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CLINICAL QUICKVIEW ISBARR: IDENTIFY (self, taking to who, about) Æ SITUATION Æ BACKGROUND (history) Æ ASSESSMENT Æ RECOMMENDATION Æ RETURN (relay message back) 3A7IEN7¶6 5IGH76: PATIENT / MEDICATION / DOSE / TIME / ROUTE / REASON / RESPONSE / DOCUMENTATION / ASSESSMENT / EDUCATION / REFUSE created on August 2019 by Adriana Perez VITAL SIGNS INTRAVENOUS THERAPY INTAKE & OUTPUT CRANIAL NERVES ASSESSMENT BP 120/80 T 36 ± 37.5C (96.8 ± 99.5F) fever = 41C (105.8F) RR 12 ± 22/min HR 60 ± 100/bpm (*Apical/1 min) O2 sat 95 ± 100% 88 ± 92% (COPD) Pain 1-10 Q2H: assess tubing, IV site Q8H: SL Q72H: change IV site change IV tubing - CONT: Q96H - INTER: Q24H **label solution & tubing 125 mL: milk (small), jello (small), pudding, ice cream, sherbet, juice 180 mL: soup, broth, crystal light, lemonade, coffee tea 240 mL: milk (big), jello (big) I OLFACTORY close eyes & identify smell II OPTIC assess visual fields III OCULOMOTOR penlight for 6 ocular movements IV TROCHLEAR penlight for 6 ocular movements V TRIGEMINAL touch to face, clench teeth NORMAL: 1500 ± 2400 mL/24H 40 ± 80 mL/H ABNORMAL: < 500 mL/24H < 30 mL/h VI ABDUCENS move eyes side to side VII FACIAL smile/frown, raise eyebrows, taste VIII AUDITORY close eyes, check hearing Q4H: assess UO, drainage system & tubing Q8H: measure & document I&O IX GLOSSOPHARYNGEAL taste, move tongue up&down/L&R X VAGUS speech XI ACCESSORY shrug shoulders, turn head L&R MEDICATION ANTIDOTES THERAPEUTIC LEVELS XII HYPOGLOSSAL stick tongue out & move L&R acetaminophen N-acetylcysteine carbamazepine 4 ± 12 mcg/mL HOURLY ROUNDING (whiteboard) benzodiazepines flumazenil digoxin 0.5 ± 2 ng/mL PAIN ± POTTY ± POSITIONING POSSESSIONS ± PATHWAY ± PUMPS cholinergic crisis atropine sulfate gentamicin not > 2 mcg/mL digoxin Digibind lithium 0.5 ± 1.5 mEq/L SIX Ps heparin protamine sulfate magnesium sulfate 4.3 ± 7.3 mg/dL PAIN ± PALLOR ± PARALYSIS (late) PARESTHESIA ± PULSELESSNESS ± POIKILOTHERMIA insulin glucose phenobarbital 10 ± 40 mcg/mL magnesium calcium gluconate phenytoin 10 ± 20 mcg/mL BED POSITIONS opioid naloxone/Narcan valproic acid 50 ± 100 mcg/mL SEMI- FOWLER¶S = 15 -45 FOWLER¶S = 45± 60 warfarin vitamin K vancomycin 10-15 mcg/mL TRENDELENBURG = head low, feet raised EQUIVALENTS FORMULAS REVERSE TRENDELENBURG = head raised, foot lowered 1 kg = 1000 g 1 T = 3 t = 15 mL D/H x Q = X IV RATE: (mL/min) x (60 min/hr) = mL/hr DRIP RATE: (mL/min) x (gtt/mL) = gtt/min FLUID MAINTENANCE 0 ± 10 kg 100 mL/kg = 1000 mL > 10 kg 1000 mL + 50 mL/kg > 10 kg) > 20 kg 15000 mL + 20 mL/kg > 20 kg ARTERIAL BLOOD GASES DHS HOLDS 1 g = 1000 mg 1 t = 5 mL pH 7.35 ± 7.45 5150 (72H): DTS, DTO, GD 1 mg = 1000 mcg 1 L = 1000 mL PaCO2 35 ± 45 5250 (14 day): DTS, DTO, GD 1 g = 15 gr 1 cc = 1 mL HCO3- 22 ± 26 5260 (2 nd 14 day): DTS 1 gr = 60/65 mg 30 mL = 1 oz = 2 T PaO2 60 ± 100 5300 (180 day): DTO (1/150) gr = 0.4 mg 8 oz = 1 cup = (~) 240 mL alkalosis: n RR 5270 (30 day): GD 1 kg = 2.2 lb 500,000 U = 0.5 million U acidosis: p RR 6000: voluntary INSULIN TYPE ONSET PEAK DURATION INDICATION MIXING INSULINS RAPID ± lispro/Humalog (clear) 5 ± 15 min 30 ± 90 min 2 ± 5 hrs rapid BG reduction **clear BEFORE cloudy** inject air Æ NPH inject air & withdraw Æ regular withdraw Æ NPH SHORT ± regular/Humulin (clear) 30 min 2.5 ± 5 hrs 6 ± 8 hrs given 20 ± 30 min AC INTERMEDIATE ± NPH (cloudy) 1 ± 2 hrs 6 ± 12 hrs 18 ± 24 hrs given AC LONG ± glargine/Lantus (clear) 1 hr NONE 24 hrs control fasting BG MIXED ± NPH/regular 70:30 (cloudy) 30 min 4 ± 8 hrs 22 ± 24 hrs prevent hypo/hyperglycemia ELECTROLYTES p Na+ muscle weakness, HA, lethargy, confusion, seizures, ABD cramps, NV p K+ skeletal muscle weakness, EKG changes, (D) GI motility, irregular/weak pulse p Ca2+ anxiety, irritability, numbness/tingling around mouth, tetany, bruising, dysrhythmias, (+) TURXVVeaX¶V Vign (BP cXff = hand fle[eV) , (+) ChYRVWek¶V Vign (WaS cheek = WZiWch) p Mg2+ asymptomatic until 1 mg/dL, tetany, hyperexcitability: tremors, face twitch, ventricular tachycardia p PHOS weak muscles, tremors, paresthesia, bone pain n Na+ thirst, flushed/dry skin, agitation, impaired LOC, muscle twitching, seizure, coma n K+ EKG changes, tachycardia to bradycardia, GI hyperactivity, numbness/tingling in extremities n Ca2+ flabby/weak muscles, pain over bony areas, bradycardia, dysrhythmias n Mg2+ lethargy, drowsy, weakness, paralysis, deep tendon reflex loss, hypotension n PHOS tetany (+ p Ca2+), weak muscles, paresthesia: fingertips, mouth DIABETES MELLITUS BLOOD ADMINISTRATION - check ORDER & BG - draw up insulin & perform 2 RN independent double check - verify 3 pt ID (name, DOB, MRUN) & allergies - perform proper SUBQ injection insulin administration: rotate site, clean site, inject - apply pressure 2x2 gauze, no rubbing - check order & verify 3 pt ID - check labels on blood bag & transfusion record - baseline VS, use minimum 18 g + NS - blood administration set with filter - transfuse when Hgb < 7 or symptomatic - change blood tubing Q4H - infuse each unit over 2-4H ONLY **reactions occur within first 25 mins or first 50 cc HYPERGLYCEMIA 3 Ps: polydipsia, polyuria, polyphagia, fruity breath, blurred vision, hot, dry skin & mouth INTERVENTIONS: check BG, call MD > 200 mg/dL TRANSFUSION REACTIONS ALLERGIC: mild Æ hives, pruritis, facial flushing; severe Æ SOB, bronchospasm, anxiety FEBRILE: chills, fever, HA, flushing, tachycardia, increased anxiety HEMOLYTIC: low back pain, hypotension, tachycardia, fever, chills, CP, tachypnea, hemoglobinuria INTERVENTIONS - stop transfusion & notify MD - change IV tubing, O2, fluids, Epi - recheck cross match - obtain 2 blood samples distal to site - UA test (hemoglobinuria) & monitor F&E (Ca2+) HYPOGLYCEMIA cold, shaky, diaphoretic, dizzy, hunger, tachycardia, weak, HA, irritable, pale INTERVENTIONS: OJ, hard candy - recheck BG after 20 min, call MD if s/s do not stop ADVENTITIOUS LUNG SOUNDS CRACKLES: fine = high pitch @ end insp, coarse = low pitch @ insp & exp d/t HF, PNA, pulm edema WHEEZE: high pitch ³VTXeak´ d/W aVWhma, giYe bronchodilator RONCHI: low pitch, coarse, loud, snoring @ exp d/t chronic bronchitis PLEURAL FRICTION RUB: low pitch coarse grating @ insp & exp STRIDOR: harsh high pitch breathing d/t obstruction, anaphylaxis, epiglottitis

1 Created on August 2019 by Casandra Joseph MEDICATION x Medication administration 1. 8 rights 2. Identify pt with 2 identifiers (ask pt for full name, check the arm band for name and MRN (b day) 3. Ask pt for allergies 4. Check if pt is ready for meds 5. Scan meds into computer 6. Administer meds 7. Sign on computer INJECTIONS x Draw up meds with drawing up needle x Aspirate before giving IM injections Subcutaneous Intramuscular I &O x Water 480mL x Coffee 150 mL x Juice 112 mL x Milk 120mL (small) 236mL (large) x Styrofoam cup 150mL x Jell-O 120 mL x Ice ½ mL of solid occupancy x Broth dish 180mL x Ica cream 120mL NORMAL VITALS RANGES x Temperature: 36-37.5 C ± Oral 1 min ± Axilla/rectal 3 min x Pulse: 60-100 BPM 30 sec x2 Apical 1 min x Respiratory: 12-22/min 30 sec x 2 x O2Sat: 95%-100% HEAD TO TOE x Person, place, situation, date, suicidal thoughts x Any dizziness, difficulty swallowing/chewing x P.E.R.R.LA x Listen to heart x Listen to lungs front/back ± Crackles: fluid in lungs ± Rhonchi: gurgle sound may clear with cough (mucus) ± Wheezing: constriction x skin for any breakdown x Any sores on butt x Assess all pressure points x Stomach (assess, auscultate, palpate) x Last BM (color, consistence, trouble/pain going) x Any trouble peeing (any burning, discharge, color) x radial pulses, cap refill, squeeze fingers x legs any pain, tenderness, edema, sensation x Assess feet, cap refill, pulses x Have pt push against hands with feet ± In dorsiflexion and again with plantarflexion INSULIN Name Onset Peak Duration Indication Action Lispro (clear) 5-15 min 30- 90 min 2-5 hrs Rapid reduction of BG Rapid acting Regular (clear) 30min 2.5- 5 hrs 6-8 hrs Usually administered 20-30 min before meals Short acting NPH (cloudy) 1-2 hrs 6-12 hrs 18-24 hrs Usually taken after meals Intermediate Glargine (Lantus) (clear) 1 hour No peak 24 hrs Control fasting BG levels Very long lasting NPH/reg 70:30 (cloudy) 30 min 4-8 hrs 22-24 hrs Prevent hypo/hyper glycimia Combination ADMINISTER INSULIN x Supplies ± Insulin, insulin syringe, alcohol pre, 2x2 x Wash hangs x Roll intermediate or long actin insulin bottle between palms of hand to mix insulin x Clean vile with alcohol prep x Draw air into the syringe to match insulin dose x Inject air into bottle, turn the insulin and syringe upside down x Pull plunger down slowly to get insulin into syringe be sure to get number of unite Route Gauge Length Amount Angle Intradermal 25 , 26, 27 3/8, 1/2, 5/8 0.1 mL 15 Subcutaneous 25 , 26 3/8, 1/2, 5/3 0.5-1 mL 45-90 Intramuscular 20, 21 , 22 1, 1 1/2 1-2 mL Deltoid (0.5-1mL) 90

3 Created on August 2019 by Casandra Joseph ± Do not pretest balloon ± Retract the foreskin if uncircumcised ± Use non-dominant hand to grasp penis below glans, hold firmly upright (make OK sign with hand) ± Wipe with swab stick from the center of the meatus in a circular motion around glans ± Use all three swab sticks and discard off the sterile field ± Instill 10-15 mL Xylocaine gel into meatus ± Insert catheter & advance 6-9 inches or until you see urine & advance 1-2 more inches ± Ma\ aOVR adYaQce WR WKe bLIXUcaWLRQ aW WKe ³Y´ RI WKe catheter ± Inflate balloon with designated volume with dominant hand ± Gently pull back catheter ± After catheter in place, retract foreskin, if uncircumcised ± Secure catheter using stat lock & skin prep ± Hang collection bag to non-movable part of bed frame ± Wipe any remaining antiseptic or lubricant from perineal area ± Label time and date with labels provided in kit x Female 14-16 Fr ± Position: dorsal recumbent ± Lubricate catheter 1-2 inches of catheter ± Use non-dominant hand to spread the labia so that the meatus is visible ± Locate the meatus during the cleansing process ± Use separate iodine swab (cleansing ball) for the following Wipe top to bottom labia majora (one side) Wipe top to bottom labia majora (other side) Wipe top to bottom cleans directly over meatus ± Advance catheter 2 inches after urine begins to flow to ensure catheter is in bladder completely x Documentation ± Insertion 9/10/2015 14:00 inserted 14 Fr. Foley catheter using aseptic technique. Bulb inflated with 10 mLs sterile saline. Catheter secured to left inner thigh. 500 mLs clear yellow urine return noted in bag. Drainage bag to gravity. Pt tolerated procedure well. Provided teaching Side rails up 3 times, bed in low position, call light within reach. x Assess a minimum of every 4 hours ± Urine output ± Drainage system & tubing ± S/S UTI ± Bladder distention ± Measure and document I&O Q8 hours x Removal ± Gather equipment: bedpan, towel, clean gloves, sterile syringe (10mL) ± Drain bag & measure output ± Remove catheter securing device with alcohol swab ± Insert syringe into balloon port to withdraw fluid ± After fluid has been withdrawn, remove catheter and place in towel ± Provide urinal or bedpan (for next void) ± Determine time of first void (*8 hrs. inform MD) x Documentation removal ± Removal 9/15/15 14:00 250 mLs clear yellow urine emptied from Foley bag. Bulb deflated with 10 mLs of fluid return. Removed catheter using clean technique. Catheter tip clean and intact. Patient denies discomfort. Side rails up times 3, bed in low position, call light in reach. ± Voiding after removal o 9/15/15 1530 patient assisted to bathroom - 300 mls of clear yellow urine noted. Patient denies dysuria or discomfort. Assisted back to bed. Bed in low position, call light within reach OSTOMY x Assessment/Documentation ± Stoma (Q8 hrs): color, shape, bleeding ± Appliance (Q8 hrs): intactness, cleanliness ± Output (Q8 hrs): volume, characteristics ± Peristomal skin (with appliance change): intactness, maceration, redness/rash, itching ± Change appliance Q 7-10 days or when leaking ± Empty ostomy pouch when 1/3 full ENEMA x Position: Left Sims (left side lying, R knee flexed) x Lubricate tip (water soluble lubricant) x Insert toward umbilicus, 3-4 inches (past internal sphincter) x 100 ° F (37.7 ° C) x *Remember: instruct patient not to flush. Observe results to accurately document. x *Assess for F&E imbalances, fluid overload SPECIMEN COLLECTION x Sterile technique may be required for some samples (ex: urine/ wound) ± Transport to lab promptly ± Time may effect results x All Specimen Collection: Nursing Responsibilities ± Identify your patient (MRUN #) ± VeULI\ DU¶V order: Understand the order ± Use appropriate tube or container ± Print out labels & forms, fill out properly ± Label properly at bedside Directly under cap Name at the top Barcode straight x Blood Culture Specimen

4 Created on August 2019 by Casandra Joseph ± If possible obtain specimen before starting antibiotic therapy ± Scrub top of cultural bottle with alcohol pad, leave pad on top of bottle until blood is ready to be injected ± Should not be obtained from CVC unless MD order specifies it and CVC infection is suspected ± Cleanse site for 30 seconds with alcohol pad to remove excess debris ± Then clean aseptically clean the venous site with chlorhexidine (or iodine if pt is allergic) ± When drawing blood cultures specimen with other test draw blood cultures FIRST ± Blood culture bottles Blue-aerobic Yellow-anaerobic Grey top instead of blue if pt is on antibiotics ± Blood needs to be drawn from 2 peripheral sticks Both sticks need a blue or gray and a yellow top for a total of 4 bottles ± Aerobic (blue bottle) first ± Fill bottle 8-10 ml (line on bottle indicate 5ml) x Stool Collection ± Check MD order/rationale ± Explain procedure ± ID patient at bedside with specimen and label Ensure specimen label and lab requisition have correct information ± Send in bag to lab immediately Fresh specimens provide most accurate results ± Document Color, consistency, odor, amount x Urine Specimen ± Clean Catch Urine Specimens Identifies microorganisms causing UTI Collect in sterile specimen container Teach client to wash perineal area with soap and water Use antiseptic towelette Female: wipe front to back Male: use circular motion to clean urinary meatus, then down shaft Cleans from area of least contamination to most contamination. Use towelette once. ± Timed Urine Specimen Collection To start: have client void and discard the first urine then start collection If urine is discarded, the procedure must be UeVWaUWed« ± Indwelling Catheter Specimen Collection Obtain urine from closed drainage system Clamp drainage tubing below sample port: (about 30 minutes, allows fresh sample) Use needleless port, and Luer-Lok syringe Chloraprep port, aspirate urine, transfer to container Sterile urine from catheter Use needleless port to obtain urine specimens Scrub port with Chloraprep TM (scrub port for 15-30 seconds, allow to dry for 15 seconds) x Sputum Specimen ± Offer mouth care ± HeOSV Ļ PLcURRUJaQLVPV LQ WKe PRXWK ± Ask client to cough up sputum into specimen container (1-2 teaspoons) ± After offer mouth wash to remove any unpleasant taste ± Document color, consistency, odor Note presence of hemoptysis Note measures to obtain specimen Note patient discomfort (if present) x Nose Specimen ± Blow nose ± Check nostril for patency ± Insert swab slowly for 5 seconds to absorb sections, keeping the swab near the floor & the septum of the nose ± Remove swab & place in swab transport medium x Throat Specimen ± Collected from the mucosa of the oropharynx and tonsillar region using culture swab ± Insert swab along tonsils and areas of pharynx that are red or contain exudate ± Beware of the GAG ± Sit client upright ± OSeQ PRXWK«e[WeQd WRQJXe«Va\ AK« x Wound Culture ± Apply clean gloves & remove previous dressing ± Assess dressing for: drainage, color, odor, consistency ± Assess wound ± Apply sterile gloves and assess wound ± Cleanse the wound ± Remove residual antiseptic prior to culture ± Using sterile gauze pad ± Discard gloves & perform hand hygiene ± Apply clean gloves ± Open specimen tube and place on sterile surface to prevent contamination ± Rotate the swab back and forth ± Do not touch swab to intact skin at the wound edges ± Return swab to culture tube ± Crush the transport medium at the bottom of the tube ± May need specimens from multiple sites ± Label appropriately GI TUBES x Decompression: max suction 120 ± Assessment Q4 hours o Respiratory distress o Patency of tube

6 Created on August 2019 by Casandra Joseph x NGT Feeding ± Verify Order ± Gather supplies ± Wash hands ± ID patient ± Explain what & why ± Don Gloves ± Pre-Feeding Assessment Check bowel sounds Check placement Check residuals ± Continuous Feeding Place feeding tubing into pump Determine how much feeding into bag or spike bag Label bag Kangaroo pump o Prime o Program rate o Program volume to be delivered o Program routine flushes CRQQecW WR SaWLeQW WKeQ ³RUN´ Document ± Deliver Bolus Feeding Deliver bolus via Kangaroo pump Use intermittent feature Max rate of 400mL/hr Program for one feeding only UVe ³IOXVK QRZ´ IeaWXUe Disconnect and cover tip x NGT REMOVAL ± Assess for bowel sounds ± Prevent aspiration: Patient position: High- FRZOeU¶V Clear tube w/ 50mL air Have patient hold breath during removal ± Protect self from splashes TRACHEOSTOMY CARECARE x Three interventions to perform on patient prior to suctioning ± ID patient ± Respiratory Assessment ± Establish communication via hand signals x Six objects that must be in the room prior to suctioning ± Obturator ± Extra boxed trach or inner cannula ± O2 wall/tank set up (with tubing) ± Ambubag ± Suction setup (including suction canister and tubing) ± O2 Sat machine (especially if 02 Sat is low) x Equipment ± Bedside Obturator, Extra boxed trach or inner cannula, O2 wall/tank set up (with tubing), Ambubag, Suction setup (including suction canister and tubing), O2 Sat machine (especially if 02 Sat is low) ± Procedure Tracheostomy Clean and Care Tray o Pack: Tray (with 3 sections),Vinyl Gloves, Drape, 2 Pipe Cleaners, 2 Gauze, 5 Cotton Tip Swabs, Trach Dressing, Brush, Twill Tape, Hydrogen peroxide Saline. x Check orders first (for when the trach was placed, size of trach & for 02) x Check to see when the last time the skill was done on the patient x Perform hand hygiene x Introduce yourself and ask for permission to clean tracheostomy site. x ID your patient (since probably cannot talk, check name, DOB, MRUN, & FIN# against ID band) x Explain to patient what you will be doing x Clean bedside table x Offer privacy x Remember to loosen caps of bottles (NS and/or H202) prior to opening up packages (if bottles have already been opened and used lip the bottle by pouring a little bit out first into sink or trash) x Open Pack, pull out sterile drape and apply to bedside table x Put supplies on sterile field [DO NOT put the Tracheostomy Kit itself in sterile field] x Pour cleaning solutions. About 50mL of H202 and 50mL of NS to large section of tray. Then fill NS only to both smaller sections of tray x With clean gloves remove old dressing and observe it as well as the site [look for any redness, skin breakdown, inflammation, or infection] x Now stabilize the outer cannula and the base plate (flange) of the tracheostomy with one hand, rotate the lock of the inner cannula and with a counter clockwise motion with your other hand to release it from the outer cannula. x Continue to hold the base plate and gently remove the inner cannula and stick it in the H202/ NS solution x Apply sterile gloves x Place all cotton tipped applicator sticks in one of the smaller Normal Saline compartments x Moisten the brush and scrub the inner cannula [the hand KROdLQJ WKe WRS eQd RI WKe LQQeU caQQXOa LV QRZ ³dLUW\´] x Use back & forth motion to loosen and remove secretions x Place inner cannula in the section of the try with NS ± Agitate inner cannula in NS to rinse off H202 x Then remove the inner cannula from NS, tap it against the inner surface of basin to shake off extra moisture x Dry inner cannula with pipe cleaners x Reinsert inner cannula and lock in place [with dirty hand] x Reattach O2 or check if pt needs two puffs of air form the ambubag

7 Created on August 2019 by Casandra Joseph x Cleanse tracheostomy site ± Clean by using applicator sticks to clean skin beneath trach. Repeat as needed to remove secretions. Use one stick to clean flange. [dirty hand can lift the flange for cleaning] ± Place dry clean drain sponge (4x4) underneath trach tube flanges (plate) [sterile hand to get and place 4x4, dirty hand can lift flange] ± Change trach ties, supporting the outer cannula at all times (may need a second person to assist)[we are done with sterility] ± Start on side furthest from you (have pt look toward you to make it easily assessable) ± DO NOT remove old ties until the new one is in place ± Make sure to check sizing of trach ties to assure that one finger can be placed under the ties. Also examine neck for sores, erythema, or skin breakdown. ± Place O2 back on pt ± Discard all contaminated supplies in appropriate biohazard (red) container ± Wash hands x Document procedure ± Date and time of procedure Note size and type of trach Describe cOLeQW¶V WROeUaQce RI SURcedXUe Record amount and consistency of secretions - thick (tenacious), watery (thin), scant (small amount), copious (large amount), frothy (with bubbles), color-clear, white, yellow, green, gray, brown, bloody, and any odor x Assess the Following a Minimum of Every 4 Hours ± VS ± Resp. pattern & lung sounds ± Chest expansion ± Use of accessory muscles (retractions, nasal flaring) ± Secretions ± Cough ± Skin and nail bed color ± Pressure Ulcers ± Suture site for new trach ± Infection ± Cuff leak ± Pulsating trach ± Need for suctioning minimum of q 4hrs, prn and after nebulizer Tx ± O2 sat ± Need to change disposable inner cannula minimum of q 8hrs x Tracheostomy Tube Care ± Clean site q 8hrs or more frequently if soiled ± Clean non-disposable inner cannula q 8hrs with 1:1 H2O2/NS mixture and rinse with NS or with solution as ordered. Hold plate to stabilize trach tube while removing & replacing inner cannula ± Change disposable inner cannula with same size cannula when soiled or at least every 72 hrs. ± Change trach ties/Velcro holder q 24hrs or more frequently if soiled. If new trach, see MD orders SUCTIONING A TRACHEOSTOMY x Three interventions to perform on patient prior to suctioning ± ID patient ± Respiratory Assessment ± Establish communication via hand signals x Six objects that must be in the room prior to suctioning ± Obturator ± Extra boxed trach or inner cannula ± O2 wall/tank set up (with tubing) ± Ambubag ± Suction setup (including suction canister and tubing) ± O2 Sat machine (especially if 02 Sat is low) x Get equipment. ± Suction kit 1 suction catheter Sterile gloves ± Normal saline ± Towel ± Connect suction to wall and make sure it is on x Introduce yourself, let pt know what you will be doing and ask permission to do suction. Check ID band while doing this. x Place in proper position, raise HOB. x Put a pad (or towel) across chest. x Get suction tubing (not catheter) and check that it is at the right amount of pressure. x Have ambubag close by. x Mask, goggles and gown not needed unless isolation or you feel the need to protect yourself in this manner. x Clear bedside table (clean it also if dirty.) x Open up the suction kit, open up the bottle of saline. x Put on the sterile gloves. x Pick up suction catheter with dominate hand by the chimney valve, then with non-dominate hand wrap the remainder of the tubing around the middle, ring and pinky finger x Then using your non-dominant hand, pour NS into the empty suction tray (you can lip the bottle by pouring out a small amount into trash). x Your dominant hand must remain sterile during the procedure, while your non-dominant hand is considered clean rather than sterile. x With your non-dominant gloved hand pick up suction tubing and connect the tubing to the suction catheter. x Moisten the catheter by dipping it into the sterile saline solution and occlude the chimney valve with your thumb to give it the proper suction. The saline should move up the catheter and tubing into the collection canister on suctioning. This checks if suction power is working.

9 Created on August 2019 by Casandra Joseph o If all connections are secure and checkmark does not reappear replace unit If check mark still does not appear call MD ± Assess patency of chest tube If drainage blood, pus, any thick fluid appear in the tubing, milk the tubing by progressively pinching and releasing along the length of the drainage tubing ± Assess collection chamber if drainage has spilled into other compartments of collection chamber Measure amount in each chamber and calculate to determine total amount If drainage spills into suction or water seal change the system ± Change entire system when chamber is full ± Assess for disconnection of drainage system from chest tube Clean with chlorohexidine both ends and reconnect If contaminated create water seal with a bottle of sterile water or NS until new drainage system is set up or MD arrives ± Assess for dislodgment of chest tube o Place 4X4 over chest tube incision site and tape only 3 sides o Notify MD ± Assess for dependent loops in CT drainage Coil on bed Maintain drainage system at foot of bed and tubing straight from pt to collection chamber Maintain drainage system below the pt chest level ± NEVER CLAMP CHEST TUBE x Assess every 4 hours ± Vital signs ± Pain ± Dressing ± Chest tube system ± Pleural chest tube Breathing pattern, quality, symmetry S/S of tension pneumothorax o Hypotension o Tachypnea o Tachycardia o Respiratory distress o Unilateral diminished or absent breath sounds ± Mediastinal ECG S/S of tamponade o Narrowed pulse pressure o Tachycardia o Tachypnea, x Mark drainage section ever 8 hrs x Every 2 hours cough and deep breath x Every hour use incentive spirometer 10 times x Change dressing every 3 days x X-ray post insertion and daily after that BLOOD WITHDRAWAL x Normal blood draw ± Gather equipment Butterfly needle with vacutainer, tourniquet, vacutainer, chlorhexidine, 2x2, band aid/ tape, tubes to put blood in, labels ± Preparing patient Pt identifiers Double check that the patient's name matches the name on the labels Ask if the patient has any allergies or has had any issues or complications during previous blood draws Ask the patient to extend their arm and place a clean towel or paper underneath. Explain the blood draw procedure and get verbal consent. ± Locate the vein Look for a good size viable vein Apply the tourniquet 3 to 4 inches above the venipuncture site. ± Disinfect site Cleanse the site with an chlorhexidine by starting from the center of the venipuncture site and working outwards, covering roughly 2-4cms Be sure to allow the area to dry to reduce the risk of contamination. Be sure to NOT touch the disinfected site. If site has been touched or contaminated, repeat the cleaning process. ± Draw blood Place your thumb BELOW the venipuncture site to anchor the vein. Be sure not to touch the venipuncture site or you will need to repeat the cleaning process. Have the patient ball up their hand (form a fist). With bevel of the needle pointing up puncture the vein quickly and at a 30 degree angle or less. Attach the tube and full to the correct amount o Tube order ¾ Direct draw (order of draw) Blue, gold, lavender, pink, gray ¾ Transfer method Blue lavender, pink, gold, gray Once the blood has been collected leave the last tube collected, first release the tourniquet and then release the tube. Slowly withdraw the needle and gently apply pressure to the puncture site with a clean gauze or cotton ball. Have the patient hold the gauze or cotton on the site with their arm extended. Apply tape or band aid Discard needle in the sharps container Apply labels o Sticker and date, time, initials

10 Created on August 2019 by Casandra Joseph Slowly invert tube to mix with solution in the tube Inform pt not to bend arm because this can cause a hematoma Also the tape can be removed in 1 hour x Blood Draw Central Venous Catheter ± Make sure to pause anything currently infusing for at least 5 min ± Supplies 2 Chlorhexidine, two 10 ml syringe or greater, three 10 ml flush, curos (green cap), transfer set ± Identify pt ± Double check that the patient's name matches the name on the labels ± Cleans the IV port for 15-30 sec ± Attach the 10ml flush and unclamp the lower lock flush the line ± After the flushing the line use the now empty flush to withdrawal 4-6 ml for the blood discard and re-clamp the line ± Attach 2 nd syringe unclamp and withdrawal the amount needed for the blood sample and then re- clamp ± Attach flush unclamp line, flush line with 20ml, and then re-clamp line ± Clean catheter tube with chlorhexidine and recap ± Attach the blood filled syringe to the transfer set ± Fill tubes in appropriate order ± Labe the specimen tubes ± Discard the syringe and the transfer set in the sharps container INTRAVENOUS INSERTION x Gauge of needle 24 Infants, children, elderly, adults with small veins, 20 and 22 Suitable for most infusions an applicable to all age groups 18 Blood administration, caustic or viscous fluids 16 Large volume of fluids, trauma pt, major Sx x Start distal as possible x Try not to use dominate hand x Change every 96 hours (4day) ± May stay longer if venous access is limited ± IV site longer than 4 days must be justified by the physician and documented by the RN x IV site in use assessed every 2 hours x IV site not in use assessed every 8 hours x No more than 3 attempts on a pt x Gather equipment ± IV starter kit, chlorhexidine (or iodine if pt is allergic), 2 needles, flush, towel, stat lock x Preparing patient ± Pt identifiers ± Instill normal saline into the IV extension set ad set aside ± Prepare saline lock tape ± Place towel underneath pt arm x Finding a vein ± Tie tourniquet 4-6 inches above insertion site x Site preparation ± Use chlorhexidine to clean site in a circular motion and allow to dry x Insertion techniques ± Remove needle cover ± Hold catheter hub and rotate barrel 360 degrees ± Make sure the push take is facing up ± Use non dominate hand to pull the skin taut below the entry site ± Place needle at an angle (approximately 10 -30 degrees) and insert the needle bevel up in to the skin ± Once you see the flash lower the catheter angle and advance the catheter and the needle slightly ± Push the catheter off the needs and into the vessel until the hub it at the venipuncture site ± Release the tourniquet ± Apply pressure above the catheter hub and retract the needle ± Attach the extension set and flush ± Apply tape to stabilize ± Apply skin protector and allow to dry completely ± Apply Statlock ± Apply Tegaderm ± Date, time, gauge, initial site x Blood Culture Specimen ± If possible obtain specimen before starting antibiotic therapy ± Scrub top of cultural bottle with alcohol pad, leave pad on top of bottle until blood is ready to be injected ± Should not be obtained from CVC unless MD order specifies it and CVC infection is suspected ± Cleanse site for 30 seconds with alcohol pad to remove excess debris ± Then clean aseptically clean the venous site with chlorhexidine (or iodine if pt is allergic) ± When drawing blood cultures specimen with other test draw blood cultures FIRST ± Blood culture bottles Blue-aerobic Yellow-anaerobic Grey top instead of blue if pt is on antibiotics ± Blood needs to be drawn from 2 peripheral sticks Both sticks need a blue or gray and a yellow top for a total of 4 bottles ± Aerobic (blue bottle) first ± Fill bottle 8-10 ml (line on bottle indicate 5ml) CENTRAL VENOUS CATHETER DRESSING CHANGE x Check order to make sure PICC line is ok to use, last time it was changed, what number the pic line should be at x Supplies ± Central line kit