Skills Lab NUR 310

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Skills Lab NUR 310

• Diane E. White RN CCRN PhD

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Intravenous Catheter Insertion

• Purpose is to give intravenous fluids and
  medications to patient
• Types of peripheral intravenous catheters
  winged butterfly needles and over the needle
  catheters
• Sizes for over the needle catheters based on
  length and gauge (bevel)
• Larger the number size, smaller the gauge

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Equipment Needed

• IV start kits may be available at clinical sites
• Tourniquet, tape, 2x2 gauze, alcohol prep,
  betadine prep, transparent covering and label
• Disposable gloves
• IV catheter and catheter adapter

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Selection of Vein

• See text for various sites
• Select the most distal vein of the non-dominant
  hand if possible
• Size of catheter fluids/medications may
  determine placement site
• Avoid areas of bifurcation, knotted veins,
  crooked veins, and previous sites of infiltration
  or bruised areas

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Insertion Procedure

• Verify order (physician or standing order)
• Gather equipment
• Verify patient with 2 information identifiers
• Explain procedure to patient
• Wash hands
• Don clean gloves
• Place tourniquet above veinipuncture site

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Insertion Procedure

• Palpate veins with extremity in dependent
  position if applicable
• Prep area using a circular motion away from
  insertion site use Alcohol then Betadine to
  prep. Allow to dry flush adapter with NS
• Stabilize the vein by pulling taut opposite the
  direction of venipuncture
• Take protective shield off of IV catheter and
  insert bevel up at a 10-30 degree angle

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Insertion Procedure

• Once flashback of blood is seen in catheter,
  advance catheter and remove needle from catheter
  using the one-hand or two-hand technique apply
  pressure at site
• Remove tourniquet and place adapter on the hub of
  the catheter may draw blood for lab if needed
• Aspirate for blood return and flush with at least
  3 ml of normal saline
• Stabilize IV catheter with tape and dressing NO
  occlusive dressings as seen in text!!!!

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IV Insertion

• Time, Date, and Initial Dressing
• Remove gloves and wash hands
• IV catheters changed every 72 hours or sooner if
  needed sign and symptoms of problems
• Document site of insertion, gauge of IV catheter
  used, and fluids or medication given

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Intravenous Fluids

• Types Isotonic, Hypotonic, Hypertonic, Colloids
• Isotonic no fluid shifts .9 Normal Saline,
  Lactated Ringers
• Hypotonic extracellular to intracellular D5W,
  .45 Normal Saline
• Hypertonic intracellular to extracellular .3
  Normal Saline, HAL, Albumin

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Intravenous Fluid Administration

• Verify Order
• Identify Patient Explain procedure
• Select appropriate primary or secondary tubing
  clamp down roller
• Spike IV fluid bag
• Squeeze IV fluid chamber
• Prime tubing
• Attach to IV adapter on patient
• Slowly open roller clamp and count drops for
  ordered rate

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IV Fluid Rate Calculation

• Amount of volume in bag divided by amount of time
  in minutes to infuse and multiply by drip factor
  of tubing gtts/minute
• Order infuse 1 liter .9 NS over 8 hours
• 1000ml/ 8 125 ml/hour
• 125ml/ 60 2.08 x 15 gtt factor 31.2 gtts/min
• Order Rocephin 1 GM in 100 ml of normal saline
  to infuse over 30 minutes
• 100/ 30 3.33 X 15 49.99

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Secondary IVPB

• Verify order and check patient identification
• Select appropriate secondary tubing clamp down
  roller
• Spike IVPB
• Squeeze chamber
• Prime tubing and attach to Y connecter on
  primary tubing
• Lower the Primary IV fluid bag
• Regulate flow of IVPB by unclamping secondary
  roller clamp and using roller clamp on Primary IV
  fluid. Look at the secondary IVPB chamber to
  count drops per minute

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Intravenous fluid Devices

• May use dial-flows to regulate drip rates
• May use IV infusion pump devices to infuse
  primary and or secondary fluids
• These devices infuse fluids at the rate of
  ml/hour, NOT ml/minute
• Do not need to calculate gtts/minute so you do
  not need a tubing gtt factor
• No gravity needed

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Intravenous Medication Administration

• Select the appropriate syringe size based on
  amount and type of volume (3ml, 5ml, 12ml,
  5units, 40 units, etc.)
• Select the appropriate needle to aspirate the
  medication or for injection (subcutaneous,
  intramuscular, viscous solution, etc..)

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Medication Preparation

• Vials versus Ampules
• Drawing up medications from ampules
• Have Medication Administration Record (MAR)
  with you at ALL times!!!
• Verify MAR with original order if needed and
  check patient identification
• Tap tip of ampule and place a gauze or alcohol
  pad around neck of ampule break neck of ampule
• Withdraw medication with filtered needle

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Medication Preparation from a Vial

• Verify order Patient Identification!!
• Remove cap of unused vial or single dose vial
  alcohol off the top of multi-use vials inject
  solution for reconstitution if indicated
• Use syringe with needle or adapter to puncture
  the vial
• Inject amount of air needed into vial
• Turn vial upward with needle below the fluid line
  aspirate desired dosage
• Dislodge air bubbles (2-ways)
• Place correct needle or adapter on syringe and
  used needle into sharps container
• Aspirate if indicated and Inject medication at
  designated rate flush with 3 ml normal saline
  prior to and after medication if indicated

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Central Venous Catheters

• Types PICC,TLC, Hickman/Groshong, and
  Port-A-Cath
• Inserted by Physician, Physician Assistants and
  some Advanced Practice Nurses in some States
• Inserted into the jugular, subclavian, or femoral
  veins
• Insertion with Sterile Technique

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Central Venous Catheters

• Indications large amount of fluid
  administration, central venous pressure (CVP)
  monitoring, total parental nutrition (TPN) or
  hyperalimintation (HAL), frequent blood draws
• Nursing Management trouble shooting catheters,
  assist with insertion, and changing dressings

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CVL Dressing Change

• Sterile technique used
• Wash hands
• Identify Patient/Explain procedure
• Open sterile kit and place mask on yourself and
  patient clean prep, sterile gloves, tegaderm,
  tape, and gauze
• Don clean gloves to remove dressing
• Inspect insertion site
• Take gloves off

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CVL Dressing Change

• Don sterile gloves and open necessary containers
  of prep supplies
• With a circular motion AWAY from the insertion
  site, clean the site. Use one swab if applicable,
  per circular motion and discard swab
• Cover insertion site with tegaderm
• Secure dressing around edges with transparent
  tape if needed
• Initial, date and time the dressing

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CVL Dressing Change

• Flush port caps with NS change port caps flush
  per hospital protocol clamping ports
  controversial
• Remove masks, gloves, and wash hands
• Document procedure

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Endotracheal Suctioning

• Identify Patient/Explain Procedure
• Position Patient
• Ascultate lungs bilaterally all lobes
• Check suction on wall (80-120mm)
• Open Sterile Suctioning kit and pour sterile
  normal saline into basin
• Don Sterile gloves and decide which hand will
  remain sterile and which will NOT be sterile

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Endotracheal Suctioning

• Connect suction catheter to wall suction device
  and check for suction ability
• Hyper oxygenate patient
• Insert suction catheter into inner cannula 6-8
  inches in the adult WITHOUT suction
• Remove suction catheter using circular motion and
  INTERMEDIATE suctioning
• Suction no longer than 10 seconds with each
  suction pass

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Endotracheal Suctioning

• Place oxygen device back on patient stoma
• Clean suction catheter with normal saline
• Repeat suction pass 2-3 times as needed
• Ascultate lungs bilaterally all lobes
• Dispose of kit and wash hands
• Document procedure
• In-line suctioning used on ventilated patients

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Tracheostomy Care

• Most inner cannulas are disposable
• Identify Patient and Explain procedure
• Wash Hands
• Open Tracheostomy Care kit
• Pour Normal saline and hydrogen peroxide into
  containers inside kit
• Don sterile gloves designate sterile and
  non-sterile hands

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Tracheostomy Care

• Saturate a 1-2 Q-tips in kit with normal saline
  and peroxide each set to side on sterile field
• Remove inner cannula with non-sterile hand and
  drop into peroxide
• Provide oxygen over outer cannula
• Clean inside cannula with brush using non-sterile
  hand and holding cannula with sterile hand
• Place inner cannula into normal saline with
  sterile hand to rinse
• Dry cannula off with gauzes and pipe cleaners
  provided inside kit using non-sterile hand

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Tracheostomy Care

• Remove oxygen source
• Replace inner cannula into outer cannula and lock
• Place oxygen source on patient
• Clean around stoma with Q-tips on sterile field
  and discard
• Replace ties securing tracheostomy
• Replace gauze around stoma
• Document procedure