushing a peripheral lock vi. Transfusing blood d. Review IV equipment, pumps, controllers, and charting in agency Clinical requirements e. It is essential that the staff or instructor verify all IV administration. f. IV solution and rate must be verified against written physician orders. g. Determine the purpose of the IV solution. h. Communicate with staff nurse and instructor each day to clarify learning objectives, responsibilities, and supervision needed. Suggested sequence: i. Assessment of patient 1. Inspect IV site and dressing 2. Inspect IV for bubbles, flow rate, and verify orders 3. Complete a detailed fluid balance assessment ii. IV maintenance 1. Regulate flow rate 2. Observe IV administration 3. Observe IV starts 4. Make out time labels 5. Verify dates on tubing 6. DC IV s and peripheral locks iii. Change or hang IV solutions 1. Schedule times supervision required 2. Communicate with instructor General policies for maintenance of primary IV s i. Assessment at beginning of each shift i. IV site for redness, swelling, coldness, pain ii. Dressing and security of taping iii. Verify tubing is free of kinks iv. Check position of involved extremity v. Check IV for 1. Correct solution 2. Volume remaining in bag 3. Rate 4. Tubing change date 5. Clarity of solution j. Hourly checks i. Amount of solution administered ii. Rate iii. Condition of site 84

5 k. Charting i. Time each new bag is hung ii. Number of bag (according to hospital policy) iii. Name of solution, additives, and volume iv. Time bag completed v. IV site assessment l. At end of each shift i. Chart amount of solution remaining in bag ii. Chart amount of solution administered iii. Zero IV pump m. Tubing changes i. All primary IV tubing are changed every 72 hours ii. All tubing must be dated iii. PPN filters and tubing changed every 24 hours. iv. Lipid tubing is changed every 24 hours (no filters are used). v. No solution bag should hang for more than 24 hours General policies for peripheral lock maintenance n. Instruct patient to inform nurse of pain, swelling, or bleeding at site o. Instruct patient to keep dressing and site dry. If may shower, wrap site with plastic and secure well with tape p. Caution patient not to lie directly on insertion site q. Assess site at beginning of each shift and every two hours r. Always check for patency by flushing with 3mL of sterile NS and chart. s. Chart condition of site and dressing Flushing a peripheral lock to maintain patency t. Frequency i. Check agency policy ii. Immediately before and after any medication is given u. Equipment i. Syringe with 3mL sterile Normal Saline ii. Alcohol swab v. Procedure i. Verify order and check IV site ii. Wash hands iii. Clean rubber stopper on tubing with alcohol iv. Insert syringe into stopper. Aspiration for patency check is optional. v. Flush slowly with normal saline and observe for pain, swelling, or difficulty with flush vi. Remove syringe vii. Wash hands viii. Chart Solution bag change with new tubing w. Equipment i. Correct solution ii. Primary IV tubing iii. Extension tubing if agency requires one iv. Flow meter label if agency requires one x. Procedure i. Verify order and check solution and expiration date ii. Wash hands iii. Inspect solution for clarity and leaks 85

6 iv. Attach flow meter label if required by agency v. Remove IV tubing from package and close roller clamp and attach extension tubing. If 3-way stopcock with extension tubing is used attach to end of IV tubing and turn arrow to point to tubing vi. Remove plastic protector from IV bag and uncover tubing spike vii. Squeeze drip chamber prior to inserting spike into bottle to activate air vent viii. Insert spike, invert solution and suspend on pole ix. Fill drop chamber to ½ full x. Open roller clamp and slowly clear tubing of air xi. Close roller clamp xii. Take to patient room and verify arm band against bottle label xiii. Aseptically connect to patient s IV catheter after stopping running IV and carefully disconnecting from hub of IV catheter xiv. Adjust drip rate xv. Date tubing xvi. Chart Converting a peripheral lock to an IV y. Equipment i. Same as procedure for changing an IV and tubing plus ii. One 3mL syringe with sterile normal saline iii. Tape z. Procedure i. Follow steps of procedure for changing IV and tubing to step 12 ii. Flush peripheral lock with NS and assess site iii. Attach end of IV tubing into rubber connection of peripheral lock with needleless system or protected needle or into hub of catheter iv. Retape as indicated v. Follow steps 13, 14, and 15 of procedure for changing an IV and tubing Changing an IV solution aa. Equipment i. Solution bag ii. Flow meter label bb. Procedure i. Verify order and check solution bag and expiration date at least one hour before needed ii. Wash hands iii. Inspect solution for clarity and bag for leaks iv. Label bag with flow meter label if required by agency v. Take bag to patient room and verify against I.D. arm band vi. Turn roller clamp on IV tubing off, if on pump place on hold vii. Remove spike from empty bag avoid touch contamination of spike viii. Insert spike into new solution bag and suspend on I.V. pole ix. Open roller clamp and adjust drip rate or set pump to run x. Chart 14. Converting an IV to a peripheral lock a. Equipment i. Peripheral plug or adapter ii. Syringe filled with 3mL sterile NS iii. Clean gloves iv. Tape 86

7 b. Procedure i. Verify order ii. Wash hands iii. Open adapter iv. Insert needle and syringe or needleless system with NS and fill adapter/plug. v. Take equipment into room vi. Check arm band, explain procedure, check IV site vii. Wear clean gloves viii. Remove tape from IV site carefully to expose needle hub.*leave at least one piece of tape in place to avoid accidental removal of catheter. ix. Check adapter and add NS to fill if necessary x. Turn off IV xi. Carefully remove tubing from catheter hub xii. Attach peripheral plug or adapter and slowly inject NS - assess site xiii. Remove gloves and tape site securely, leaving rubber diaphragm exposed Hanging an I.V.P.B. Equipment xiv. Medication in solution bag xv. IV primary tubing xvi. Syringe with 3mL sterile NS xvii. Alcohol swab and tape c. Procedure Verify order Wash hands and take equipment into room Verify patient ID with arm band and medication bag label. Assess peripheral site and flush with 3ml NS Connect IV tubing to IVPB bag and clear tubing of air i. Cleanse rubber diaphragm of peripheral lock with alcohol swab ii. Insert needleless system of IV tubing into peripheral lock and set calculated flow rate. Secure tubing with tape. iii. Assess patient s response and chart iv. When medication completed remove tubing and protect connection end with sterile plug adapter. v. Flush peripheral lock with 3mL NS and re-assess site vi. Wash hands. d. IVPB medication into running IV i. Equipment 1. Medication premixed in solution bag 2. Secondary IV tubing 3. Alcohol swab ii. Procedure 1. Verify order and wash hands 2. Verify patient ID with arm band and assess IV site 3. Close roller clamp of secondary tubing and spike medication bag with secondary tubing. Clear tubing of air. Close roller clamp. 4. Wipe IV port of primary tubing with alcohol swab 5. Insert needleless system of secondary tubing into primary IV port 6. Open roller clamp of secondary tubing and set ordered drip rate 7. Assess patient response and chart. 8. When medication completed, close roller clamp on secondary tubing. 87

8 NURS 143 Category A Video Skill Evaluation Scenario 1 Conversion of saline lock to running IV Student: Pass Fail Evaluator: Date: Camera Operator: 1. Standard protocol 2. Prepares IV and tubing. Inspects solution for clarity and expiration date. Removes IV tubing from package and closes roller clamp. Removes plastic protector from IV bag and uncovers tubing spike while maintaining sterility of both. Squeezing drip chamber, inserts spike into IV bag outlet, inverts solution on suspends on pole. Fills drop chamber 1/3 to 1/2 full and opens roller clamp to clear IV tubing of air. 3. Peripheral (Saline) lock flush: Cleanses saline lock port with alcohol swab Flushes slowly with 3 ml. sterile normal saline while observing IV insertion site for pain, swelling, leakage, or difficulty with flush 4. Aseptically connects IV tubing to extension port of saline lock. 5. Opens roller clamp and adjusts drip rate after correct calculation of flow rate and confirms IV flow. Assesses site. 6. Dates tubing 7. Standard protocol S U NP Comments 8. State what you would document and show calculation Additional comments: 88

9 NURS 143 Category A Video Skill Evaluation Scenario 2 Solution bag change with new tubing & conversion to saline lock Student: Pass Fail Evaluator: Camera Operator: Date: S U NP Comments 1. Standard protocol 2. Prepares IV and tubing. Inspects solution for clarity and expiration date. Removes IV tubing from package and closes roller clamp. Removes plastic protector from IV bag and uncovers tubing spike while maintaining sterility of both. Squeezing drip chamber, inserts spike into IV bag outlet, inverts solution on suspends on pole. Fills drop chamber 1/3 to 1/2 full and opens roller clamp to clear IV tubing of air. 3. Closes roller clamp of running IV and removes from extension port. 4. Aseptically connects new IV and tubing to extension port of IV access line. 5. Opens roller clamp and adjusts drip rate after correct calculation of flow rate and confirms IV flow. Assesses site. 6. Closes roller clamp and disconnects IV tubing from extension port. 7. Peripheral (Saline) lock flush: Cleanses saline lock port with alcohol swab Flushes slowly with 3 ml. sterile normal saline while observing IV insertion site for pain, swelling, leakage, or difficulty with flush. Closes clamp on saline lock extension tubing 8. Standard protocol 9. State what you would document and show calculation Additional comments: 89

10 NURS 143 Category A Video Skill Evaluation Scenario 3 Conversion of saline lock to running Blood transfusion Student: Pass Fail Evaluator: Date: Camera Operator: S U NP Comments 1. Standard protocol 2. Prepares Blood tubing. Removes Blood tubing from package and closes all roller clamps. Removes plastic protector from Sterile Normal saline solution and uncovers one of the Y tubing spikes while maintaining sterility. Inserts spike into IV bag outlet, inverts solution and suspends on pole. Fills drip chamber to completely cover filter with normal saline and opens roller clamp to clear remaining IV tubing of air. 3. Peripheral (Saline) lock flush: Cleanses saline lock port with alcohol swab Flushes slowly with 3 ml. sterile normal saline while observing IV insertion site for pain, swelling, leakage, or difficulty with flush 4. Aseptically connects Blood tubing to extension port of saline lock. 5. Opens roller clamp and adjusts drip rate to establish slow, keep open rate. 6. Obtains blood product from laboratory and checks patient identity and blood criteria on slip and bag in the patient room with another RN. 7. Obtains and records patient s vital signs. 8. Puts on gloves 9. Attaches second Y spike to blood, closes normal saline Y roller clamp and opens blood Y roller clamp and begins transfusion at rate of gtts/min for first 15 minutes. Measures and records vital signs. 10. Stays with patient for first 15 minutes then measures and records vital signs and adjusts flow rate to run at ordered rate. Continues to check vital signs as per agency protocol 11. State what you would document and show calculation 90

11 NURS 143 Category A Video Skill Evaluation Scenario 4 Conversion of saline lock to PPN Student: Pass Fail Evaluator: Camera Operator: Date: S U NP Comments 1. Standard protocol 2. Prepares IV and tubing. Inspects solution for additives and expiration date. Removes IV tubing from package and closes roller clamp. Attaches required filter to distal end of IV tubing. Removes plastic protector from IV bag and uncovers tubing spike while maintaining sterility of both. Squeezing drip chamber, inserts spike into IV bag outlet, inverts solution on suspends on pole. Fills drop chamber 1/3 to 1/2 full and opens roller clamp to clear IV tubing of air. 3. Peripheral (Saline) lock flush: Cleanses saline lock port with alcohol swab Flushes slowly with 3 ml. sterile normal saline while observing IV insertion site for pain, swelling, leakage, or difficulty with flush 4. Aseptically connects IV tubing to extension port of saline lock. 5. Opens roller clamp and adjusts drip rate after correct calculation of flow rate and confirms IV flow. Assesses site. 6. Dates tubing 7. Standard protocol 8. State what you would document include 4 specific interventions In relation to PPN administration include calculation Additional comments: 91

12 NURS 143 Category A Video Skill Evaluation Scenario 5 IVPB with running IV & conversion to SL Student: Pass Fail Evaluator: Camera Operator: 1. Standard protocol S Taping Date: U NP Comments 2. Prepares IVPB and tubing. Inspects solution for additive and expiration date. Removes secondary IV tubing from package and closes roller clamp. Removes plastic protector from IVPB bag and uncovers tubing spike of secondary tubing while maintaining sterility of both. Squeezing drip chamber, inserts spike into IVPB bag outlet, inverts solution and suspends on pole. Fills drop chamber 1/3 to 1/2 full and opens roller clamp to clear IV tubing of air. 3. Aseptically connects tubing to proximal extension port of primary IV tubing. (above pump) 4. Lowers running IV solution lower than IVPB. (if required by pump or if no pump in use) 5. Opens roller clamp of IVPB and adjusts drip rate after correct calculation of flow rate and confirms IV flow. 6. After IVPB infused, closes roller clamp on secondary tubing and clears entire primary IV tubing line with required amount of sterile normal saline. 7. Disconnects primary IV line, cleanses saline lock extension port with alcohol and flushes with 3 ml sterile NS, closes clamp on saline extension line. 8. Standard protocol 9. State what you would document include calculation Additional comments: 92

13 NURS 143 Scenario 6: Video Skill Evaluation Procedure: Care of Patient with Pleural Chest Tube to Closed Chest Drainage Unit (CDU) Student Student Videographer Evaluator Recording Date Pass Fail Step Description Standard Protocol (Describe Only) Assess patient color, position, VS, lung sounds, respiratory effort, pain level. With gloves on, assess chest dressing for security, drainage. Check connecting tubes for kinks, pressure areas, dependent loops, secretions, and clots. State that if respiratory distress is present the major hazard is tension pneumothorax with the most likely cause being obstructed tubing If respiratory distress is present, state your nursing action would be to quickly assess the tubing s patency and notify the doctor immediately. Note if tidaling is present (fluctuation of fluid with inspiration / expiration in the water seal chamber / air leak meter - normal finding; absence = abnormal Check that chest drainage unit is at floor level and secure at all times including during transfers. For videotaping purposes, student may place chest drainage unit on a table. In a wet CDU, name the 3 chambers and describe use of each chamber (the collection chamber, water seal chamber and wet suction control chamber). In a dry CDU identify the collection and water seal chambers, the dial and indicator window (replaces the wet suction chamber in the wet CDU) Note color (bloody, straw-colored, or purulent), consistency (thick, thin), amount of drainage in drainage chamber (total since insertion or amount from last shift in ml) State where to note drainage between shifts (amount, date and time in chart and marked on collection chamber). Check level of fluid in water seal air leak meter section of the water seal chamber (2 cm). State that if the patient has a large pleural air leak you will see vigorous bubbling in this water seal chamber. If a wet CDU (e.g. Ocean, Rain), turn off wall suction briefly and note solution level in suction control chamber (20 cm). Refill with sterile H20 if needed. Turn wall suction back on continuous suction (usually set between to create gentle bubbling in suction control chamber). If a dry CDU (e.g. Sahara, Oasis, Cactus) check the dial is preset for an adult (20 cm). Make sure the suction source is turned up enough so that the orange baffle or float appears in the indicator window. State the dial would be adjusted lower than 20 cm for children Describe the purpose of the 1 or 2 clamps attached to suction unit (to be used during drainage unit replacement and for checking air leaks. These are unclamped immediately and never left on or patient could develop tension pneumothorax - a medical emergency!) Post Procedure Protocol (Describe Only): Include in your documentation your assessment, pain control, drainage, air leak, crepitus, condition of dressing, and any reports to physician per agency standards S U NP Comments Additional comments: 93

14 Nurs 143 Scenario 7 Video Skill Evaluation Category B Procedure: Tracheostomy Care Student: Taping Date:Videographer: Evlauator: Pass: Fail: S U NP Comments 1. Standard Protocol: Intro, identify, explain procedure, privacy, no pain assessment needed in most cases. 2. Apply gloves and other protective devices as needed; suction first if needed. 3. Assessment: With clean gloved hand gently pull off old trach dressing, noting amount, color and odor of secretions on dressing. Discard dressing. Assess condition of stoma and surrounding skin. Remove & discard gloves. 4. Establish / maintain a sterile field: Open trach kit box. Using sterile technique, remove sterile towel and place on a clean table, plastic side down. Touching only the outside of the box, carefully pour/place contents of trach kit box onto the sterile towel. Place trach kit box beside, but not on, sterile towel. Touching only the outside, remove small inner box from sterile field and place beside divided trach kit box, next to, but not on, sterile towel. 5. Prepare equipment: a. Fill small compartment of trach kit box with N.S. only. b. Fill large compartment of trach kit box with a mixture of 50% N.S. and 50% hydrogen peroxide. c. Put on sterile gloves d. Dip 1 gauze dressing and cotton applicators into hydrogen peroxide mixture. Squeeze out and put in extra, empty sterile container. e. Dip 1 gauze dressing into N.S. mixture, squeeze out and set to one side in extra container. 6. Designate non-dominate hand as a Clean hand and dominant hand as a Sterile hand. 7. Using clean hand, move trach mask aside, gently unlock and pull out inner cannula. Drop inner cannula into hydrogen peroxide mixture for soaking. Put trach mask back in place. 8. Cleaning & replacing inner cannula: a. Using sterile hand, pick up inner cannula touching only the end which is opposite the white end. Transfer cannula to the clean hand holding only the white end with the clean hand, not allowing your hands to touch each other. b. Using sterile hand, scrub off secretions from inner cannula using brush &/or pipe cleaners. c. When clean, drop inner cannula into N.S. to rinse. 94

15 S U NP Comments d. With sterile hand, remove cannula from N.S. and shake off excess N.S. e. With clean hand, move trach mask aside. f. Insert inner cannula back into outer cannula with sterile hand, using a slightly downward motion. g. Lock inner cannula in place. Note: Now this procedure becomes a CLEAN procedure, so both hands can be used as clean. (No need to keep dominate hand sterile.) 9. Using tissue forceps or gloved fingers, cleanse skin around stoma and under flange using gauze and cotton applicators dipped in the peroxide/n.s. mixture. Use gauze squares or applicators only once before discarding. Repeat until area is clean. 10. Rinse skin around stoma with gauze dipped in plain N.S. Use cotton applicators to clean dried secretions off of flange, if necessary. 11. Apply dry split- dressing. Replace trach mask. 12. Change trach ties if they are wet or soiled. Secure new ties before removing soiled ones to prevent accidental removal of trach during procedure. Use SQUARE KNOTS. 13. Documentation: Include condition of stoma, condition of skin around stoma, presence of drainage, amount, color, odor of drainage and how patient tolerated procedure. Additional Comments: 95

16 NURS 143 Video Skill Evaluation Scenario 8 - Category B Skill Procedure - Tracheostomy Suctioning Student Camera Operator: Evaluator Taping Date Pass Fail Step Description Standard Protocal - (Describe Only) Assess lung sounds, Sp02, VS, respiratory effort, pain level Hyperoxygenate to deliver 100% O2 when SpO2 of patient is below 92% - (Describe Only) Prepare equipment, put on protective equipment. Turn on wall suction. Check suction pressure, mm Hg with tubing occluded. Put on goggles or face shield. Using sterile technique, open package. Open cup. Fill cup with sterile NS. Put on sterile gloves. Designate clean and sterile hand With sterile hand, pick up sterile catheter about 5 inches from the tip. Attach catheter to suction tubing. Moisten catheter tip by dipping in cup with sterile NS. Apply suction to test presence of suction Remove patient tracheostomy mask with designated clean hand to expose opening. Without applying suction, gently and quickly insert catheter into trach opening. Insert with inspiration until resistance is met or patient coughs (about 4 in.) Withdraw catheter 1/2 inch before applying suction. Apply intermittent suction by placing and releasing thumb over catheter vent. Slowly withdraw catheter while moving catheter side to side between thumb and forefinger. Limit suction time to less than 10 seconds. Replace trach mask. Rinse catheter by dipping in cup with sterile NS and applying suction. Note amount, color and consistency of secretions. May repeat suctioning prn. Encourage patient to cough to check for more secretions. Suction as above prn. Assess patient s condition during and after each suctioning. Stop suctioning if HR increases by > 60 bpm or drops by < 40 bpm from baseline. Check Sp02 during and after procedure. Assess lung sounds, pain level and respiratory effort Document: color, odor, amount, consistency of secretions, VS, SpO2 Post Procedure Protocol (Describe Only) S U NP Comments Additional comments: 95