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A Basic guide to Critical Care nursing and Medication administration- COVID 19 Plan- DCCQ

Please note this pack has been collated by Gill Holebrook & Louise Stratten, using multiple Education/guidelines from DCC, Su Jeffries.

It is specifically for use during COVId 19 . APRIL 2020

DCC QAH COVID 19. Gill Holebrook/Louise stratten

NOTE: DOOR CODES ARE NOT TO BE SHARED OUTSIDE OF THE UNIT

UNIT CODESLadies Changing RoomMen’s Changing RoomBin StoreMedication RoomClean StoreEquipment StoreWest Seminar Room

Useful numbers

East side: 6852/6853West side: 6385/6035Referral phone number: 5752Outreach: bleep 1676.ITU reg: bleep 1987/2003ITU SHO: bleep 1660/1664Teaching team: 3628Nurse in charge bleep 1663

Peed recovery (DCCR) anaesthetist bleep-2131Paed recovery (DCCR) NIC bleep 2130

Shift timesEarly 07.00-15.00Late 12.30 to 20.30Long day 07.00-20.30Night 20.00 to 07.30


Practical competencies for Intensive care Nursing

Nursing care Competency CompletedEnvironment Safety checks at the bed space (e.g., alarm limits,

water circuit, suction port, oxygen port)Carry Out a top to toe/ ABCDE assessment of the patientDiscuss Admission proceduresDiscuss discharge procedures

Airway *Check Endotracheal Tube(ETT) placement including- ETT cm’s at the teeth, cuff pressure and knowing normal pressure*Demonstrate use of sub-glottic suction port on ETT*Discuss trouble shooting to ensure maintenance of airway (e.g. balloon leak, displacement, severing of pilot tube).*Note grade of intubation*Check securement of Tracheostomy including caring for the tracheostomy -(dressing clean and dry/ Inner cannulae patent)* Discuss trouble shooting (e.g. displacement, accidental decannulation, and blockage).*Inline suction both ETT and Tracheostomy (correct size and length)-*Procedure for suction both via ETT & tracheostomy*Discuss the use of pre-oxygenation*Suction Tracheostomy and ETT using soft tip suction catheter*End tidal Co2- should be continuously monitored on all Ventilated patients- both numerical and waveform. Discuss importance of continuous monitoring*Importance of continuous SpO2 monitoring*Non-bronchial lavage sample (NBL)- for standard culture & Covid 19 PCR/Swabs should be taken for all possible COVID 19 patients*Identify s signs of airway obstruction and interventions*Discuss the process of intubation and extubation and the role*Review Rapid sequence induction guide(RSI)

Breathing Carry out auscultation of the patient’s chest; discuss different breath sounds and interventions.- IN COVID 19 auscultation is avoided.*Monitor rise and fall of chest**Discuss the need for chest physio*Explain the setting of Ventilation parameters will - Tidal volume (TV) - normal6ml/kg- Using ideal


weight via ulnar length guide.*Minute volume= TVXRR*Demonstrate/discuss setting alarm limits on ventilator*Explain Peep/Cpap and setting on ventilator*Administer Non-invasive ventilation face mask*Give a nebuliser ( trachy and ETT)*Change HME filter – discuss clamping ETT during this procedure.*Discuss normal values of Arterial blood gas(ABG)*Select the correct size inline suction for ETT and Tracheostomy*Administer humidified mask and speaking valve for tracheostomy patients*Assist with the process of proning patient indications, procedure, SOP, monitoring, aftercare. Key pressure area considerations

Circulation *Assess patient’s circulation (e.g. pulse, pallor, temp, CRT)*Discuss ECG traces and what are appropriate interventions (e.g. CPR and Defibrillation*Obtain and run ABG sample from an arterial line*Set up for arterial line insertion*Discuss arterial line – Transducer system/process of zeroing/levelling/fluid bag at 300mmhg/ 0.9% saline. ONLY*Complications/removal*Central line care- Normal value- taking into consider ventilator/ peep. Tracy care/dressing. Norm 7 day’s insitu/Monitoring site... Procedure to remove.*Perform 12 lead ECG*Take blood sample from an arterial line and central line*Discuss the use of electrolyte replacement – Na/K /MG/Phosphate (infusions of phosphate run at 21mls/hr on critical care patients)*Discuss administration of high dose potassium – norm 60mmols KCL in 100mls N/S over 3 hours. Via volumetric/central Line and ECG monitoring*Discuss normal BP and treatment for high and low BPWithin Critical care we will titrate medication to Mean arterial pressure(MAP)> 65mmgg- COVID 19 patients*Discuss signs of shock

*VTE assessment prophylaxis- Normal TED or Calf Pumps and clexane (norm 40mg).*Measure urine output


Renal *Calculate fluid balance (include insensible loss)*Discuss the normal urea/creatinine levels- importance of monitoring in relation to renal function

Neuro *Assess patients consciousness level using GCS/AVPU*Assess Pupils (size and reaction)*Administer appropriate painful stimuli (e.g. NOT sternum rub)*Normal sedation regime midazolam 50mg/50mls IVI ((0-10mls/mgs per hr)) and Morphine VI (1-10mls per hr)* Alternatively regime propofol 1% IVI 0-30mls per hour, as sedative agent*discuss the side effects of sedation analgesic/boluses/side effects- renal considerations*Assess patients sedation score using RASS*Discuss indication for sedation and neuromuscular blockade agent (NMDA)- used severe respiratory failure – Norm atracurium IVIAdminister train of 4 test – used to titrate/optimise (NMDA)

Gastro *Assess patient’s abdomen (e.g. distended, firm, soft, bowel sounds)-AVOID using stethoscope*Check placement of NG tube (position, Ph. and aspirate volume).CXR*Set up patient feed*Administer medication down NG tube*Assess the health of a stoma*Change a stoma bag*Obtain and discuss normal blood sugar levels normally 2-4 holy*Assess need for sliding scale*Discuss signs, symptoms and management of hypo/hyperglycaemia*Administer feed via a PEG/JEG (DON’T aspirate)*Administer medication into a PEG/JEG*Normal enteral feed regime Nutrison protein plus fibre, at 15mls. Increase as per NG feed regime- dependant on aspirates.

Integumentary *Assess appearance of skin (e.g. Integrity, pallor. Elasticity, lesions)*Assess integrity of wound dressing (e.g. strike through, blood)*Assess patients level of independence and provide appropriate level of personal care*Assess insertion site of all invasive linesPeripheral venous cannula 3 days insituArterial line-7 daysCVC – 7days


*use Purpose T scoring to assess for the risk of pressure sores act accordingly*Change dressings on lines and add date of insertion*Assess for pressure sores on invasive devices*Carry out Eye and mouth care in accordance with SOP (Observe for contact lenses)*Monitor drain output, volume and insertion site*Encourage/ assist with patient mobility or provide regular passive movements*Liaise with physiotherapist with regard to goalsAssess for signs of poor limb perfusion in patients with inotropes

Psychosocial *Promote family involvement – USE of PASSWORDS*Assess for signs of delirium*Give reassurance and explanations of care*liaise with outreach regarding patients discharged to the ward

Main mode of ventilationPRVCVPCVC+

Pressure Regulated Volume Control

Adaptive Pressure Ventilation

AutoFlow

Variable pressure control

Combination of pressure control and volume control adapting to patient

Target volume maintained with lowest possible pressure,pressure varies as ventilator adapts to changes in compliance and resistance, decelerating flow pattern

Assisted breath or pressure supported breath if included in settings

Tidal volume Upper pressure limit Pressure support

limit if used Respiratory rate I:E ratio PEEP


BASIC NURSING CARES

Eye care:Eyes should be cleaned with sterile water and gauze. Pour sterile water on to gauze (use 10ml plastic ampoules), wipe from inside of eye to outside, maintaining ‘clean hand, dirty hand’ technique (i.e. clean hand picks up gauze, dirty hand wipes the eyes). Dispose of gauze pad after each wipe.Hypermellose eye drops should be applied regularly, or other eye drops if prescribed. Ensure excess is wiped away from skin.

Mouth care:Mouths should be cleaned regularly, suggested 2-4 hourly. Mouth care packs available on the unit – minimum should be mouth cleansed with water (using green oral sponge), mouthwash, lips cleaned, petroleum jelly applied to maintain moisture.

Trache care:Care of the inner tube: inner tube should be switched with clean one regularly – inner tube cleaning kits available and should be kept at bedside. Non-sterile procedure, tube can be cleansed with water and cleaning brush (for traches).Trache site should be inspected and dressing changed regularly. Trache dressings available in store cupboard. Note correct side of dressing to patient (shiny side to skin). Trache securing tapes also in store cupboard. Trache should be secured firmly, check two fingers under tapes, but be aware of pressure damage. Inspect ears, back of neck and surrounding area for signs of damage.

Dressings:All lines/cannula/wounds should have appropriate dressings in situ, clean and dated. Lines should be listed on chart and no. of days inserted documented.IV3000 for arterial lines and central lines, cannula dressings for peripheral lines. Should be able to see line and surrounding skin. Check VIP scores regularly. Re-dress as required.Wounds should have wound care plan. If unable to source correct dressings, contact Tissue Viability Nurse.

Turns and positioning:ITU patients are susceptible to pressure area damage. Patient’s skin should be inspected at time of handover and regularly throughout shift. Patients should be turned 2-3 hourly as standard (except proned patients who maintain prone position for 16-18 hours, however arms and head position should change regularly – see proning guidelines). Pressure damage should be noted and reported using DATIX. Staging of the damage should be in discussion with NIC and documented. Liaise with Tissue Viability if damage is severe and requires specialist dressings.


Medication on Critical Care

1. Professional guidance, legal and accountability

NMC

10 October 2018

From the Code-

11 Be accountable for your decisions to delegate tasks and duties to other people.

18 Advise on, prescribe, supply, dispense or administer medicines within the limits of your training and competence, the law, our guidance and other relevant policies, guidelines and regulations.

1 April 2017 to 31 March 2019 NHS acute trusts submitted 113,384 Medicines incidents.

311 per day VIA NRLS

Prescribing and administration errors-

“The single most common theme from our analysis of notifications was prescribing errors. Notifications consistently reported incidents where prescriber’s had made an error that resulted in patients receiving the wrong medicine, the wrong dose, medicines that interact with each other or no medicines at all. Transcribing errors were often cited as cause. Other causes included allergies not recorded on prescription charts, which resulted in people being given medicines they were allergic to, and body mass incorrectly estimated, or not considered by prescribers at all. The consequence of this ranged from people receiving toxic, to suboptimal doses.

Care quality commission: Medicines in health and adult social Care.

Downloaded 12/7/2019


2. Departmental Guidelines:

Please review these Critical Care specific medication guidelines:-

- Mixing of IV medications- Vasopressin- Inotropes- High dose Potassium- Hyperglycaemia management- Heparin- Sliding scale- Anaphylaxis Policy- Penicillin compatibilities

All Guidelines can be found on the Critical Care guideline/SOP’s page and/or Pharmacy intranet page.


Self Certification:-

Vasoactive/Inotrope medication:

Vasoactive medication Administration Self certificationNoradrenaline 12mgs/100mls Dextrose

(120mcgs/ml)

Adrenaline 6mgs/100mls Dextrose (60mcgs/ml)

Dobutamine 500mgs/100mls Dextrose(5mgs/ml)

Vasopressin 20 units/50mls Dextrose (0.4u/ml)

Metaraminol 30mgs/60mls Saline (0.5mgs/ml) (only inotrope which can be delivered peripherally).

Key considerations administering vasoactive medication- Dept of critical care.

BAND6/7 involved in checking procedure (or delegated BAND 5) Central line access (damaging to peripheral veins)- Monitoring of MAP normally via continuous arterial monitoring Demonstrate safe practice with B Braun purple volumetric pump Purple labels. Dedicated single line use. Continuous infusion, avoid interruption during bag changes. NEVER bolus. Draw back fluid when infusion finished to clear line-10mls ANTT. Never let infusion run out- accurate VTI- 25mls in line


High Risk Medications:-

1. Heparin IVI

2. Gentamicin IV

3. Vancomycin

4. Insulin IVI

5. Amiodarone IVI

6. High dose Potassium

7. Insulin/Dextrose infusion

High Risk medication Administration Self certificationHeparin 40,000 units neat

Gentamicin 0.5mgs/kg in 100mls Saline (check levels 6-14 hours post dose)

Vancomycin Refer to continuous Vancomycin guideline.

Insulin (sliding scale) 50 unitsActrapid/50mls Saline (refer to Critical Care sliding scale chart)

Amiodorone 300mgs/250mls dextrose (loading dose)900mgs/500mls dextrose @ 21mls/hr.

High dose Potassium 40-60mmols Potassium/100mls Saline (administered via CVC or PICC).

Insulin/Dextrose 10 units Actrapid/50mls 50% Dextrose (refer to Hyperkalaemia management guideline).


Sedation/Paralysis/Analgesia:

1. Propofol2. Midazolam3. Morphine4. Alfentanil5. Atracurium

Medication Administration Self certificationPropofol 500mgs/50mls neat

(0.5mgs-2mgs bolus)

Midazolam 50mgs/50mls Saline(0.5mgs-2mgs bolus)

Morphine 50mgs/50mls Saline(0.5mgs-2mgs bolus)

Alfentanil 20mgs/40mls Saline(0.5mgs/ml). No bolus

Atracurium 500mgs/50mls neat(0.3mgs/kg bolus,Commence infusion at0.3mgs/kg/ml) – refer to TOF guideline.


Antibiotics:

1. Tazocin2. Clarithromycin3. Co Amoxiclav4. Meropenim5. Co Trimoxazole (Septrin)6. Aciclovir

Antibiotic Administration Self certificationTazocin 4.5 mgs/20 mls Saline (over

30 minutes)

Clarithromycin 500mgs/250mls Saline (over 1 hour)

Co Amoxiclav 1200mgs/20 mls water for injection (over 2-4mins)

Meropenim 1g/20mls water for injection (over 2-4mins)

Co Trimoxazole (Septrin) 960mgs/250mls Saline (60-90minutes)

Aciclovir 10mgs/kg (100mls Saline/Dextrose doses 250-500mgs, 250mls Saline/Dextrose doses >500mgs) Infused over minimum 1 hour


Other medications:

1. Ranitidine2. Omeprazole3. Keppra (Levetiracetam)4. Phenytoin

Medication Administration Self certification

Ranitidine 50mgs/20mls Saline (over 3-5 minutes)Omeprazole 40mgs/100mls Saline (over 20-30minutes)

Keppra (Levetiracetam) 1000mgs/100mls Saline (over minimum 15 minutes)

Phenytoin 20mgs/kg (loading dose) into 100mls Saline (dose <1g) 250-500mls Saline (dose >1g). Concentration no greater than 10mgs/ml. Use 0.2micron filter.Infuse at rate 50mgs/min.Maintenance dose 100mgs 6-8 hourly (undiluted) Use 0.2micron filter.Administered into green cannulae or centrally. Incompatable with Dextrose

Discuss use & administration. Assessors name

Signature

1.Use of BBraun Volumetric pumps

2.Use of BBraun (Inotrope) Volumetric pumps-please ensure you have run through & set up an infusion not just discussed as stated on previous page.

3.Use of BBraun Syringe pumps

4.Adminstration of a bolus dose via volumetric & Syringe pumps

5.Adminstration of TPN

6.Adminstration of Blood products (according to trust policy)

7.Adminstration of IV fluids (i.e. crystalloid, colloid)


7. Summary

IV administration is very high risk intervention within the Critical care Department.

Please ensure that you adhere to departmental/ PHT guidelines and if in doubt ask for senior advice!

Image below- Medicines in health and adult social care.

CQC. June 2019


DAILY ROUTINE FOR SAFE PRACTICE

Nursing care, its planning, implementation and evaluation are the responsibility of the nurse caring for the patient. He/she works with other colleagues as a member of the team. The nurse should decide when to give the care required for the patient but certain routine guidelines need to be followed to ensure safe nursing practice.

AT HANDOVER/BEGINNING OF EACH SHIFT

1. Check all equipment in use including suction, rebreathe bag & Ambu-bag sealed for use or if have been used checked working order and oxygen supply (Wall and oxygen cylinder under the bed) to ensure that they are present and functioning correctly.

2. Check all alarm settings - monitor and ventilator. Re-zero all transducers.

3. Check all infusion rates, concentrations and prescriptions. Establish when infusions, giving

sets and filters need changing. Establish when prescribed drugs are due. Identify a spare drug port in case of emergency.

4. Ensure patient’s comfort and vital parameters - Air entry _ - NO stethoscope Ventilator parameters Neurol status/sedation score Blood sugar

5. Check ET tube size, length and number of days since insertion of all lines. Record on Chart.

6. Ensure safety of working area, a clean, safe environment, stocked as required/necessary. 7. Complete assessment and plan care for patient using ITU nursing care plan notes.

8. Deliver care/participate in treatments allowing adequate time for the patient to rest (Within your scope of practice and knowledge limits)

9. Understand treatment and drugs prescribed. Continuously reassess and monitor patient to ensure safety and comfort. Ensure adequate understanding of blood gases, U & Es and haematology results.

10. Empty/change drainage bags/chest drains as required.


EXAMPLE AND FORMAT OF CARE PLAN TO BE USED ON DCCQ

RESPIRATORYUnable to breathe adequately; requiring sedation with possible aspiration Plan:Care of ETT,Monitor ventilation parameters and document on chart. Wean ventilation as able whilst maintaining adequate gaseous exchange.Perform ABGs as clinically indicated, continuous monitoring of SpO2 and EtCO2Chest auscultation and monitor work of breathingTracheal suctioning as required, monitor secretion load and type.PhysiotherapyEvaluation:Ventilation weaned to PS with good tidal Volume and gaseous exchange. CO2 monitor temperamental and records at ~4.5kpaPatient position changed regularly to aid ventilation, has a tendency to desaturation right side lyingBreath sounds to lung zones diminished to both bases, occasional crackles apically but has a good spontaneous cough, minimal secretions cleared with tracheal suction.ETT tapes moved position as not to dig into skin causing breakdown, sponge around ties applied, may benefit from anchorfast to secure ETT if not able to wean quicklyPt has been trying to use his tongue to dislodge/remove his ETT CXR reviewed as oxygenation issues continuing and not able to wean and chest shown to be ‘wet’ Furosemide prescribed.Seen by Physios this amNBL obtained as sputum green

CARDIOVASCULARNot supported with medication, NIBP monitoring and ECG monitoring insituHas been hypothermic with warming blanket insitu? At risk of DVT's due to immobilityPlan:Monitor cardiac parametersMonitor temp observing for arrhythmiasMonitor CRT and Fluid BalanceObserve, monitor and treat for potential DVT'sMonitor electrolytes and give prescribed replacement electrolytesEvaluation:CVS stable, not requiring any support, no ectopic.Temp now 37.2c so Bair hugger stopped. Family report that **** always has cold peripheries which may explain slow CRTNot on prescribed Heparin/Enoxaparin due to low platelets, Teds and sequential pressure device insituEpisode of self limiting AF that didn’t compromise BP. Potassium and magnesium replaced.

RENALUrinary catheter insitu to monitor accurate fluid balance


Plan:Monitor diuresis and record on fluid balance hourlyMonitor Urea and Creatinine Catheter careEvaluation:Diuresing well with greater volume following diuretic

NEURO / PAINAltered conscious level due to and seizure activity and requiring sedationPlan:Stop sedation to assess neuro statusObserve pupilsMonitor for any signs of deterioration and fitting.Evaluation: Becoming more awake but not quite opening eyes or responding appropriately to commands. However, strength improving and making strong movements to ETT.Pupils 3mm and brisk throughout am.No further seizures notedAppears to be comfortable and no evidence of pain or discomfort

GASTOINTESTINALUnable to eat and drink due to Intubation and altered neuro stateOn Steroids. Enteral feed in progress via NGTS/S Insulin infusion in progressMUST Score - 1Plan: Strict monitoring of BM'sAdjust insulin according to prescribed sliding scale.Aspirate NGT to check for absorption and increase feed as per DCCQ protocolCheck PH of aspirateMonitor abdomen, bowel sounds and movementsCare of NGTMust – Medium Risk – weigh every 5 days and monitor intakeEvaluation: Blood sugars and sliding scale titrated accordingly - may need tighter glycaemic control as BM's on the decline, so observe please.NG aspirated as per protocol, more aspirate obtained therefore rate maintained at 12:30pm with IVI insitu.Abdomen soft with small bowel action of formed stool

INTEG/INFECTpossible aspiration during seizures - Not on AB therapy as no indication at presentPeripheral cannula insituAt Risk of Pressure sores due to immobilityArt Line -D2Central Line -D1Peripheral 1 -D2Peripheral 2 -D2Plan:


Care of cannula sites - Observe for extravasation.TEDS and AV boots insitu - Remove for max time 30mins pressure relieving.Nursed on pressure relieving mattress, observe pressure areas for signs of breakdownAttend to hygiene requirements and linen changes as requiredEvaluation: One cannula removed as 'pulled out' with continual movement and therefore bleeding.PA's – both heels, elbows, head, back and bottom all unimpaired.Very wriggly in the bed, tending to favour left side more despite continuous efforts to change position.

PSYCHOSOCIAL/FAMILYExplain all procedures so that ***** is able to understand with rationale of care.Visited by Son **** and wife this am/lunch time. They have been brilliant in assisting with keeping ***** relaxed and preventing him from pulling out his ETT. Family happy with explanations and care **** is receiving.USE OF PASSWORDS- All covid 19 patients


ARTERIAL BLOOD GASES – normal values and meaning

Result Normal values What it means

Hb 80 (120)-180

Haemoglobin in RBCs transport O2 around the body. Low Hb = organs not getting enough O2 therefore may require transfusion

pH 7.35-7.45Measures the activity of the hydrogen ion. Low pH = acidic, High pH = alkalotic

H+ 35-45 mmols

Acid part of acid-base reaction (reacts with bicarbonate (base) to neutralise). High H+ = acidotic, Low H+ = alkalotic

pO2 10-14 kPa

Partial pressure of O2 (hypothetical pressure of a certain gas, from a mixture of gases, if it were to occupy the same volume of the mixture at the same temperature)

pCO2 4-6 kPa Partial pressure of CO2 (see pO2 also)

HCO3- 22-26 mmolsBicarbonate (base), crucial in pH buffering system – reacts with H+ (acid) to neutralise

ABE -2 to +2Base excess and base deficit – measure deviation of level of base (predominantly bicarbonate)

Lac <2A constituent of lactic acid – used to determine status of acid-base homeostasis

Na+ 135-145

Essential nutrient to regulate blood volume and pressure, osmotic stability and pH. Most abundant cation in extravascular fluid

K+ 3.5-5.0Electrolyte for nerve function, osmotic balance, prevention of muscle contraction and the sodium-potassium pump

Glu 3.5-6.0 Amount of glucose in blood. Hyperglycaemia treated with insulin, hypoglycaemia treated with glucose


BLOOD RESULTS – normal values and meanings

Result Normal values What it means

Albumin 35-48 g/LLarge protein which forms part of the cell membrane – low albumin means fluid can leak into extracellular tissues

ALT M: 10-40 IU/LF: 7-35 IU/L

Alanine transaminase – liver enzyme, most sensitive to hepatic cellular damage

APTR 0.8-1.2 Activated partial thromboplastin time (or ratio) - coagulation

Bilirubin 3-20 Breakdown product that causes yellow colour – jaundice, bruising, urine, faeces

CK M: 38-220 IU/LF: 32-165 IU/L

Creatine kinase – CK enzyme reaction generates ATP (adenosine triphosphate)

Creatinine 60-110Breakdown product of Creatine phosphate in the muscle – important indicator of renal health

CRP <5 mg/L CRP elevated in bacterial, fungal and parasitic disease

Digoxin 0.9-2.6 nmol/L As per trust protocol to measure digoxin level

Fibrinogen 1.5-3.5 g/L Plasma protein to fibrin (for clotting)

Haematocrit Volume (%) of red blood cells

INR 0.8-1.2International normalised ratio – to measure the effect of warfarin on coagulation

Magnesium 0.74-1.03 Electrolyte for muscle, nerve and enzyme function, aids with production of energy and movement of sodium and potassium

Phosphate 0.8-1.5 Ion that helps nerve function and muscle contractility – affects the level of calcium (as Na rises, Phosphate falls)

Platelets 150-400 x 109/L

Causes of decreased platelet count include infection, haemorrhage, DIC (disseminated intravascular coagulation), HIT (heparin induced thrombocytopenia), ITP (idiopathic thrombocytopenia purpura), TTP (thrombotic thrombocytopenic purpura) and HUS (Haemolytic uremic syndrome). High platelet count caused by chronic iron deficiency, post-splenectomy, chronic infections, rheumatoid arthritis and malignancy.

Troponin <0.04Structural protein component of muscle – troponins T and I are only found in cardiac muscle

Urea 2.9-7.1Product of ammonia breakdown. Low levels seen incirrhosis, high levels in renal failure

WBC 4-11 x 109/LWhite blood cells (or white cell count WCC). Raised or lowered common in critical illness


Drop calculation rates.

When using gravity giving sets, to allow for an accurate time frame you will need to calculate the drip rate / minute.

There is a general formula for calculating this:

Drop rate = Drop factor x ( Volume in mls / 60mins ) / time (hours).

Drop factor = drops per ml.

Two common sizes:

- 20 drops per ml ( clear /crystalloid fluids)

- 15 drops per ml ( colloid / albumin / blood products )

20 drops per ml

Time Drops/minute1000mls 500mls 250mls 100mls 50mls

12 hours 28 14 711 hours 30 15 810 hours 34 17 89 hours 37 19 98 hours 42 21 107 hours 48 24 126 hours 56 28 145 hours 67 33 17 7 34 hours 84 42 21 8 43 hours 111 56 28 11 62 hours 167 83 42 17 81 hour 333 167 84 34 17

30 minutes 67 33

Drop Calculation rates


15 drops per ml

Time Drops / minute

500mls 350mls 300mls 250mls 200mls 150mls 100mls 50mls4 hours 31 22 19 16 13 9 6 33 hours 42 29 25 21 17 13 8 42 hours 63 44 38 32 25 19 13 61 hour 125 88 75 63 50 38 25 13

30 minutes

250 175 150 125 100 75 50 25


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