NURSING SKILLS CLASS - Langara College · The Nursing Skills Class complements the theoretical component by teaching you the hands- on nursing skills that supports people’s healing

NURSING PROGRAM

NURSING 2250

HEALING I

NURSING SKILLS CLASS

TERM III

SECTION 1 & 2

Revised by Salima Bhanji August 2006

Langara

College

Fall 2

006 -

archive

d

Nursing Skills Class

Page 2 of 85

Welcome to Nursing Skills, a component of Nursing 2250 - Healing I.

This packet includes information about the course and learning activities. Other learning activities may be distributed

during the term.

Have a pleasant and fun semester! La

ngara Colle

ge

Fall 2

006 -

archive

d


Page 3 of 85

SCHEDULE FOR NURSING SKILLS CLASS (N2250) SECTION 1 & 2

FALL 2006 A-369

WEEK

DATE

CLASS CONTENT

1 SEPT 8 Introduction to Term III Skills Class O2 Therapy (Low & High Flow), Nebulisers Infection Control – Standard and Transmission Based Precautions

2 SEPT 15 Anatomy of a Syringe Withdrawing Medications from a Vial Administering IM Medications – Single Medications

3 SEPT 22 Withdrawing Medications from an Ampoule Administering SC Medications – Single Medications Administering SC Medications through SC Butterfly Cannulas

4 SEPT 29 Administering Mixed Medications

5 OCT 6 Quiz #1 Administering IM Meds via Z-track Method Consolidation and Practice for Injectable Medications

6 OCT 13 Safe Practice Appraisal #1 – Injectable Medications

7 OCT 20 Review of Quiz #1 Regulating & Maintaining Peripheral IV Infusions

8 OCT 27 Conversion of a Continuous IV to a Saline Lock Introduction to Surgical Asepsis Sterile Gloving

9 NOV 3 Introduction to Wound Care Closed Wounds - Incisional Care

10 NOV 10 Open Wounds – Pressure Ulcers Irrigation

11 NOV 17 Quiz #2 Consolidation and Practice for Wound Care

12 NOV 24 Safe Practice Appraisal #2 – Wound Care

13 DEC 1 Review Quiz #2 Comprehensive Review of Skills Content

Langara

College

Fall 2

006 -

archive

d


Page 4 of 85

TABLE OF CONTENTS

COURSE OUTLINE

Course Description 5

Summary of the Distribution of Marks 10

LEARNING ACTIVITIES

Clients Requiring Oxygen Therapy 12

Clients Requiring Asepsis – Infection Control 14 Clients Requiring Parenteral Medications – Introduction 21 Clients Requiring Intramuscular Injections 23

Clients Requiring Subcutaneous Injections 33

Clients Requiring Mixed Medications for Injections 41

Clients Requiring Peripheral Intravenous (IV) Infusions 49

Clients Requiring a Conversion from an Existing IV to a Saline Lock 62

Clients Requiring Asepsis – Simple Wound Care 67 Clients Requiring Asepsis – Sterile Gloving 74

APPENDIX

Appendix I – Clients Requiring Controlled Volume Infusions 77 Appendix II – Intravenous Therapy and Medication Policy 79

Langara

College

Fall 2

006 -

archive

d


Page 5 of 85

CCOOUURRSSEE OOUUTTLLIINNEE COURSE DESCRIPTION

Nursing 2250 is divided into two different Healing Workshop (Healing I) and Nursing Skills Class and the classes complement each other. In the healing class you will learn the theory behind people’s experience in healing from an episodic health challenge. The Nursing Skills Class complements the theoretical component by teaching you the hands- on nursing skills that supports people’s healing. For example in your healing class, you will learn about fluid and electrolyte balances and imbalances created by various health challenges. In your skills class, you will learn how to administer and maintain intravenous fluids required to assist the body’s return to homeostasis. In addition, theoretical concepts such as pain, transition, anxiety/fear, vulnerability, healing and trust are incorporated into the learning activities associated with each new psychomotor skill.

This Nursing Skills Class will give you the opportunity to develop nursing skills, interpersonal skills, organizational skills, pattern recognition, critical thinking, clinical judgment and decision making skills in simulated situations involving episodic health challenges. Finally, knowledge and skills learned within the Nursing Skill classes are integrated into Nursing practice classes and Nursing praxis. ENDS-IN-VIEW Participants will have the opportunity to: • Learn skills related to the concepts of asepsis, therapeutic agents/modalities,

assessment, and safety. • discuss the purpose, principles and rationale involved with each practice skill • practice the psychomotor skill in the context of the whole person using critical

thinking and clinical judgment • demonstrate the critical components of all skills including: assessment, comfort,

privacy, asepsis, teaching, safety, organization, resources, body mechanics, documentation

• understand self-evaluation • Practice safely.

Langara

College

Fall 2

006 -

archive

d


Page 6 of 85

PROCESS

Although the NERC setting differs from clinical practice, the facilitators have simulated nurses’ work by situating nursing skills in the context of practice through paradigm cases. You will use previous cognitive, organizational, and communication skills you learn the concepts and skills in Term III.

In order to be successful in the Nursing Skills class you should think about and practice the ABC’s.

is for attendance. You are expected to attend all Nursing Skills Classes. Class time will be from 0830-1130 Friday morning. Attendance will be

taken at the start and at the end of the lab. It is your responsibility to sign in and out of the labs on the signature sheets provided. All missed hours will be recorded on your performance appraisal face sheet. If you are sick and unable to come to class, please leave a voice mail for me @ 604-323-5808 before 0830 on the day of the lab. If you miss a lab it will be your responsibility to acquire the learning on your own. The facilitator and the lab demonstrator will not re-teach the lab.

is for be prepared. In order to maximize your learning opportunities in lab, it is important that you complete the “IN PREPARATION” section of the

required learning activity prior to the lab. The skills learned in Term III lab are more complex then those learned in Term II. Students who come prepared learn the concepts and the skills in more depth then those who are not prepared. This can make a critical difference to your anxiety level when it comes time for your competency appraisal.

As a courtesy to others, please come to class on time. Space is at a premium in the lab so please put your packs and coats on the book racks provided. While in the lab we ask that you tie your hair back and wear your Langara ID. Return all equipment, chairs and supplies to their proper places before leaving the lab.

is for contribute. Participation is critical when learning. Your active involvement in lab, by asking questions or problem solving with a peer

will enhance your learning and your enjoyment of the learning process. Practicing with peers as well as supervised practice sessions will increase your comfort with the skill and your confidence in your ability to perform the skill.

A

B

C La

ngara Colle

ge

Fall 2

006 -

archive

d


Page 7 of 85

CONCEPTS

The learning activities will also reflect the concepts from Healing I and include; pain (acute), transition, anxiety/fear, unpredictability, vulnerability, healing, trust, and control.

Practice skills include the concepts of asepsis, assessment, mobility/immobility, therapeutic modalities, and irrigation/drainage. When learning and practicing skills in context you will need to apply and understand:

1. Relevant principles, procedures and rationales 2. Psychological and physical patient comfort 3. Privacy 4. Asepsis 5. Teaching 6. Safety 7. Organization (sequence and time) 8. Resources (equipment and human) 9. Body mechanics (for client and self) 10. Documentation

RESOURCES

Several different types of resources will be utilized in Nursing Skills class. This will include your facilitator, the lab demonstrator, WebCT, videos, demonstrations, models, computer assisted learning, and readings. 1. Facilitators: Section 1: Maureen Maloney Section 2: Salima Bhanji Office: B010-d Office: B153-f Phone: 604-323-5758 Phone: 604-323-5808 E-mail: [email protected] E-mail: [email protected] 2. Lab Demonstrators:

Judith Grieve & Monica Chan Office: A371

Phone: 604-323-5244 E-mail: [email protected] & [email protected]

3. Quiz marks will be available through WebCT. The calendar will contain the lab

schedule, dates for competency appraisals, and reminders and messages. If you are not familiar with WebCT an orientation can be found at http://gambit.instruct.langara.bc.ca/edtech/webct_orientation

Langara

College

Fall 2

006 -

archive

d

mailto:[email protected]



http://gambit.instruct.langara.bc.ca/edtech/webct_orientation


Page 8 of 85

4. Readings will be assigned from the following texts: Abrams, A., Pennington, S. & Lammon, C. (2004). Clinical drug therapy: Rationales

for nursing practice. Philadelphia: Lippincott, Williams and Wilkins. Buchholz, S. (2006). Henke’s Med-Math: Dosage calculation, preparation &

administration. Philadelphia: Lippincott, Williams & Wilkins. Kozier, B., Erb, G., Berman, A., Burke, K., Bouchal, D., & Hirst, S. (2004).

Fundamentals of Nursing: The nature of nursing practice in Canada. Toronto: Prentice Hall.

Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical surgical nursing:

Assessment and management of clinical problems. St. Louis: Mosby. Weber, J. & Kelley, J. (2003). Health assessment in nursing. (2nd edition).

Philadelphia: Lippincott, Williams and Wilkins. EVALUATION

The final mark for N2250 consists of your marks from Healing Workshop, the Episodic Health Challenge Paper and the Nursing Skills class. The Nursing Skills Class will make up 40% of your final mark.

Learning in the Nursing Skills class will be evaluated through quizzes, a final comprehensive exam and safe practice appraisals. Quizzes

Quizzes will accompany each sage practice appraisal. All quizzes will be multiple choice questions that test your knowledge of the theory and practice facts related to your learning in Nursing Skills class. Final Exam

The final will be a comprehensive exam written in the exam period. It will be worth 10 marks and test your knowledge at an application level of knowledge or higher using clinical based scenarios.

Langara

College

Fall 2

006 -

archive

d


Page 9 of 85

Safe Practice Appraisals In Term III the Safe Practice Appraisals are done with the instructors and the lab

demonstrator functioning as evaluators. The Safe Practice Appraisal will occur during regular lab hours. During your Safe Practice Appraisals you will be expected to apply the principles, procedures and rationales as per the 10 Critical Components of a Skill:

1. Assessment 2. Comfort – physical and psychological 3. Privacy 4. Asepsis 5. Teaching 6. Safety 7. Organization – sequence and time 8. Resources – equipment and human 9. Body mechanics – self and patient 10. Documentation If you are successful on your first appraisal you will receive 4 marks. If you are not

successful in your first attempt you will have another opportunity to repeat the appraisal AFTER practicing in the lab. If you are successful on your second attempt you will receive a score of 2 marks. If a third attempt after practice is made and you are unsuccessful you will receive a mark of 0. After this, 2 marks will be deducted for each unsuccessful attempt from your Quiz. Note: there are a limited number of opportunities for a student to demonstrate their practical competency. You will not be permitted to perform the skill in clinical until you are successful in your Safe Practice Appraisal.

Langara

College

Fall 2

006 -

archive

d


Page 10 of 85

SUMMARY OF THE DISTRIBUTION OF MARKS FOR NURSING SKILLS CLASS

Quiz #1 6 marks

Safe Practice Appraisal #1 – Injectable Medications 4 marks

Quiz #2 6 marks

Safe Practice Appraisal #2 – Wound Care 4 marks

Final Exam (Written during the final exam week) 20 marks

Total value of marks from Nursing Skills class 40 marks

Nursing Skills Class accounts for 40% of the final mark for N2250.

In order to be successful and progress to the next term, students must achieve a cumulative mark of 60% in both N2250 theory and skills class.

Langara

College

Fall 2

006 -

archive

d


Page 11 of 85

LEARNING ACTIVITIES

Langara

College

Fall 2

006 -

archive

d


Page 12 of 85

Learning Activity

Clients Requiring Oxygen & Nebulization Therapy -

- Health perception & Health Maintenance, Therapeutic agents/modalities, Assessment

CONCEPTS: TRANSITION,

VULNERABILITY, HEALING, SUFFERING, RESIILIENCE/HARDINESS, CONTROL

OVERVIEW Oxygen is precious to life and when it is compromised in any way individuals can experience an array of feelings. Dyspnea, or shortness of breath, is a common symptom of many chronic health challenges and requires individuals to use excessive effort to obtain oxygen (Craven & Hirnle, 2003). Individuals experiencing dyspnea (http://www.alcase.org/education/symptoms_dyspnea.html) have described this symptom as ‘being unable to catch their breath’ or ‘air hunger’. "It can make you feel as if you can't get enough air into your lungs. Dyspnea is a frightening sensation as it feels like suffocation. Episodes of dyspnea can easily begin a vicious cycle of breathlessness and panic as it feels like being deprived of air. As your anxiety level increases, you consume more oxygen, and in turn worsen the sensations. It is essential for nurses to assess factors that hinder normal breathing and to implement healing modalities to reverse the cycle of breathlessness. Clients with compromised air entry and breathing difficulties may benefit from Oxygen therapy. Oxygen therapy supplies an individual with supplemental amounts of oxygen in concentrations greater than found in atmospheric air. Medications delivered into the tracheobronchial tree via inhalation can also restore normal air entry. This method delivers the medication immediately and is not associated with parenteral or oral medication administration complications. There are two common types of delivery or aerosol nebulization therapy – the small volume jet and the direct inhaler (DuGas, Esson, Ronaldson, 1999). ENDS –IN- VIEW

• To identify the factors that promotes or hinders health respiratory functioning • To distinguish normal from adventitious breath sounds upon chest auscultation • To develop beginning skills of a respiratory assessment • To document assessment findings • To understand the rationale for the use of oxygen and aerosol nebulization

medication therapies • To identify and practice using the specific equipment related to oxygen and aerosol

Langara

College

Fall 2

006 -

archive

d


Page 13 of 85

nebulization medication therapies • To understand the relevance of measuring oxygen saturation levels pre and post

oxygen and aerosol nebulization medication therapies IN PREPARATION 1. From this course packet:

Read the learning activity on Clients Requiring Oxygen & Nebulization therapy

2. Read:

Kozier, Erb et al (2004), Chapter 39, p.1019 - 1052 Weber & Kelley (2003), Chapter 14 Abrams, Pennington & Lammon (2007), Chapters 44 – Drugs for Asthma and other Broncho-constrictive disorders.

3. For class:

Wear loose fitting clothes Bring your stethoscope

Langara

College

Fall 2

006 -

archive

d


Page 14 of 85

Learning Activity

Clients Requiring Asepsis: Isolation Precautions

- Asepsis, Safety, Health perception & Health Maintenance, Assessment


VULNERABILITY, HEALING, SUFFERING, RESILIENCE/HARDINESS, CONTROL,

OVERVIEW “A major concern of health practitioners is the danger of spreading micro organisms from person to person and from place to place. Micro organisms are naturally present in the environment, where some are helpful and some are not. As the primary care giver the nurse needs to be involved in identifying, preventing, controlling and teaching clients about infection” (Taylor, 1997, p.556). The practice of asepsis assists in preventing the spread of infection. There are 2 types of aseptic techniques – medical and surgical. Medical asepsis or clean technique includes practices that decrease the number and transfer of pathogens, e.g. hand hygiene; it cannot be repeated too often. Standard Precautions are used for all clients since it is not always known when a client has an infection. However, situations exist where additional precautions are necessary to prevent the spread of infections. Depending on the nature of the infection, clients may also require additional or Transmission Based Precautions to prevent the spread of an infection. These precautions may include the utilizing of specific Personal Protective Equipment (PPE) masks, gloves, gowns, goggles, face shields, or even placing the client in an isolation room with or without negative air pressure. ENDS-IN-VIEW

• To apply the principles of medical asepsis. • To review the chain and stages of infection, and the body’s natural defence

system. • To identify clients at risk for developing infections (external and/or hospital

acquired). • To understand the modes of transmission and Transmission Based Precautions. • To understand and apply the use of Standard Precautions and Personal Protective

Equipment (PPE) with the transmission based precautions. • To explore the effects and strategies to alleviate the effects of isolation on clients

and their families. • To demonstrate the correct application, removal and disposal of PPE.

Langara

College

Fall 2

006 -

archive

d


Page 15 of 85

IN PREPARATION 1. Before the scheduled infection control class review the following video:

Superbugs Call Number – QR 177 S96 1998

2. From this Course Packet:

Read the learning activity on Clients Requiring Asepsis: Infection Control Review the case scenarios and their infectious diseases

Complete the Study Guide for Clients Requiring Asepsis: Infection Control

3. From Kozier, Erb et al (2004), read: Chapter 32, p.743 – 768, Infection control for health care workers, p.770 - 778

IN NERC In pairs or small groups complete the activities related to the scenario. Be prepared to share your learning with the large group. IN NURSING PRACTICE Review the policies and procedure manual for the various types of Transmission Based Precautions used in your agency. IN REFLECTION

• How would you empower a client who requires isolation precautions? • How do you feel about caring for a client that has a transmittable infection? • How do you feel about caring for a client who requires isolation precautions? • How will you explain isolation precautions to the client’s family and/or visitors? • With respect to confidentiality, should signs outlining the specific isolation

precautions required be posted outside the client’s door?

DID YOU KNOW . . . Hand hygiene is the single most important measure for preventing the

transmission of infectious diseases.

Langara

College

Fall 2

006 -

archive

d


Page 16 of 85

STUDY GUIDE FOR

CLIENTS REQUIRING ASEPSIS: INFECTION CONTROL 1. In your own words, describe the sequence of applying and removing masks, gowns

and gloves when entering and leaving an isolation room. 2. Define pathogen.

3. What is an antibiotic resistant microbial strain and why do they occur?

4. What are the 2 most common antibiotic resistant microbial strains?

5. Define virulence.

6. Differentiate between medical and surgical asepsis.

7. Define and provide and example of the infection:

i. Contact precautions

ii. Airborne precautions

iii. Droplet precautions

8. Define protective isolation.

9. Differentiate between:

i. Local vs. systemic infection

ii. Acute vs. chronic infection

10. Describe the psychological effects of isolation.

11. What is a hospital acquired infection? Give examples.

12. Which body system(s) is/are the most common site(s) for a hospital acquired

infection?

13. Describe the stages of infection.

Langara

College

Fall 2

006 -

archive

d


Page 17 of 85

PRACTICE SCENARIOS

READ EACH SCENARIO AND SELECT AN ANSWER(S) FOR EACH CORRESPONDING

QUESTION. Scenario #1:

A 20 year old male patient is admitted from Emergency with complaints of a headache and a stiff neck. He was previously well and can move all his limbs. He has no slurred speech. A lumbar spinal tap was done and tested positive for Meningitis.

1. In addition to Standard Precautions, what type of Additional Transmission Based

Precautions should you use when caring for this patient?

a. Airborne b. Droplet c. Contact d. Droplet & Contact e. Airborne & Contact

2. What type of PPE should you wear to protect yourself from being exposed to this

disease when providing direct patient care?

a. Gloves b. Gown c. Regular mask d. N95 mask e. Eye protection f. None of the above

Scenario #2:

A 55 year old female, who immigrated from China 2 years ago, is admitted to your unit with a 2 month history of a chronic cough with expectoration of yellow colored sputum, intermittent fevers and recent weight loss of 10 lbs. Based on her symptoms and chest x-ray, she has been diagnosed with Pulmonary Tuberculosis.

1. In addition to Standard Precautions, what type of Additional Transmission Based



Langara

College

Fall 2

006 -

archive

d


Page 18 of 85

2. What type of PPE should you wear to protect yourself from being exposed to this disease when providing direct patient care?


Scenario #3: An 85 year old male patient on your unit has developed a rash two days ago. The rash is only on the left side of his lower back around the lumbar spine, extending down to his left gluteal and the back of his left thigh and leg. The rash is red with small blisters. Some of the blisters have burst and are starting to crust over, but there are still some new blisters. The patient states that the areas are extremely painful. In general his immune system is normal. This patient has Shingles. 1. In addition to Standard Precautions, what type of Additional Transmission Based






Langara

College

Fall 2

006 -

archive

d


Page 19 of 85

Scenario #4: A 42 year old female has been diagnosed with Cellulitis of her right leg. She has a history of IV drug use and lives in the Downtown East Side. Her previous admission, her nose and peri-rectal swabs were positive for Methicillin Resistant Staphylococcus Aureus (MRSA) 1. In addition to Standard Precautions, what type of Additional Transmission Based






Scenario #5: An 82 year old female has been transferred from an extended care centre to you medical unit with a sacral ulcer. In the past, her rectal swab was positive for Vancomycin Resistant Enterococci (VRE). 1. In addition to Standard Precautions, what type of Additional Transmission Based



Langara

College

Fall 2

006 -

archive

d


Page 20 of 85

2. What type of PPE should you wear to protect yourself from being exposed to this disease when providing direct patient care?


Scenario #6: A 54 year old female patient presented at the Emergency Department with abdominal pain and diarrhea. She had a bowel resection 3 weeks ago for cancer. Her incision looks well healed. She had some diarrhea prior to going home and was prescribed with Flagyl p.o which resolved her diarrhea. However, 1 week ago, her diarrhea started again and worsened. She has not taken any laxatives. A stool specimen for C & S and Clostridium Difficile (C-Diff) was collected and sent to the lab. Her results indicate that she is positive for C-diff. 1. In addition to Standard Precautions, what type of Additional Transmission Based






Langara

College

Fall 2

006 -

archive

d


Page 21 of 85

Learning Activity

Clients Requiring Parenteral Medications

- Asepsis, Therapeutic agents/modalities, Assessment

CONCEPTS: TRANSITION, VULNERABILITY, HEALING, SUFFERING, RESILIENCE/HARDINESS,

CONTROL OVERVIEW Parenteral medications can be administered intradermally, subcutaneously (SC), intramuscularly (IM), or intravenously (IV). Common examples of each type of injection will be discussed in class. As parenterally administered medications are absorbed more rapidly than orally or topically administered medications, the effects of parenteral medications can be irreversible. Therefore, the nurse must prepare injectable medications very carefully, accurately and aseptically as injectables are considered invasive procedures (Kozier, Erb, et al, 2004). Parenteral medications are prepared and administered aseptically using injectable equipment – syringes, needles, vials and/or ampoules. Syringes and needles come in various types and sizes. Selecting the correct syringe and needle is extremely important and is dependent of the route of administration, the size of the patient, and the amount and type of medication. The medication, usually in ampoules or vials, is withdrawn into the syringes using needles (Kozier, Erb, et al, 2004). In this learning experience, you will have the opportunity to learn the anatomy of the syringe and become familiar and comfortable with syringes and needles. You will also demonstrate and withdraw medication from a vial aseptically. ENDS-IN-VIEW

• To attach syringes and needles and their safe handling and disposal. • To accurately withdraw medication from a vial • To maintain asepsis in the preparation of parenteral medications.

IN PREPARATION 1. Before the scheduled class review the following video:

Sharps safety: A matter of survival Call Number – RC 965 M39 S53


Langara

College

Fall 2

006 -

archive

d


Page 22 of 85

Read the learning activity on Clients Requiring Parenteral Medications

3. From Kozier, Erb et al (2004): Read the section on Parenteral Medications, p.630 – 635 Read Procedure 28.3 Preparing Medications from Vials, p.636

4. From Buccholz (2006), read and complete:

Chapter 3, Drug Labels and Packaging, p.47 – 65 Chapter 5, Drug Preparations & Equipment to Measure Doses, p.88 – 92

5. From this lab you may take the, syringe, needle and vial home for practice. Please

note that this equipment is not sterile, so please use these professional discretion

IN NERC As you work in small groups, practice aseptically putting the injectable equipment together and withdrawing the correct amount of medication from a vial. Be prepared to share your learning with the large group. IN CLINICAL PRACTICE Familiarise yourself with the injectable equipment at you agency. Review the agency’s Policy and Procedure Manual about injectable medications. Review the agency’s Policy on needle stick injuries. IN REFLECTION • Why is maintaining asepsis important in the preparation of injectable medication? • How do you ensure asepsis is maintained? • How do you prevent needle stick injuries? • What would you do if you experienced a needle stick injury?

REFERENCES Kozier, B., Erb, G., Berman, A., Burke, K., Bouchal, D., & Hirst, S. (2004). Fundamentals of Nursing: The nature of nursing practice in Canada. Toronto: Prentice Hall.

DID YOU KNOW . . . BC workers suffer 6,800 needle stick injuries every year! (BCNU)

Remember Sharp Safety at all times!

Langara

College

Fall 2

006 -

archive

d


Page 23 of 85

Learning Activity

Clients Requiring Intramuscular Injections



CONTROL, ABUSE OVERVIEW Administering medications through intramuscular injections is a common action carried out by nurses. Analgesics, antiemetics, iron supplements, and antibiotics are some examples of medications which may be administered through the intramuscular route. As a nursing student, it is crucial that you follow principles of safe practice, and implement comfort measures when administering injectable medications to your clients. In addition, it is important that you consider the context in which you are completing this skill, by assessing your clients' individual needs (pain control, growth and development, coping strategies, and effectiveness of the medication). In this learning experience, you will have the opportunity to prepare an IM injection, demonstrate the four IM injections sites, showing correct anatomical landmarks and demonstrate the correct procedure for administering an IM injection on a partner. In addition, we will work through three different case scenarios involving the administration of IM injections across the lifespan. ENDS-IN-VIEW

• To understand the context of the client's experience by considering individual factors.

• To demonstrate a knowledge base of the administered medication (classification, adverse effects, dosages, factors affecting drug action, and nursing responsibilities).

• To apply mathematical principles accurately in dosage calculation. • To perform adequate explanation and teaching of medications. • To document administration of the medication.

IN PREPARATION 1. Before the scheduled class review the following video:

Administering Injectable Medications Call Number – RT 41 L73


Langara

College

Fall 2

006 -

archive

d


Page 24 of 85

Read the learning activity on Clients Requiring Intramuscular Injections Complete the Study Guide for Clients Requiring Intramuscular Injections

3. From Kozier, Erb et al (2004) read:

P.642 – 647, Intramuscular Injections 4. From Buccholz (2006), read and complete:

Chapter 7, Liquids for Injection, p.142 – 155 5. In preparation for the practice scenarios, make medication cards, know the

pharmacology and bring the cards to the lab for: Dipenhydramine Imferon

6. For this lab:

Bring a calculator Bring your syringes and needles from home Wear comfortable clothing without heavy seams for easier siting on each other.

7. From this lab you may take the vial home for practice. Please note that this

equipment is not sterile, so please use these professional discretion IN NERC As you work in pairs to complete Scenarios 1 &2, practise withdrawing from ampoules or vials, calibrating, and administrating the medication into a facsimile. Review all sites for intramuscular injections. Be prepared to share your learning with the large group. IN REFLECTION • What are the similarities or differences between administering subcutaneous and

intramuscular injections? • How will you remember the different sites and principles of intramuscular

injections? • How will you make this procedure as comfortable as possible for clients? REFERENCES Craven, R. and Hirnle, C. (2003). Fundamentals of Nursing: Human health and function. Philadelphia: Lippincott, Williams, and Wilkins.

Langara

College

Fall 2

006 -

archive

d


Page 25 of 85

STUDY GUIDE FOR CLIENTS REQUIRING INTRAMUSCULAR INJECTIONS 1. Which of the following routes of administration allows for the fastest absorption

of medication? A. Intradermal route. B. Subcutaneous route. C Intramuscular route. D. Oral route.

2. Intramuscular injections for a normal size adult client are usually given with a:

A. 21 gauge, 1 inch needle. B. 25 gauge, 5/8 inch needle. C. 20 gauge, 2 inch needle. D. 21 gauge, 1-1/2 inch needle.

3. Intradermal injections are given in the:

A. medial surface of the forearm. B. lateral surface of the upper arm. C. superior surface of the thigh. D. lower quadrant of the abdomen.

4. The site of choice for IM injections in children is the:

A. dorsogluteal site. B. ventrogluteal site. C. vastus lateralis site. D. deltoid site.

5. The anatomical landmarks for the ventrogluteal site include:

1. greater trochanter 2. anterior superior iliac spine 3. buttocks crease 4. lower abdomen

A. 1, 2. B. 3, 4. C. 1, 3, 4. D. 1, 2, 3, 4.

Langara

College

Fall 2

006 -

archive

d


Page 26 of 85

6. The maximum amount of solution which may be given IM in a well developed adult is: A. 0.1 - 1 cc. B. 2 - 3 cc. C. 4 - 5 cc. D. 6 - 7 cc.

7. The maximum amount of solution which may be given intramuscularly to babies,

elderly, or emaciated clients is usually: A. 0.5 mL. B. 0.75 mL. C. 2 mL. D. 5 mL.

8. What type of syringe would be most suitable to give 0.1 mL of solution?

A. Tuberculin syringe. B. Insulin syringe. C. 3 cc syringe. D. Tubex cartridge syringe.

9. How would you administer ordered medications that discolour or irritate

tissues? A. Intradermal. B. Z-track. C. Intramuscular. D. Intravascular.

10. Drugs that have an automatic stop date (outdated or cancelled) are?

A. Antibiotics and sedatives. B. Narcotics and sedatives. C. Antibiotics, preoperative medications and narcotics. D. Sedatives and postoperative medications.

11. Your client who is awaiting tests to diagnose abdominal pain, asks for his "pain

shot". What part(s) of his chart would you check prior to administration of his medication? A. Physician's order sheet, medication administration record, and nurses' notes. B. Medication administration record, Anaesthetic record, and nurses' notes. C. Anaesthetic record and physician's order sheet. D. Nurses' notes and physician's order sheet.

12. The doctor orders 40 u of a drug. The vial is labelled 30 u in 1 cc. How many cc(s)

would you give?

Langara

College

Fall 2

006 -

archive

d


Page 27 of 85

13. The doctor orders 300,000 u of a drug. The vial is labelled 1,000,000 u per cc. How many mL(s) would you give?

14. The drug label reads 1,000,000 u/l cc. The doctor ordered 150,000 u of the drug.

How many cc(s) would you give? 15. The order reads 8 mEq of a drug. The vial is labelled 20 mEq in 10 cc. How

many mL(s) would you administer? 16. The drug label reads: 50 mEq/50 cc. The doctor orders 75 mEq of this drug.

How many cc(s) would you give? 17. The doctor ordered 60 mEq of a drug. The drug is available as 40 mEq/20 mL.

How many cc(s) would you give? 18. The doctor has ordered 50 mg of a drug. The label on the vial reads 25 mg/mL.

How many mL(s) would you give? 19. The doctor orders 8 mg of a drug. The vial is labelled 5 mg/mL. How many

mL(s) should be given? 20. The doctor has ordered 20 mg of a drug. There are six ampoules on stock. Each

ampoule contains 25 mg per 2 cc. of the drug. How many cc(s) would you give? 21. The doctor orders 200 mg IM of a drug. The vial contains 1 gram of the drug.

"Add 3.6 mL of sterile water for injection to yield 4 mL." How many mL(s) should the client receive?

Langara

College

Fall 2

006 -

archive

d


Page 28 of 85

22. The doctor orders 600 mg of a drug. The vial contains 1 gram of the drug. The directions read, "add 8.5 mL of sterile water to yield 1 gram/10 mL." How many mL(s) should the client receive?

23. The doctor orders Demerol 100 mg IM. The drug label reads 50 mg/mL. How

many mL(s) should the client receive? 24. The order is for Streptomycin 1 gram IM. The drug label reads 5 grams in 12.5

mL. How many mL(s) should the client receive? 25. The doctor orders Keflin 250 mg IM. The drug label reads "Contains Keflin 1

gram. Add 1.8 mL sterile water to yield 2 mL of solution". How many mL(s) does the client receive?

26. The doctor orders Atropine 0.6 mg IM. The drug label reads 0.4 mg/mL. How

many mL would be given? 27. The order is for Keflin 350 mg IM. The drug label reads "Contains 0.5 g. Add 5

mL of sterile water to yield of 6 mL of solution. How many mL(s) does the client receive?

28. The doctor's order is Demerol 75 mg IM. The ampoule contains 100 mg/mL.

How many mL(s) will you give?

Langara

College

Fall 2

006 -

archive

d


Page 29 of 85

PRACTICE SCENARIOS BEFORE STARTING THE SCENARIOS, DISCUSS AND DO THE FOLLOWING ITEM(S): 1. Explore the syringe. 2. Discuss aseptic principles of preparing injections for clients. 3. Practise withdrawing medications from vials. What are the principles? 4. Site all intramuscular injection sites on a partner.

Jamie Bradshaw, 80 years old, a resident of Beachview Lodge, has been admitted to your medical unit with CHF and has a history of hypertension. Jamie had been experiencing fatigue and light headedness and was placed on Imferon while at the Lodge.

Situation 1: 1. Morning report stated that Jamie had developed a rash. While doing your

morning assessment, you notice that Jamie is itching his back and arms. What would your assessment include?

2. While giving him a bath, you notice that there are reddened, elevated spots that

are blanchable. What would your priority nursing care include? 3. As per Dr’s order’s which medication would you administer and why? 4. What dosage and route of administration would you consider? Why? 5. Prepare and administer the medication. 6. What would your patient teaching include? 7. What would your documentation include?

Langara

College

Fall 2

006 -

archive

d


Page 30 of 85

Situation 2: You are to give Jamie 50 mg dose of Imferon IM this morning. 1. Determine the data required to administer this medication. 2. Identify the most important information to teach Jamie about this injection and

explain your rationale. 3. What do you know about this drug? 4. Which IM technique would you use to administer this drug? Why? 5. Practise the intramuscular injection technique on the facsimile.

Langara

College

Fall 2

006 -

archive

d


Page 31 of 85

9034095770002 Jamie Bradshaw

DOB: January 28, 1926 Dr. A. Merrell

Langara Hospital PHYSICIAN’S ORDERS

DATE TIME ORDERS Sept 10, 2006 0900 Vital signs regular with O2 sats qshift and prn Digoxin 0.125mg po od Imferon 50mg IM now and qweekly Losartan 50mg od Lasix 20mg po od

K-dur SR 20mEq po bid Pravastatin 40 mg od AAT Low salt CBC, lytes, BUN, Cr, Chest x-ray--------Dr. A. Merrell Sept 14, 2006 1900 Dipenhydramine 25 – 50 mg IM q6h prn--T/O by Dr. A.

Merrel La

ngara Colle

ge

Fall 2

006 -

archive

d


Page 32 of 85

9034095770002 Jamie Bradshaw

DOB: January 28, 1926 Dr. A. Merrell

ALLERGIES: NKA

MEDICATION ADMINISTRATION RECORD FROM 0800 15 SEPTEMBER, 2006 TO 0759 16 SEPTEMBER, 2006

08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 06 07 Medications Order #1 Digoxin 0.25mg tab (Lanoxin or equiv) Ordered 10 Sept 2006 0.125mg po od 08 Apical = Order #2 Imferon 50mg/mL inj Ordered 10 Sept 2006 50mg IM every week 08 Order #3 Losartan 50mg tab (Cozaar or equiv) Ordered 10 Sept 2006 50mg po od 08 Order #4 Furosemide 20mg tab (Lasix or equiv) Ordered 10 Sept 2006 20 mg po od 08 Order #5 Potassium Chloride SR 20mEq tab (K-dur) Ordered 10 Sept 2006 20mEq po bid (take with food) 08 17 Order #6 Pravastatin 20mg tab (Pravachol or equiv) Ordered 10 Sept 2006 40mg po od 08 PRN Medications Order #1 DipenhydrAMINE 50mg/mL inj (Benadryl or equiv) Ordered 15 Sept 2006 25 – 50mg IM q6h prn 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 06 07

Checked by: S. Rose, RN

Langara

College

Fall 2

006 -

archive

d


Page 33 of 85

Learning Activity

Clients Requiring Subcutaneous Injections



CONTROL, ABUSE OVERVIEW Giving injections is a skill which you will encounter frequently as a nurse. For clients, receiving an injection can be an anxiety provoking experience, which may be compounded by the fact that they are in pain, nauseated, fearful, or otherwise uncomfortable. As a nursing student, it is crucial that you follow principles of safe practice, and implement comfort measures when administering injectable medications to your clients. In addition, it is important that you consider the context in which you are completing this skill, by assessing your clients' individual needs (pain control, growth and development, coping strategies, and effectiveness of the medication). Injections may be subcutaneous (SC), intramuscular (IM), or intradermal. Subcutaneous injections involve administering medications into the connective tissue beneath the dermis. Since the “Subcutaneous tissue is not richly supplied with blood as the muscles, medication absorption is somewhat slower than with IM injections. However, medications are absorbed completely if the client’s circulatory system is normal. Because subcutaneous tissue contains pain receptors, the client may experience some discomfort” (Potter, Perry et al, 2006, p.890) In this learning experience, you will have the opportunity to prepare a SC injection, demonstrate the SC injections sites, showing correct anatomical landmarks and demonstrate the correct procedure for administering an SC injection on a partner. In addition, we will work through three different case scenarios involving the administration of SC injections across the lifespan and withdrawing medications from an ampoule. ENDS-IN-VIEW

• To understand the context of the client's experience by considering individual factors.

• To demonstrate a knowledge base of the administered medication (classification, adverse effects, dosages, factors affecting drug action, and nursing responsibilities).

• To administer subcutaneous injections safely • To apply mathematical principles accurately in dosage calculation. • To perform adequate explanation and teaching of medications. • To document administration of the medication.

Langara

College

Fall 2

006 -

archive

d


Page 34 of 85

IN PREPARATION 1. From this Course Packet:

Read the learning activity on Clients Requiring Subcutaneous Injections Complete the Study Guide for Clients Requiring Subcutaneous Injections

2. From Kozier, Erb et al (2004), read:

P.639 – 642, Subcutaneous Injections

3. In preparation for the practice scenarios, make medication cards, know the pharmacology and bring the cards to the lab for:

Heparin Morphine Scopolamine

4. For lab:

Bring a calculator Wear a sleeveless top or a top with sleeves that can rolled up easily to expose the

upper arms. 5. From this lab you may take the vial home for practice. Please note that this

equipment is not sterile, so please use these professional discretion IN NERC Complete the scenarios as you work in pairs. Familiarize yourself with the equipment. Practise withdrawing from ampoules and vials, calibrating, and administrating the medication into a facsimile, and document the medications given. Be prepared to share your learning with the large group. IN REFLECTION What feelings did you experience when giving and receiving the injection? How will you remember the different subcutaneous sites and the principles of administrating the injection? How will you make this procedure as comfortable as possible for clients? REFERENCES Craven, R. and Hirnle, C. (2003). Fundamentals of Nursing: Human health and function. Philadelphia: Lippincott, Williams, and Wilkins. Curren, A. and Munday, L. (2000). Math for meds: Dosages and solutions. California: Wallcur Inc. Potter, P., Perry, A., Ross-Kerr, J., & Wood, M. (2006). Canadian Fundamentals of Nursing. Canada: Ellsevier Mosby

Langara

College

Fall 2

006 -

archive

d


Page 35 of 85

STUDY GUIDE FOR

CLIENTS REQUIRING SUBCUTANEOUS INJECTIONS Complete the following questions: 1. What are the standard needle sizes for sc injections? 2. What is the maximum volume of medication that can be given sc? 3. What are the most commonly used sites for sc injections? 4. What are some special considerations when administering Heparin? 5. What is the rationale for rotating sc sites? 6. Pressure must be equalized in a vial to prevent creation of:

A. negative pressure in a vial. B. positive pressure in a vial. C. atmosphere pressure in a vial. D. unsterile solution in a vial.

7. The chief disadvantage of parenteral medications is their:

A. slow action. B. effect on gastric enzymes. C. introduction of a needle through the skin. D. dependence on the consciousness of the client.

8. Subcutaneous injections are usually given with a:

A. 22 gauge needle. B. 19 gauge needle. C. 25 gauge needle. D. 20 gauge needle.

Langara

College

Fall 2

006 -

archive

d


Page 36 of 85

9. Which of the following site(s) can be used for subcutaneous injections? 1. outer aspects of upper arms 2. anterior aspects of the thighs 3. below the scapula 4. lower abdomen

A. 1, 2. B. 3, 4. C. 1, 2, 4. D. 1, 2, 3, 4.

10. A subcutaneous injection may be given at:

a. 15 degrees. b. 65 degrees. c. 45 or 90 degrees. d. 75 or 90 degrees.

Langara

College

Fall 2

006 -

archive

d


Page 37 of 85

PRACTICE SCENARIOS BEFORE STARTING THE SCENARIOS, DISCUSS AND DO THE FOLLOWING ITEM(S): 1. Explore the syringe. 2. Discuss aseptic principles of preparing injections for clients. 3. Practise withdrawing medications from ampoules. What are the principles? 4. Practise the subcutaneous injection technique on the facsimile. 5. All subcutaneous sites on a partner.

Jas Sodhi is 60 years old and has been diagnosed with lung cancer with metastasis to the liver and bone. Jas’s health status has been declining and is a terminal palliative care patient on your unit and requires comfort measures. Jas is non-ambulatory and has altered level of consciousness.

Situation 1: It is now 1000 and you need to administer Jas’s medications 1. What do you know about this drug? 2. What assessment(s) and lab test(s) would you consider prior to giving this

medication and why? 3. Identify the most important information to teach patients about this injection

and explain your rationale. 4. Prepare and administer the medication. 5. Document. 6. What are the differences between administering this medication and a typical

subcutaneous injection?

Langara

College

Fall 2

006 -

archive

d


Page 38 of 85

Situation 2: While you were turning and positioning Jas, you noticed that your patient had facial grimacing and was groaning. 1. From your assessment you determine that Jas is experiencing pain. In general

how do you assess pain? 2. From his MAR which medication would you administer for Jas’s pain? What is

the rationale for your decision? 3. What do you know about this drug? 4. What assessments would you perform prior to administering this drug? 5. Identify the most important information to teach patients about this injection

and explain your rationale. 6. What dosage and route of administration would you consider? Why? 7. Since Jas is receiving analgesia frequently, the RN has inserted a SC butterfly

cannula for analgesic administration to prevent from continually poking the patient. Prepare and administer his analgesic via the SC butterfly.

8. Document. Situation 3: While doing your assessment, you hear gurgling sounds while Jas is breathing. You inform the RN who suctioned the mouth for the secretions, after which you perform mouth care. Within an hour you notice that Jas you hear the gurgling breathing again and request the RN to suction the mouth. 1. Knowing that Jas has altered level of consciousness, what would your priority

nursing care include? 2. After consulting with your clinical instructor and the RN, you decide to

administer Scopolamine. What is the drug for? 3. What dosage and route of administration would you consider? Why? 4. Prepare and administer the drug. 5. Document.

Langara

College

Fall 2

006 -

archive

d


Page 39 of 85

9934393570001 Jas Sodhi DOB January 28, 1946 Dr. Andrew Merrell Langara Hospital PHYSICIAN’S ORDERS

DATE TIME ORDERS Sept 08, 2006 0900 Vital signs regular with O2 sats DAT AAT IV D5W @ 75cc/hr Heparin 5,000u sc OD Rabeprazole 20mg od Folic acid 5mg od Morphine 1-2 mg sc q4h Tylenol 1-2 tabs q4h prn Tylenol 3 ii tabs q4h prn Dimenhydrinate 25 – 50 mg IM prn Scopolamine 0.35 mg sc q6h prn CBC, lytes, BUN, Cr, LFT, Chest x-ray, INR, PTT DNR O2 at 2L/min to keep O2 sats > 88% -----Dr. A. Merrell

Langara

College

Fall 2

006 -

archive

d


Page 40 of 85

9934393570001 Jas Sodhi DOB January 28, 1946 Dr. Andrew Merrell ALLERGIES: NKA


08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 06 07 Medications Order #1 Heparin 10,000u/mL inj (Heparin or equiv) Ordered 08 Sept 2006 5,000u sc od 10 Order #2 Rabeprazole 20mg tab (Pariet or equiv) Ordered 08 Sept 2006 20mg po od 08 Order #3 Folic acid 5mg tab (Folic acid or equiv) Ordered 10 Sept 2006 5mg po od 08 PRN Medications Order #4 Acetaminophen 325mg tab (Tylenol or equiv) Ordered 08 Sept 2006 325 – 650mg po q4h prn Order #5 Acetaminophen 325mg / Codeine 30mg tab (Tylenol #3) Ordered 08 Sept 2006 2 tabs po q4h prn Order #6 Morphine 10mg/mL inj (Morphine or equiv) Ordered 08 Sept 2006 1 – 2mg sc q4h prn Order #7 DimenhyDRINATE 50mg/mL Inj (Gravol or equiv) Ordered 08 Sept 2006 25 – 50mg IM q4h prn Order #8 Scopolamine 1mg/mL inj (Scopolamine or equiv) Ordered 08 Sept 2006 0.35mg sc q6h prn 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 06 07


Langara

College

Fall 2

006 -

archive

d


Page 41 of 85

Learning Activity

Clients Requiring Mixed Medications for Injections


CONCEPTS: TRANSITION, VULNERABILITY, HEALING, TRUST, RESILIENCE/HARDINESS,

CONTROL, ABUSE OVERVIEW On some occasions, clients may require 2 injectable medications, either as a subcutaneous or an intramuscular injection at the same time. For instance, clients may have nausea and pain. Would you prepare the antiemetic and analgesic in one syringe or in two syringes? Can these medications be combined? Nurses have to be cognizant of the principles of mixing 2 medications in one syringe. This learning activity focuses on the application of administrating 2 medications in one syringe. ENDS-IN-VIEW

• To withdraw medications from ampoules. • To apply the principles of mixing medications in one syringe. • To be knowledgeable about the administered medication (classification, action,

dosage, adverse effects, dosages, and nursing responsibilities). • To administer medications using the "Critical Components of a Skill". • To document administration of the medication.

IN PREPARATION

1. From this course packet: Review the learning activity on Clients Requiring Subcutaneous Injections

Complete the study guide for clients requiring mixed medications for injections

2. From Kozier, Erb et al, read:

Procedure 28.2, p.635 P.637 – 638, Mixing Medications in One Syringe

3. Read about Insulin in Lewis & Heitkemper, Medical-Surgical Nursing:

Assessment and management of clinical problems

Langara

College

Fall 2

006 -

archive

d


Page 42 of 85

4. From Buccholz (2006), read and complete: Chapter 7, Liquids for Injection, p.156 – 162 & 175 - 181

5. In preparation for the practice scenarios, make medication cards, know the

pharmacology and bring the cards to the lab for: Insulin – Regular and NPH Dimenhydrinate Morphine Dipenhydramine

6. For this lab:

Bring your calculator Bring your practice syringes to class. Wear a short sleeved top to expose the upper arms and comfortable pants

without heavy seams to facilitate siting on each other. IN NERC Divide into pairs and work through the 2 case scenarios and discussion questions. As a pair, discuss the questions. Each student needs to prepare and administer the medications as listed. IN CLINICAL PRACTICE Review your agency's Policy and Procedure Manual. What are the difference and/or similarities between your hospital and the class material? Inform your practice facilitator that you have completed this learning activity. Seek opportunities to apply this nursing skill. IN REFLECTION • What principles will guide you to administer 2 medications in one syringe? • What steps can you take to administer the medications safely and competently? REFERENCES

Craven, R. and Hirnle, C. (2003). Fundamentals of Nursing: Human health and function. Philadelphia: Lippincott, Williams, Wilkins Curren, A. and Munday, L. (2000). Math for meds: Dosages and solutions. California: Wallcur Inc. Lewis, S., Collier, I., and Heitkemper, M. (2004). Medical surgical nursing: Assessment and management of clinical problems (4th Ed.). St. Louis: Mosby-Year Book Inc.

Langara

College

Fall 2

006 -

archive

d


Page 43 of 85

STUDY GUIDE FOR CLIENTS REQUIRING MIXED MEDICATIONS FOR INJECTIONS 1. The doctor orders Demerol 100 mg and Atropine 0.6 mg IM for his client.

a) How do you know if you can give two medications in one injection?

b) Will you give 1 or 2 injections?

c) What factors must you consider?

d) What reference source(s) will help you answer the above question? 2. While administering the Demerol and Atropine IM, you encounter the following

problems. What would you do if you:

a) Had difficulty injecting the solution? Why?

b) Saw a little fluid leaking at the site of the needle puncture as you withdrew the needle? Why?

c) Observed bright red blood from the puncture site after you withdraw the needle? Why?

d) What would you do if you aspirated blood in the syringe? Why? 3. If one medication is from a multi-dose vial and the other is from an ampoule,

which medication would you withdraw first? Why? 4. If both medications are in ampoules, which medication would you withdraw first?

One of these medications is a narcotic. Why? 5. Your client is ordered to receive 20 units regular insulin and 15 units NPH insulin

Langara

College

Fall 2

006 -

archive

d


Page 44 of 85

before breakfast. Which medication would you draw up first? 6. When charting an IM medication you suddenly discover that you have given a

dose greater than the ordered dose of the drug. What would you do? Why? 7. When mixing two drugs in one syringe you notice that the fluid becomes cloudy.

What would you do?

8. You are counting the remaining ampoules of Demerol in the narcotic cupboard.

According to the narcotic record, 24 ampoules should be left but you count 23 ampoules. What would you do?

9. You are in the medication room at your hospital. The RN walks in, puts the

narcotic keys on the counter, says she has to check on a client, and leaves. The narcotic keys are still on the counter. What would your actions be and why?

Langara

College

Fall 2

006 -

archive

d


Page 45 of 85

PRACTICE SCENARIOS

A driver speeding through a road construction site struck 26 year old Pat Lee, a municipal road worker. Pat has been admitted to your hospital with a fractured right elbow and severe lacerations to the right thigh and forehead. Pat has been an Insulin dependent diabetic for 12 years.

Situation # 1: It is now o800 and you need to administer Pat’s Insulin. 1. What information and/or assessment do you need prior to preparing the

Insulin? 2. What do you know about the Insulins that you are going to administer? 3. In what order will you prepare the insulin? What is your rationale? 4. Prepare and administer the Insulin. 5. What teaching would you do with Pat? 6. Document 7. What are the differences between administering insulin and a typical

subcutaneous injection? Situation #2: Pat developed generalised, pruritic rash yesterday, which the Doctor felt was an allergic reaction to Tylenol #3. Today Pat complains, “I am very itchy all over and to make matters worse, my hand hurts very much. Before you ask, the pain is at an 8/10.” 1. What is/are your priority nursing care? 2. From his MAR, which medication(s) will you administer and why? 3. What information/assessment would you require prior to administering these

medication(s)? 4. What dosage and route of administration would you consider? Why? 5. Prepare and administer the medication(s)

Langara

College

Fall 2

006 -

archive

d


Page 46 of 85

6. What information will you provide about these medications? 7. Document. Situation #3: Later in the day, Pat complains of feeling extremely nauseous and right arm and thigh pain. Pat again rates the pain at an 8/10 1. What is/are your priority nursing care? 2. From his MAR, which medication(s) will you administer and why? 3. What information/assessment would you require prior to administering these

medication(s)? 4. What dosage and route of administration would you consider? Why? 5. Prepare and administer the medication(s) 6. What information will you provide about these medications? 7. Document.

Langara

College

Fall 2

006 -

archive

d


Page 47 of 85

9730457390003 Pat Lee

DOB April 4, 1980 Dr. A.Merrell


DATE TIME ORDERS Sept 27, 2006 0900 Vital signs regular DAT AAT IV NS at 50cc/hr Tylenol 3 ii tabs q4h prn CBC, lytes CBG qid Insulin R sliding scale tid:

<8 = 0u 8.1 – 10 = 2u 10.1 – 16 = 4u 16.1 – 21 = 6u >21.1 = 8u

Insulin N 8u bid-----Dr. A. Merrell Sept 28, 2006 1030 Discontinue Tylenol #3 Allergic to Tylenol #3 Morphine 1mg SC/IM q4h, prn Dimenhydrinate 25 – 50 mg SC/IM prn Dipenhydramine 25 – 50 mg IM prn -----Dr. A. Merrell

Langara

College

Fall 2

006 -

archive

d


Page 48 of 85

9730457390003 Pat Lee

DOB April 4, 1980 Dr. A. Merrell

ALLERGIES: Penicillin & Codeine


08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 06 07 Infusions Normal saline at prescribed rate Medications Order #1 Insulin Hum. Reg. sliding scale sc tid inj (Humulin R or equiv) Ordered 27 Sept 2006 >21.1mmol/L = 8units (give 30 minutes before food) 16.1 – 21 = 6

10.1 – 16 = 4 8.1 – 10 = 2 <8 = 0units

08 1130 1630 Order #2 Insulin Human NPH 100u/mL inj (Humulin N or equiv) Ordered 27 Sept 2006 8 units bid ac breakfast and supper (give thirty minutes before food) 08 1630 PRN Medications Order #3 Morphine 10mg/mL inj (Morphine or equiv) Ordered 08 Sept 2006 1 mg sc/IM q4h prn Order #4 DimenhyDRINATE 50mg/mL Inj (Gravol or equiv) Ordered 08 Sept 2006 25 – 50mg IM q4h prn Order #5 DipenhydrAMINE 50mg/mL inj (Benadryl or equiv) Ordered 08 Sept 2006 25 - 50mg IM q6h prn 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 06 07


Langara

College

Fall 2

006 -

archive

d


Page 49 of 85

Learning Activity

Clients Requiring Peripheral Intravenous Infusions



CONTROL, ABUSE OVERVIEW The administration of intravenous (IV) fluids into clients' veins is often a part of the healing process. IV fluids are given to clients with fluid and electrolyte, nutritional, or haematological problems. The intravenous can be also used as a vehicle for administrating medications. Physicians order the type, rate, and duration of intravenous fluids; nurses prepare the intravenous equipment, assess, monitor, maintain, and implement intravenous orders. This learning activity focuses on caring for clients with intravenous infusions. ENDS-IN-VIEW

• To be cognizant of the intravenous equipment. • To complete an assessment of an intravenous from site to source. • To prepare an intravenous bag and tubing and apply principles of bag and tubing

change at the catheter site according to the Critical Components of a Skill. • To infuse and regulate the intravenous fluids at the ordered rate and discontinue

the intravenous as ordered. • To teach your client about having and caring for an intravenous. • To document the client's care or potential complications involved with having an

intravenous. IN PREPARATION 1. Before the scheduled class, review the following audiovisual aids:

Introduction to IV Medications: The Continuous Medication Infusion Intravenous Therapy:

Call numbers – RT 62 L52 #9 & RM 170 I58

2. Using your assigned readings from Healing Workshop review: Intravenous solutions. Fluid and electrolytes.

Langara

College

Fall 2

006 -

archive

d


Page 50 of 85

3. From this course packet, read: The learning activity on Clients Requiring Peripheral Intravenous Infusions The Intravenous Therapy and Medications Policy for Nursing Students, Langara College (Appendix II)

Complete the Study Guide for Clients Requiring Peripheral Intravenous Infusions.


P.647, Intravenous Medications P.1103 – 1104, p.1106 – 1114 Procedure 40.1, p.1109 - 1112

5. From Buccholz (2006), read and complete:

Chapter 8, Calculation of Basic IV Drip Rates, p.197 - 229 6. For class, please bring:

a calculator skills packet

IN NERC Review the math required to maintain an IV infusion at the prescribed rate. Practise assessment of an intravenous site, regulating an IV, priming IV tubing, changing bags, and changing intravenous tubings at the catheter site. Consider client teaching. Be prepared to share your learning with the large group. Complete Med Math during the class time or as independent study work. IN CLINICAL PRACTICE Familiarize yourself with the intravenous equipment at your agency. Review your agency's Policy and Procedure Manual about intravenous therapy before having a client with an intravenous. Be knowledgeable of the assessment/maintenance of an intravenous and policies involving intravenous therapy such as bag and tubing changing. IN REFLECTION • What are the principles involved in caring for a client with an intravenous? • How can you assist a client who has an intravenous? • What can you do to reduce the risk of potential complications associated with this

nursing skill?

Langara

College

Fall 2

006 -

archive

d


Page 51 of 85

REFERENCES Craven, R. and Hirnle, C. (2003). Fundamentals of Nursing: Human health and function. Philadelphia: Lippincott, Williams, and Wilkins. Curren, A. and Munday, L. (2000). Math for meds: Dosages and solutions. California: Wallcur Inc.

DID YOU KNOW . . .

One of the main complications of IV therapy is infection. Staphylococcus aureus is the organism that is most often

responsible. Do you know where that bug lives? Yes – on your hands! So when

you are working with IVs – remember - keep sterile what is sterile and wash your hands! You may save your patient an extended and distressing hospital stay. You

may even prevent their death.

Langara

College

Fall 2

006 -

archive

d


Page 52 of 85

STUDY GUIDE FOR CLIENTS REQUIRING PERIPHERAL INTRAVENOUS INFUSIONS

You are assigned to care for Mrs. Prim, an elderly woman with dehydration and pneumonia. She has an IV ordered and your RN will start it. She asks that you collect the necessary equipment and leave it at the bedside. She also asks that you prepare the patient.

1. In order to complete these tasks what must you know?

a) About the IV

b) About the patient

2. Where do you find this information?

a) About the IV

b) About the patient

3. What equipment should you collect and leave at the bedside? (Pretend you are looking in the clean supply room. You have many choices in front of you – be specific in your answer)

4. Identify four points that nurses should teach to all clients having intravenous therapy.

a)

b)

c)

d)

Langara

College

Fall 2

006 -

archive

d


Page 53 of 85

5. In the process of collecting and preparing the equipment, what would you do if:

a) The IV bag and is wrapping is damp?

b) The bag of solution you've just removed from its wrapper is cloudy?

c) Your client's IV isn't dripping but there is no swelling at the site, and the site is the same temperature as the other extremity?

d) Blood is "climbing up" the IV line (from the point of insertion)?

e) Your client complains of soreness at his IV site?

f) Your client continues to readjust his/her own drip rate despite your request not to?

g) You've calculated and checked the drip rate correctly but in the last hour only half the expected amount has been absorbed?

h) Your client's IV arm-board and anchoring linen is damp but there is no problem with the IV site or the infusion rate?

i) Your confused client keeps pulling at his/her IV line?

j) The IV disconnects at angiocatheter and IV tubing?

k) The day shift nurse did not change the IV tubing according to hospital policy? You discover the wrong IV solution infusing?

l) Your client's IV rate is ordered at 150 cc/hr but over the past half hour 150 cc has been absorbed?

Langara

College

Fall 2

006 -

archive

d


Page 54 of 85

m) The IV nurse tells you to "...see what you can do to bring up those veins..." in an elderly client?

n) Your client's arm is reddened along the line of the vein?

o) You administer an IV of D5W intended for Client A to Client B by mistake and discover the error an hour later?

p) You walk into a client's room with his 0800 medications and notice that the IV bag is completely empty and fluid is half-way down the tubing?

q) Your early a.m. assessment of Client A's IV reveals 100 cc remaining but you were told in "report" that 600 cc were remaining?

r) Your early a.m. assessment of Client B's IV reveals 1000 cc remaining but you were told in "report" that 500 cc were remaining?

s) The x-ray department phones and tell you that they won't be through with Mr. Greenwood, who had a cholecystectomy 2 days ago, for another half an hour and that there is only 50 cc left in the bag?

6. 1000 mL of NS is to be infused at 150 mL/hour. The drop factor is 10 drops/mL.

What are the drops/minutes? 7. 1000 mL NS is to be infused at 150 mL/hour. The drop factor is 60 drops/mL.

What is the drops/minutes?

You may have noticed that caring for a client having intravenous therapy requires

understanding new language. Before you complete the next learning activity on complications with peripheral IVs it will help if you understand the following

terms:

Infiltration, extravasation, induration, inflammation, thrombus, thrombophlebitis, mechanical, chemical and bacterial phlebitis

Langara

College

Fall 2

006 -

archive

d


Page 55 of 85

CRITICAL THINKING EXERCISE: CLIENTS DEVELOPING COMPLICATIONS

WITH IV THERAPY

SITUATION ASSESSMENT CLINICAL IMPRESSION

COURSE OF ACTION

1. Mrs, Prim’s IV isn’t dripping. There is no swelling at the site and it is the same temperature as the extremity.

2. The time tape on Mr. Conrad’s IV shows that the IV is running 1 ½ hrs behind time.

3. You walk into your client’s room and find the IV bag is completely empty and the fluid is ½ way down the tubing.

4. Ms. Mirhashimi states that she noticed some swelling around her IV site. When you palpate close to the site you feel her skin is cool to touch.

5. Your early morning assessment of your 78 year old patient reveals 100cc remaining in the bag that you were told in report that there was 900cc to be absorbed.

Langara

College

Fall 2

006 -

archive

d


Page 56 of 85

SITUATION ASSESSMENT CLINICAL IMPRESSION

COURSE OF ACTION

6. The IV is flowing well but your patient’s arm is reddened.

7. When you come on shift you see that the IV bag has 1000cc in it but you were told in report that 500cc were remaining

8. You administer an IV of D5W to Mrs. Marion, but it was supposed to be hung for Ms. Jung and 300cc has been absorbed.

9. Mrs. Grewal’s IV is infusing very slowly and her vein is hard and painful to touch.

10. The transparent dressing holding the IV in place is wet and the bed is damp. The IV is infusing on time.

11. Joanne’s IV is infusing well. The site is appropriate in temperature and colour, however, she states that the site is sore.

Langara

College

Fall 2

006 -

archive

d


Page 57 of 85

PRACTICE SCENARIOS

You have been assigned to Sam Young, who was admitted to your unit two days ago with a GI bleed. Sam is not drinking well.

Situation #1: For the purpose of this learning activity, consider the 500 cc intravenous fluid bag as the primary infusion. Complete and discuss the following items: 1. Dr. Merrell has ordered a normal saline IV. Is this an appropriate

fluid to give Sam? Why? 2. Calculate all the drops gtt/minutes ordered by Dr. Merrell (see the

physician’s orders on the next page). 3. In relation to IV Therapy, what is/are your responsibility(ies) at

that start and end of your shift? 4. Complete a site to source assessment. 5. Complete a time tape for Sam’s intravenous. 6. During your shift, the IV bag and tubing need to be changed.

Prepare the IV bag and tubing. 7. Hang the IV and set the rate of flow to the most recent orders. 8. Document your nursing activities and set up the Fluid Balance

Record. 9. Change an IV bag without changing the tubing. 10. What information about the IV would your provide to Sam?

Langara

College

Fall 2

006 -

archive

d


Page 58 of 85

Situation #2: Sam has been scheduled for an ultrasound of the abdomen at 1030. Sam is to remain NPO for his test. You have saved Sam’s breakfast tray for later. 1. What solution should the next IV bag contain? 2. How does NS differ from D5W? What does it provide for Sam that the NS does

not? 3. Why would Sam be started on D5W? 4. Complete a time tape for Ms. Prim's next bag of intravenous fluid and calculate the flow rate. 5. Using the new IV bag and existing tubing, change the tubing at the catheter site

and complete the required documentation. 6. It is now the end of your shift. Complete the required end of shift IV

documentation.

Langara

College

Fall 2

006 -

archive

d


Page 59 of 85

9730457390003 Sam Young

DOB January 15, 1956 Dr. A.Merrell


DATE TIME ORDERS October 18, 2006 0900 Vital signs regular Clear fluid to full fluid to DAT AAT IV NS at 150cc/hr x 24 hours, then 75cc/hr to saline

lock when drinking well CBC, lytes, BUN, Cr, stool for C&S, abdominal

ultrasound Rabeprazole 20mg po od Tylenol ii tabs q4h prn Gentamycin 40 mg IV tid. Hydromorphone 1mg SC q4-6h, prn Dimenhydrinate 25 – 50 mg SC/IM prn--Dr. A. Merrell October 19, 2006 0900 NPO midnight for abdominal ultrasound Start IV D5W at 75cc/hr on Oct 20 at 0800 Saline lock IV after abd ultrasound --Dr. A. Merrell La

ngara Colle

ge

Fall 2

006 -

archive

d


Page 60 of 85

9730457390003 Sam Young

DOB January 15, 1956 Dr. A. Merrell

ALLERGIES: Animal Dander

MEDICATION ADMINISTRATION RECORD FROM 0800 20 OCTOBER, 2006 TO 0759 21 OCTOBER, 2006

08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 06 07 Infusions

IV Normal saline at prescribed rate Order #1 Gentamycin 40mg/mL inj Ordered 18 Oct 2006 40mg IV tid (Dilute in 100 mL of 5DW or NS. Infuse over 30 minutes.) 14 22 06 Medications Order #2 Rabeprazole 20mg tab (Pariet or equiv) Ordered 18 Oct 2006 20mg po od 08 PRN Medications Order #3 Acetaminophen 325mg tab (Tylenol or equiv) Ordered 18 Oct 2006 650mg po q4h prn Order #4 Hydromorphone 2mg/mL inj (Dilaudid or equiv) Ordered 18 Oct 2006 1 mg sc q4-6h prn Order #4 DimenhyDRINATE 50mg/mL Inj (Gravol or equiv) Ordered 18 Oct 2006 25 – 50mg IM q4h prn 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 06 07


Langara

College

Fall 2

006 -

archive

d


Page 61 of 85

LANGARA HOSPITAL

FLUID BALANCE SHEET

DATE: ____________ Fluid Restriction: ____________ INTAKE OUTPUT Time Start

Solution/Drug/Flow Rate

Amount Start

Volume Infused

Initial Time Oral Tube Time Urine Tube

Subtotals

Combined Total

24 Hour Balance =

Langara

College

Fall 2

006 -

archive

d


Page 62 of 85

Learning Activity

Clients Requiring Conversion from an Existing Intravenous to an Intermittent Infusion Device

(Saline Lock)



CONTROL, ABUSE OVERVIEW Intravenous medications can be administered by continuous or intermittent infusion patterns. What is an intermittent infusion device? An intermittent infusion device or saline lock is a re-sealable injection site that is connected to an angiocatheter or intravenous cannula. It is referred to as a saline lock because it requires periodic injections of normal saline to maintain the patency of the intravenous cannula. Saline locks are the most common type of intermittent infusion devices that you will encounter as a student nurse in this program. This learning activity focuses on converting an existing intravenous to a saline lock and vice versa. ENDS-IN-VIEW

• To be cognizant of the purposes of an intermittent infusion device. • To apply principles of converting an existing intravenous to a saline lock safely

and vice versa. • To understand the advantages and disadvantages of saline locks.

IN PREPARATION

1. From this course packet: Review the learning activity on Clients Requiring A Conversion From An Existing Intravenous To An Intermittent Infusion Device

2. From Kozier, Erb et al, read:

Procedure 40.5, p.1118 - 1119

3. For this lab: Bring your practise syringes and needles to the lab Bring your calculators Bring your primary IV bags and solution sets

Langara

College

Fall 2

006 -

archive

d


Page 63 of 85

IN NERC Work in pairs to discuss principles of these nursing skills. Using Scenario #1, practise converting an existing intravenous to an intermittent infusion device. Be prepared to share your learning with the large group. IN CLINICAL PRACTICE Review your agency's Policy and Procedure Manual prior to converting an existing intravenous to an intermittent infusion device. Be cognizant of the principles while performing these procedures. As you care for these clients, observe for themes and patterns. Inform your practice facilitator that you have completed this learning activity. Seek opportunities to apply this nursing skill. IN REFLECTION • What principles are involved in the conversion of an existing intravenous to an

intermittent infusion device and administration of intravenous medications through the intermittent infusion device using an intravenous line?

• How can you do these nursing skills in a safe and competent manner? REFERENCES Craven, R. and Hirnle, C. (2003) Fundamentals of Nursing: Human, health and functions. Philadelphia: Lippincott, Williams, and Wilkins Curren, A. and Munday, L. (2000). Math for meds: Dosages and solutions. California: Wallcur Inc.

Langara

College

Fall 2

006 -

archive

d


Page 64 of 85

PRACTICE SCENARIOS

You have been assigned to Sam Young, who was admitted to your unit two days ago with a GI bleed. Sam has had the abdominal ultrasound.

Situation #1: Read and follow the Physicians' Orders on the following page. 1. As per Dr’s orders what are you expected to do? 2. Convert the continuous IV to a saline lock 4. Document the above procedure in the Nurses' Notes. Situation #2: During your shift, the RN asks if you to flush Sam’s saline lock. 1. Flush the saline lock using positive pressure.

Langara

College

Fall 2

006 -

archive

d


Page 65 of 85

9730457390003 Sam Young

DOB January 15, 1956 Dr. A.Merrell


DATE TIME ORDERS October 18, 2006 0900 Vital signs regular Clear fluid to full fluid to DAT AAT IV NS at 150cc/hr x 24 hours, then 75cc/hr to saline

lock when drinking well CBC, lytes, BUN, Cr, stool for C&S, abdominal

ultrasound Rabeprazole 20mg po od Tylenol ii tabs q4h prn Gentamycin 40 mg IV tid. Hydromorphone 1mg SC q4-6h, prn Dimenhydrinate 25 – 50 mg SC/IM prn--Dr. A. Merrell October 19, 2006 0900 NPO midnight for abdominal ultrasound Start IV D5W at 75cc/hr on Oct 20 at 0800 Saline lock IV after abd ultrasound --Dr. A. Merrell La

ngara Colle

ge

Fall 2

006 -

archive

d


Page 66 of 85

9730457390003 Sam Young

DOB January 15, 1956 Dr. A. Merrell

ALLERGIES: Animal Dander

MEDICATION ADMINISTRATION RECORD FROM 0800 20 OCTOBER, 2006 TO 0759 21 OCTOBER, 2006

08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 06 07 Infusions

IV Normal saline at prescribed rate Order #1 Gentamycin 40mg/mL inj Ordered 18 Oct 2006 40mg IV tid (Dilute in 100 mL of 5DW or NS. Infuse over 30 minutes.) 14 22 06 Medications Order #2 Rabeprazole 20mg tab (Pariet or equiv) Ordered 18 Oct 2006 20mg po od 08 PRN Medications Order #3 Acetaminophen 325mg tab (Tylenol or equiv) Ordered 18 Oct 2006 650mg po q4h prn Order #4 Hydromorphone 2mg/mL inj (Dilaudid or equiv) Ordered 18 Oct 2006 1 mg sc q4-6h prn Order #4 DimenhyDRINATE 50mg/mL Inj (Gravol or equiv) Ordered 18 Oct 2006 25 – 50mg IM q4h prn 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 06 07


Langara

College

Fall 2

006 -

archive

d


Page 67 of 85

LANGARA HOSPITAL FLUID BALANCE SHEET

DATE: ____________ Fluid Restriction: ____________ INTAKE OUTPUT Time Start

Solution/Drug/Flow Rate

Amount Start

Volume Infused

Initial Time Oral Tube Time Urine Tube

Subtotals

Combined Total

24 Hour Balance =

Langara

College

Fall 2

006 -

archive

d


Page 68 of 85

Learning Activity

Clients Requiring Asepsis: Simple Wound Care

- Assessment, Asepsis, Simple dressing change, Therapeutic

agents/modalities

CONCEPTS: ACUTE PAIN, ANXIETY/FEAR, ASSESSMENT VULNERABILITY, HEALING, TRUST, SUFFERING, RESILIENCE/HARDINESS,

CONTROL, ENERGY, UNPREDICTABILITY OVERVIEW The skin is the largest functional organ and for it to successfully protect individuals from the invasion of microorganisms, it must remain intact. Clients experience wounds as a result of health challenges, pressure, trauma, or by surgery. As wounds are a complex phenomena, specific principles and concepts must be applied to the assessment and treatment of all wounds in order to give your patient the best possible care. The simple dressing is used to cover a clean, surgical incision, or an abrasion. The purpose of the dressing is to promote comfort and protect the wound or incision from physical injury. Sterile dressing serves many purposes; they protect the incision or wound from injury, prevent the introduction and psychological comfort. Nurses apply many different types of dressings from simple to large and complex wounds. Despite their many purposes, dressings also have some disadvantages. It is difficult to assess a wound when it is covered. Dressings also create a closed environment that may encourage bacterial growth. Therefore, dressings must be changed regularly to prevent infection and breakdown of healthy tissue. Infections are also prevented by through hand washing, meticulous aseptic technique, and using sterile equipment and supplies during wound care. The goal of wound healing is the restoration of normal function and structure. Factors such as age, malnutrition, dehydration, and pre-existing disease affect wound healing. Clients requiring wound care may experience pain, anxiety, and an altered self-concept. This learning activity emphasizes the knowledge and skill required to care for clients who have a dressing change.

Langara

College

Fall 2

006 -

archive

d


Page 69 of 85

ENDS-IN-VIEW

• To understand types of wounds and process of wound healing. • To be cognizant of factors that impedes or promotes wound healing. • To understand the principles of wound healing. • To be able to assess a wound/incision accurately and comprehensively. • To apply the principles of medical and surgical sepsis. • To perform a simple dressing change on a wound and incision. • To document the assessment and dressing change. • To appreciate the stress of clients who are experiencing complex dressing

changes. • To identify potential complications and be able to determine when, why and how

to collect a culture and sensitivity on wounds. • To develop an awareness of the nurse’s role in wound care and management. • To be able to identify, prevent, control and teach individuals about wound care.

IN PREPARATION 1. From this course packet:

Review the learning activity on Clients Requiring Asepsis: Simple Wound Care Complete the study guide for Clients Requiring Asepsis: Simple Wound Care


Chapter 37, p.935 - 960 Procedure 32.2, p.771 - 774

3. Read the following chapters from Weber & Kelley:

Chapters 9 4. From Lewis & Heitkemper, Medical – Surgical Nursing: Assessment and

management of clinical problems, read: P.207 – 221. Focus on the healing process, local manifestations of inflammation, complications of healing, concepts of wound care, collaborative care, factors delaying wound healing, nursing management, inflammation & infection, and types of wound dressings.

5. View the video:

Sterile Field Scenarios (available in Video and DVD formats) Call Number – RD 113 S74 2005

Langara

College

Fall 2

006 -

archive

d


Page 70 of 85

IN NERC In pairs review the scenarios and complete the questions. Observe a complex dressing change. Using the models provided, work through the following scenarios in pairs. Assist your partner in applying the principles of asepsis and wound care. Be prepared to share your learning with the large group. IN PRACTICE Review your agency's Policy and Procedure Manual prior to a dressing change for a client with a complex wound. Do the equipment and/or supplies available in the agency vary from what was available in the lab? How can you maintain the principles you have been taught using the agency materials? Prior to completing your patient’s wound care, review the components of a wound assessment and the order in which the dressing should be completed so you can maintain the principles. Inform your practice facilitator that you have completed this learning activity. Seek opportunities to apply this nursing skill. IN REFLECTION Wound healing is complex and holistic. Wound healing requires that you care for the whole patient and not just the wound. When planning care for clients with simple wounds, reflect on your nursing and biology knowledge as well as information particular to your patient from Gordon’s Health Patterns. For example, your patient is not eating well but you know good nutrition is essential to effective wound healing. How would you utilize this knowledge to plan your patient’s care and facilitate wound healing? REFERENCES Craven, R. & Hirnle, C. (2003). Fundamentals of Nursing: Human Health and Function (4th Ed.). Philadelphia: Lippincott. Lewis, S. et al (2000). Medical – surgical nursing: Assessment and management of clinical problems. (6th ed.). St. Louis: C. V. Mosby Company.

Langara

College

Fall 2

006 -

archive

d


Page 71 of 85

STUDY GUIDE FOR CLIENTS REQUIRING ASEPSIS: SIMPLE WOUND CARE

1. Describe the structure and function of the skin.

2. Describe the phases of wound healing.

3. Describe the types of wound healing.

4. List the factors affecting wound healing.

5. List the complications of wound healing.

6. Describe a pressure ulcer.

7. What are the causes of pressure ulcers?

8. List the most common sites of pressure ulcers.

9. Define friction and shearing forces.

10. List the standards of care to prevent pressure ulcer formation.

11. List factors pre-disposing to wound infection.

12. What are the common manifestations of a wound infection?

13. Describe a sterile field

14. In your own words describe how you would prepare and maintain a sterile field.

Langara

College

Fall 2

006 -

archive

d


Page 72 of 85

PRACTICE SCENARIOS

Scenario # 1:

You are assigned to Raj Dhaliwal, an elderly gentleman, who fell three weeks ago and sustained a laceration to the medial aspect of his left knee that required 20 stitches to close. The wound is healed except for a ½ inch opening at the distal portion of the suture line which is draining a small amount of thick grey - green exudate. He now has

cellulitis in his left calf and his lower leg is swollen, red, and painful.

1. What should you do to prepare this patient for his dressing change?

2. What principles of wound care should be observed when cleaning and dressing these wounds?

3. What kind of dressing would be best suited to these wounds?

4. The skin on the lower leg is too fragile to apply tape. How will you stabilize the

dressing?

5. Prepare the equipment and the patient for this dressing change.

6. Complete the dressing change.

7. Document your findings and your nursing actions.

Langara

College

Fall 2

006 -

archive

d


Page 73 of 85

Scenario # 2:

Benjamin Tom, 71, has had a pressure ulcer on his gluteal. The pressure ulcer is an open area with a pinky red granulating wound bed. There is no undermining or tunneling and the surrounding skin is healthy. The orders are to irrigate the wound with normal saline, apply hydrogel to the wound and cover with a secondary dressing.

1. What should you do to prepare Tom for his dressing change?

2. At what stage is his pressure ulcer?

3. What principles of wound care should be observed when cleaning and dressing

this wound?

4. Prepare the equipment and the patient for this dressing change.

5. Complete the dressing change.

6. Document your findings and your nursing actions.

Langara

College

Fall 2

006 -

archive

d


Page 74 of 85

Learning Activity

Clients Requiring Asepsis: Sterile Gloving

- Asepsis, Safety, Health perception & Health Maintenance, Assessment


VULNERABILITY, HEALING, SUFFERING, RESILIENCE/HARDINESS, CONTROL,

OVERVIEW Surgical asepsis or sterile technique includes practices that keep objects and areas free of micro organisms. Examples of sterile techniques include sterile dressing changes and wearing sterile gloves. Sterile gloves act as a barrier to bacterial transfer. Nurses are able to handle sterile objects freely and to touch vulnerable parts of the body without contamination. Sterile gloves are manufactured in many sizes. It is important to determine your personal glove size for both your own comfort and safety and the client’s safety. Gloves that are too small increase the chance of tearing and gloves that are too large make handling of equipment awkward. This learning activity includes the essential knowledge and skills to facilitate the care of clients requiring specific isolation precautions. You will also have the opportunity to learn to wear and discard sterile gloves. ENDS-IN-VIEW

• To apply the principles of surgical asepsis. • To identify clients at risk for developing an infection. • To identify situations where sterile gloves are worn. • To demonstrate the correct application, removal and disposal of sterile gloves.

IN PREPARATION 1. From this Course Packet:

Read the learning activity on Clients Requiring Asepsis: Sterile Gloving Review the Study Guide for Clients Requiring Asepsis: Infection Control


Chapter 32, Sterile Technique, p.768 - 770 Procedure 32.3, p.775

Langara

College

Fall 2

006 -

archive

d


Page 75 of 85

3. View the video: Basic Sterile Technique (Please view only the donning and removal of sterile gloves)

Call Number – RA 969 142 NO.4 1995 4. For this lab:

Wear comfortable clothing. It would be preferred that you wear short sleeved shirts to practice sterile gloving.

IN NERC In pairs, practice wearing sterile gloves. Provide each other with feedback on maintenance of sterility and areas for improvement. Be prepared to share your learning with the large group. IN NURSING PRACTICE Know where sterile gloves are kept in your agency and what situations the nurses commonly use them for. IN REFLECTION

• How do you feel about caring for a patient that requires you to wear sterile gloves? • How will you explain your wearing of sterile gloves to the client’s family and/or

visitors? • What are some of your feelings with wearing sterile gloves and maintaining

sterility? • What are some situations that would require you to wear sterile gloves?

Langara

College

Fall 2

006 -

archive

d


Page 76 of 85

APPENDIX

Langara

College

Fall 2

006 -

archive

d


Page 77 of 85

APPENDIX I

Clients Requiring Controlled Volume Infusions



CONTROL, ABUSE OVERVIEW This learning activity examines the use of controlled volume infusions. Clients may require specific volumes of intravenous fluid or infusions with medications that require close monitoring which is achieved by controlled volume infusion pumps (i.e., IVAC, Alaris Pumps). The purpose of this section is to "show and tell". The paediatric setting provides the practise and application of this skill. ENDS-IN-VIEW

• To understand the purpose of controlled volume infusion pumps and buretrols. • To have a beginning knowledge about using a controlled volume pump and

buretrols. IN PREPARATION

Complete the question under the In Reflection section of this learning activity. IN CLINICAL PRACTICE • Discuss controlled volume infusion pumps (i.e., IVAC, Alaris Pumps). • Learn how to use the infusion pumps. IN REFLECTION • What are the differences between a gravity IV tubing and infusion pump tubing? • What are the advantages and disadvantages of controlled volume infusion pumps? • List the types of clients that may require either device.

Langara

College

Fall 2

006 -

archive

d


Page 78 of 85

REFERENCES Craven, R. and Hirnle, C. (2003) Fundamentals of Nursing: Human, health and functions. Philadelphia: Lippincott, Williams, and Wilkins. Curren, A. and Munday, L. (2000). Math for meds: Dosages and solutions. California: Wallcur Inc.

Langara

College

Fall 2

006 -

archive

d


Page 79 of 85

APPENDIX II

May 2005 Langara College Nursing Program

IV Therapy and Medication Policy for Nursing Students

This policy contains three sections which give direction to Nursing Students in providing intravenous (IV) and medication therapy to patients in the practice environment. The first section is “General Guidelines,” the second is “Specific Responsibilities and Restrictions Regarding IVs,” and the third is “General Restrictions.” In addition, two “Summary Charts” are provided, for quick access to information.

General Guidelines This policy is for the general use of Nursing Students as a guideline toward safe and competent nursing practice. Nursing Students are also required to follow the policies and procedures governing Registered Nurses in their respective practice settings. In instances where the agency and Langara College policies differ, the institution with the most restrictive policy will be followed.

Safety It is expected that principles of safety will be followed at all times. Safety principles involve the rule of ‘7 Rights, 3 Checks.’ In addition, they involve assessment and monitoring of IV solutions, tubings, volume control pumps, IV sites, fluid volumes, compatibilities, and rates. Knowledge and responsibility are central to maintaining safety. Students must make themselves aware of written protocols or procedures on their respective Units in relation to medications, IV pumps, patient controlled analgesia (PCA), and epidurals. Students must also be aware of specialized types of medications and procedures which require advanced knowledge or skill, and thus follow the related restrictions to students’ nursing practice. A component to responsibility is seeking clarification whenever necessary.

Knowledge and Responsibility Required of Students 1. ALL MEDICATIONS

Students must be knowledgeable about all the medications they are preparing and administering. This involves knowledge of: Class Compatibility Subclass Interactions with other medications Indications for use Practice Decision-Making Action Patient teaching Safe dosage Nursing actions Principles of drug therapy Therapeutic effects Contraindications Adverse effects Appropriate routes of administration Antidotes Related laboratory values to monitor therapeutic ranges

Langara

College

Fall 2

006 -

archive

d


Page 80 of 85

2. IV and MEDICATION RESOURCES

Students are responsible for utilizing agency resources for specific, practical information about solutions, dilutions, volumes, rates, and safe doses.

3. CALCULATIONS Students must demonstrate an understanding of math calculations (e.g. safe dosages, volumes of drug, dilutions, and rate of infusion). When calculating dosages, students are responsible for having their calculations checked by their practice facilitator before they prepare the med.

4. SPECIALIZED / EXPERIMENTAL MEDICATIONS (CPE III - Preceptorship Students) In agencies where students are permitted to administer experimental or specialized medications (e.g. cytotoxic drugs), students must validate the protocol with their practice facilitator and/or RN prior to preparing the medication.

5. PSYCHOMOTOR SKILLS Students must be duly prepared and demonstrate appropriate psychomotor skills. This includes knowledge and skill regarding volume-controlled pumps prior to use.

Specific Responsibilities and Restrictions Regarding IVs Being allowed to administer medications independently at the end of a particular term does not mean the student will be independent with this skill at the beginning of a subsequent term. Therefore, each term, students must demonstrate appropriate knowledge and skills to their facilitator before they can be supervised by an RN or complete the skill independently. 1. PERIPHERAL LINES

a.) General Responsibilities The student may: -Assess, regulate, monitor, and discontinue IVs as ordered.

-Change IV solutions. -Change IV tubings. -Change IV dressings. Note: There may be limitations to dressing changes and discontinuation of IVs in the pediatric environment.

b.) Primary IV Bag Medications Students are responsible for the assessment, regulation, and monitoring of IV meds they have prepared, as well as bags supplied by the pharmacy department. The student may: -Add compatible, safe doses of medication to a new

primary bag of IV solution.

Langara

College

Fall 2

006 -

archive

d


Page 81 of 85

Note: The student must be aware of medications that have been added to a primary bag that require an IV pump to accurately control the rate of infusion. For example, Heparin, Oxytocin or KCl in higher concentrations than 40 mEq/l. c.) Minibag, Buretrol, or Syringe Pump Medications

Students may: -Add medication to a minibag, buretrol, or syringe pump. -Hang, regulate, and monitor minibags they have prepared or that were prepared by the pharmacy department. -Monitor medications that were initiated by other health care team members

d.) IV Push Medications Prior to the administration of IV push medications, students must check the agency policy and protocols. The student must know if the medication is designated for RN administration on general nursing units, the diluents to be used, the volume of diluents, compatibilities with the primary solution and its additives, and the rate of administration. IV push medications must be supervised by the practice facilitator until the student has been deemed safe to administer IV push meds under the RN’s supervision or independently (CPE III - preceptorship).

e.) Medications NOT to be given IV Push Opioids Barbiturates Sedatives Anti-neoplastics Anti-hypertensives Agency-restricted medications

2.) SALINE LOCKS After determining patency and correct placement of the cannula in the vein, the student may: -Assess and monitor a saline lock site. -Convert a running IV into a saline lock. -Convert a saline lock into a running IV. -Administer safe, allowable medications using a minibag, buretrol, or syringe

pump. -Administer safe, allowable IV ‘push’ medications according to the recommended agency protocol -Administer the required ‘flush’ following medication administration and hospital standards. -Discontinue a saline lock, following agency policy.

3.) CENTRAL LINES (Central Venous Catheter/CVC), (including Peripherally Inserted

Langara

College

Fall 2

006 -

archive

d


Page 82 of 85

Central Catheter/PICC, Venous Access Device/VAD, Midlines) Registration Terms 1 and 2 students have NO responsibilities for any type of central line (CVC). Registration Term 3 students do not regulate nor monitor CVC lines. However, they are responsible to maintain the safety of the CVC. Following instruction and a demonstration, students may implement the immediate emergency measure of clamping a CVC. Students are expected to be prepared with relevant theoretical knowledge prior to caring for patients with a CVC or TPN. Registration Terms 4, 5 (CPE I), 6, 7, 8 (CPE II), 9 and 10 (CPE III - Preceptorship) students have responsibilities as indicated specifically below. Before taking any responsibility for CVCs, students must demonstrate to their practice facilitator that they have the knowledge and skills to care for this type of IV. Students must also check the agency policy for restrictions related to students’ care of CVCs. a.) General Responsibilities

Registration Terms 4 through 10 students may: -CHANGE THE PRIMARY SOLUTION BAG.

-Complete frequent site to source assessments. -Regulate and monitor infusions via an infusion pump (and gravity when agency permitted) after instruction and demonstration.

b.) IV Medications via Minibag, Buretrol, or Syringe Pump Registration Terms 3 through 10 students may: -Administer medication to a minibag, buretrol, or syringe pump connected to a single or double lumen central line. -Administer, regulate, and monitor compatible medications they have prepared or that were prepared by the pharmacy department.

-Monitor medications that were initiated by other health care team members.

c.) IV ‘Push’ Medications Registration Term 10 (CPE III – Preceptorship) If agency permits, students may ‘push’ meds into an already accessed CVC line, according to policy.

d.) Specific Limitations Students may NOT:

-Prime tubings. -Flush, lock or cap lines/lumens. -Change dressings. -Discontinue central line catheters.

4. TOTAL PARENTERAL NUTRITION (TPN)

Students may monitor and regulate via an infusion pump: -TPN. -Solutions contained in a bag or bottle. -TPN solutions containing medications added by a pharmacist, via

Langara

College

Fall 2

006 -

archive

d


Page 83 of 85

separate lumens of a central line.

The student may NOT: -Hang new bags or bottles of TPN. -Change TPN bags or bottles. -Add medications to TPN solutions. -Administer medications (such as IV meds in a mini-bag) into a designated TPN line. -Discontinue TPN solutions.

5.) BLOOD AND BLOOD PRODUCTS Students may (under supervision and per agency policy and procedure):

-Hang blood tubing with IV solution. -Prime blood tubing with IV solution. -Complete initial and subsequent VS checks and assessment of the patient during the infusion. -Discontinue blood infusion. -Monitor the patient according to hospital policy and work closely with the RN during the blood transfusion. -The student must be aware of agency specific limitations related to blood and blood product administration.

Students may NOT: -Hang blood or blood products or sign for blood administration. -Initiate blood or blood products independently. -Collect blood specimens from an IV cannula or central line lumen.

Langara

College

Fall 2

006 -

archive

d


Page 84 of 85

General Restrictions Students may NOT: 1.) Students must not do any skill designated as requiring RN certification, or to be done

only by a physician. 2.) Accept any verbal or telephone order (eg, for a medication, IV solution, infusion rate,

conversion of an infusing IV to or from a saline lock, or discontinuing an IV). 3.) Establish an IV. 4.) Irrigate IV cannulas. 5.) Administer medications to patients who are not on the student’s assigned unit (for

example, in alternate experience areas, such as while students’ patient is off the Unit in Surgical Daycare Unit, Operating Room, Recovery Room, Emergency, ICU, or X-ray Department etc).

Summary Chart I: Medication and IV Content per Term

Term Content Introduced in

Nursing Skills Class Content Introduced in Clinical Practice

(approx.)

I II Medications (PO, respiratory,

ointment, drops) Medications (PO, respiratory, ointment, drops)

III IV Solutions, IV Care, IV Meds IV Solutions, IV Care, IV Meds (IV meds not in Pediatrics)

IV Central Venous Catheter (CVC) Care (including Peripherally Inserted Central Catheters and Midlines), Total Parenteral Nutrition (TPN), Blood Products and their Administration

IV Solutions, IV Care, IV Meds Central Venous Catheter (CVC) Care, (including Peripherally Inserted Central Catheters and Midlines), Total Parenteral Nutrition (TPN), Blood Products and their Administration

CPE I II III

Central Venous Catheter (CVC) Care, Total Parenteral Nutrition (TPN), Blood Products and their Administration

Langara

College

Fall 2

006 -

archive

d


Page 85 of 85

Summary Chart II: Type of Student-Appropriate Care per Type of IV and Solution (*This chart serves only as a brief summary and by no means represents the full extent of required student knowledge).

Peripheral Lines Saline Locks

Central Lines TPN Blood Products

Assess, Regulate, Monitor

yes yes Term dependent

term dependent

term dependent

Hang Primary Bag yes yes term dependent

no see above text

Change Tubing yes N/A no no see above text

Dressing Change yes yes no no N/A

Administer IV Med per Minibag, Buretrol, Syringe Pump

term dependent

Term dependent

term dependent

no N/A

IV Push Med term dependent

Term dependent

no no N/A

________________ Review Date: May 2007

Langara

College

Fall 2

006 -

archive

d

Documents

NURSING SKILLS CLASS - Langara College · The Nursing Skills Class complements the theoretical component by teaching you the hands- on nursing skills that supports people’s healing