CENTRAL VENOUS PRESSURE INSERTION

INDICATIONS

Hemodynamic pressure monitoringo Central venous pressure (CVP); right-heart filling pressures, surrogate of left-heart filling

pressureso Pulmonary artery catheter insertiono Pulmonary capillary wedge pressure monitoringo Coronary sinus catheterization for minimally invasive cardiac surgery Large-bore intravenous accesso Rapid fluid resuscitationo Rapid administration of blood replacement therapy Infusion of therapeutic drugso Vasoactive substanceso Chemotherapyo Hyperalimentationo Other substances that would be too caustic to the subcutaneous or peripheral vascular spaces Plasmapheresis, apheresis Renal dialysis Transvenous pacing Aspiration of air embolism

EQUIPMENT

Sterile mask, gloves, and gown Standard monitors, such as pulse oximeter, blood pressure cuff, and ECG When possible, peripheral IV with infusion solution Sterile prep solution (e.g., chlorhexidine) Sterile drapes 5-mL sterile syringe with 25- or 30-gauge needle for local anesthetic infiltration Local anesthetic (usually 1% lidocaine) 22-gauge, 1.5-inch needle 18- or 20-gauge intravenous catheter (over a needle) on a syringe, or 18-gauge hollow-bore needle Pressure tubing Guidewire No. 11 scalpel blade Central venous catheter with dilator 3.0 suture on cutting needle 

PROCEDURE

The skin is cleaned, and local anesthetic applied if required. The location of the vein is then identified by landmarks or with the use of a small ultrasound device. A hollow needle is advanced through the skin until blood is aspirated; the color of the blood and the rate of its flow help distinguish it from arterial blood (suggesting that an artery has been accidentally punctured).

The Seldinger technique is then employed to insert the line. This means that a blunt guidewire is passed through the needle, and the needle is then removed. A dilating device may be passed over the guidewire to slightly enlarge the tract, and the central line itself is then passed over the guidewire, which is then removed. All the lumens of the line are aspirated (to ensure that they are all positioned inside the vein) and flushed

For jugular and subclavian lines, a chest X-ray is typically performed to ensure the line is positioned inside the superior vena cava and, in the case of insertion through the subclavian vein, that there is no resultant pneumothorax.

Nursing Responsibilities

After the procedure has been explained to the patient and the patient has agreed to it draw the curtains to insure privacy. Push the equipment trolley to the patient’s bedside. When the physician has put on his mask and goggles he will need to wash his hands. When he is doing that the nurse can open the contents of the different packs and set up the trolley. There should be a sterile gown on the trolley or in the pack along with sterile towels for the physician to dry his hands. It is the Nurses’ responsibility to tie the back of the physician’s gown.

The CVC insertion procedure is completed when the CVC is inserted, has been verified with a chest x-ray, adequately secured (stitched in placed) and covered with a sterile dressing. It is the physician’s responsibility to place all sharps in the sharps container while the nurse is responsible for checking all the materials used.

VENOUS CUTDOWN  

INDICATION

 Emergent venous access (when attempts to gain access by the peripheral or percutaneous routes have failed)

 EQUIPMENT

1. Sterile gloves 2. Swabs and sterile drapes 3. Skin disinfectant 4. Local anaesthetic (5ml of 0.5% lignocaine is sufficient) 5. Scalpel 6. Two small curved artery forceps 7. Sharp pointed scissors (use scalpel if scissors blunt/unavailable) 8. Ligatures (2/0 catgut / vicryl are best, but silk is adequate) 9. Skin closing sutures 10. Cannula

PROCEDURE

 Sites. In adults use the upper limb at the medial aspect of the antecubital fossa. Try to avoid the leg veins as they are thicker and more prone to thrombosis, phlebitis and infection. In children a cutdown may be performed using either the brachial or long saphenous veins.

 Technique. Clean the skin and use the drapes to create a sterile area around the chosen vein.

 (1) Infiltrate the skin with local anaesthetic.

(2) Make a 1.5 - 2cm transverse incision over the vein (a).

(3) Bluntly dissect out the vein by opening the forceps in the line of the vein (b).

(4) Make a small stab skin incision 1cm distal to the incision in the line of the vein. Pass two ligatures around the vein.

Tie the distal one, but leave the ends uncut. Hold the ends of the ligatures with the artery forceps (c).

(5) Whilst holding the ligatures tight, make a "V" shaped incision in the anterior surface of the vein with the scissors or

scalpel (d).

(6) Pass the cannula through the inferior stab incision and the through the "V" shaped incision into the vein. Tie the

proximal ligature tightly over the cannulated vein and, if there is no bleeding, now cut the ends of the ligatures. If

bleeding occurs place a further ligature around the vein. Connect the cannula to the giving set and commence the

infusion.

(7) Close the skin with sutures (f).

After the infusion is finished the cannula can be removed by a firm steady pull followed by direct pressure over the site of the incision for 5 minutes.

Nursing Responsibilities

Careful attention to the cut down site, by daily sterile dressing is mandatory, particularly in the lower extremities, in view of the increased susceptibility to infections. If any sign of infection at the site is identified the catheter has to be promptly withdrawn.

INTRA JUGULAR INSERTION CATHETER

 INDICATIONS

Administration of agents into the central vasculature Central circulation and intracardiac access Maintenance of venous access Hemodialysis and plasmapheresis

EQUIPMENT

Central venous catheterization kit: o Clear fenestrated plastic drapeo Paper drapeo Chlorhexidine antiseptic with applicatorso 1% Lidocaineo Small anesthetizing needle (25 gauge × 1 inch)o Large anesthetizing/finder needle (22 gauge × 1.5 inch)o Introducer needle (18 gauge × 2.5 inch)o Several syringes, 5 mL eacho J-tipped guidewire with housing and a straightener sleeveo Scalpel with a No. 11 bladeo Skin dilatoro Catheter (e.g., triple lumen or sheath introducer)o Gauze pads

o Suture with curved needleo Disposable needle holder Sterile gloves, sterile gown, cap, and mask with fluid shield for each member of the insertion team

**STERILE TECHNIQUE** **UNIVERSAL PRECAUTIONS** Large sterile drape (half-sheet) Extra 1% lidocaine in sterile saline suitable for injection Sterile dressing (e.g., Tegaderm, 3M Corporation, Huntingdon Valley , PA )

NURSING RESPONSIBILITIES

Confirmation of line placement Dressing changes at least every 72 hours

COMPLICATIONS

Infection Bleeding Pneumothorax (see Needle Thoracostomy for further details) Thrombosis Air embolization Arrhythmia Myocardial perforation Nerve injury]

TRACHEOSTOMY INSERTION

INDICATION

 Bypass acute upper airway obstruction.

• Chronic upper airway obstruction.

• Facilitate weaning from mechanical ventilation by decreasing anatomical deadspace.

• Prevention / treatment of retained tracheobronchial secretions.

• Prevention of pulmonary aspiration.

EQUIPMENTS

1. Tracheostomy tubes 2. Tracheostomy tube (one size smaller)3. Trach tube ties 4. Dressing supplies, gauze5. Hydrogen peroxide, sterile water, normal saline6. Water soluble lubricant such as Surgilube or KY Jelly7. Blunt-end bandage scissors 8. Tweezers or hemostats9. Sterile Q-tips10.Trach care kits and/or pipe cleaners (double-cannula trach tubes)

11.Luer-Lok tip syringes for cuffed trach tubes

 PROCEDURE

 The patient is made to lie down on their back with the neck & head extended by keeping a pillow under the shoulder and neck.

 Local anaesthesia or general anaesthesia is used for the procedure.

A horizontal cut is made across the neck above the 'sternal notch' using a knife.

The skin is separated and surrounding tissues are dissected to expose the trachea.

The 2nd or 3rd of the tracheal ring is incised for the tracheostomy tube to be placed.

A suitable size tracheostomy tube is then introduced inside. While choosing the tube, the smallest feasible tube

should be used. A general rule is that the tube should be three fourths of the diameter of the trachea.

The cuff of the tube is inflated by using 2-5 ml of air and it is held in place by using a necktie.

The incision is closed using skin sutures by the side of the tracheostomy tube.

Dressing is applied for the wound to heal.

NURSING RESPONSIBILITIES

 During the procedure, there is a risk of damaging the recurrent laryngeal nerves as a nurse we must be very observant in looking the insertion we know these nerves control the vocal cords. If one of the nerves is damaged a patient will probably have a problem with his/her voice; if both of the nerves are damaged, the patient will lose his/her speech. This risk of nerve damage is the reason emergency tracheotomies are performed higher up, in the larynx and why tracheotomies have to be done in hospital under anesthetic.

Moreover, if the recurrent laryngeal nerve is damaged, the patient will have trouble controlling the flow of air through the rima glottidis, thus ultimately leading to inhibited breathing or suffocation.

THORACENTESIS

Indications

This procedure is indicated when unexplained fluid accumulates in the chest cavity outside the lung. In more than 90% of cases analysis of pleural fluid yields clinically useful information. If a large amount of fluid is present, then this procedure can also be used therapeutically to remove that fluid and improve patient comfort and lung function.

The most common causes of pleural effusions are cancer, congestive heart failure, pneumonia, and recent surgery. In countries where tuberculosis is common, this is also a common cause of pleural effusions.

When cardiopulmonary status is compromised (i.e. when the fluid or air has its repercussions on the function of heart and lungs), due to air (significant pneumothorax), fluid (pleural fluid) or blood (hemothorax) outside the lung, then this procedure is usually replaced with tube thoracostomy, the placement of a large tube in the pleural space.

EQUIPMENTS

      1 - surgical glove

      2.  Improvised flapper valve:

      3.      10-16g IV catheter with 3-10cc syringe attached

4.      1 Pair scissors

5.      Betadine or Iodine

6.      Dressing materials: 

a)      Sterile 2x2’s

b)      Tape

 PROCEDURE

Get the standard thoracentesis kit. In addition to the kit, you will need two 1-liter vacuum bottles and Bethadine for cleaning the area. Prepare the necessary equipment for the pleural tap.

Find the anatomical landmarks before you perform the thoracentesis.

Clean the area with iodine.

Open the kit and make sure that you know which tube and needle are used for.

Practice sliding the flexible catheter.

 Prepare for local anesthesia.

Prepare the area.

 Perform the procedure (under supervision, if you are not certified). Anesthetize the skin and pleura, try to reach the effusion fluid.

 Prepare the flexible catheter.

Pass the flexible catheter over the tap needle into the pleural space and begin aspirating the fluid in the vacuum tubes.

Complete the procedure, check for complications - mainly pneumothorax and bleeding. Order a CXR to rule out pneumothorax.

Send the pleural fluid in the 1 L bottle to the laboratory. Compare the pleural fluid to the corresponding blood tests, in order to differentiate between transudate and exudate. If the patient had blood draws this morning, you can order some additional enzymes as AOT (add-on tests), if not already done before the tap.

NURSING RESPONSIBILITIES

Inform the client that although local anesthesia prevents pain as the needle is inserted, a sensation of pressure may be felt. A pressure sensation occurs as the needle punctures the parietal pleura to enter the pleural space. Monitor pulse,color,oxygen saturation,and other signs during thoracentesis. These are indicators of physiologic tolerance of the procedure.

• Apply a dressing over the puncture site, and position on the unaffected side for 1 hour. This allows the pleural puncture to heal.

• Label obtained specimen with name, date, source, and diagnosis; send specimen to the laboratory for analysis. Fluid obtained during thoracentesis may be examined for abnormal cells, bacteria, and other substances to determine the cause of the pleural effusion.

• During the first several hours after thoracentesis, frequently assess and document vital signs; oxygen saturation; respiratory status, including, respiratory excursion, lung sounds, cough, or hemoptysis; and puncture site for bleeding or crepitus. Frequent assessment is important to detect possible complications of thoracentesis, such as pneumothorax.

• Obtain a chest X-ray. Chest X-ray is ordered to detect possible pneumothorax.

• Normal activities generally can be resumed after 1 hour if no evidence of pneumothorax or other complication is present. The puncture wound of thoracentesis heals rapidly

LUMBAR PUNCTURE

 INDICATIONS

1.                  Suspected CNS infection

2.                  Suspected subarachnoid hemorrhage

3.                  Therapeutic reduction of cerebrospinal fluid (CSF) pressure

4.                  Sampling of CSF for any other reason

EQUIPMENTS

 

1.                  Lumbar puncture tray (to include 20 or 22 gauge Quinke needle with stylet, prep solution, manometer, drapes, tubes, and local anesthetic)

2.                  Universal precautions materials

 

PROCEDURE 

1- Place the patient in the lateral decubitus position lying on the edge of the bed and facing away from operator. Place the patient in a knee-chest position with the neck flexed. The patient's head should rest on a pillow, so that the entire cranio-spinal axis is parallel to the bed. Sitting position is the second choice because there may be a greater risk of herniation and CSF pressure cannot be measured

 

2- Find the posterior iliac crest and palpate the L4 spinous process, and mark the spot with a fingernail. Prepare the skin by starting at the puncture site and working outward in concentric circles. Put on sterile gloves. Drape the patient

3- Anesthetize the skin using the 1% lidocaine in the 5 mL syringe with the 25-gauge needle. Change to 22-gauge needle before anesthetizing between the spinous process. Insert in the midline with the needle parallel to the floor and the point directed toward the patient's umbilicus

4- Advance slowly about 2 cm or until a "pop'' (piercing a membrane of the dura) is heard. Then withdraw the stylet in every 2- to 3-mm advance of the needle to check for CSF return. If the needle meets the bone or if blood returns (hitting the venous plexus anterior to the spinal canal), withdraw to the skin and redirect the needle. If CSF return cannot be obtained, try one disk space down

5- When cerebrospinal fluid begins to flow from the needle, discard the first few drops. Do not aspirated cerebrospinal fluid, because a nerve root may be trapped against the needle and injuried

6- Measure the opening pressure with a manometer; allow the patient to relax, and check for good respiratory variation of the fluid level in the manometer to ensure that the needle is properly positioned.

8- Remove the manometer and allow 1 to 2 cc of CSF to flow into each of the three sterile tubes. Send the first for glucose and protein, the second for Gram stain and culture and sensitivity (C&S), and the third for cell count and differential. A fourth tube, when indicated, is collected for viral titer or cultures, India ink preparation, Cryptococcus antigen, VDRL, or cytology

9- Withdraw the needle without replacing the stylet

10- Dress the puncture site with a bandage. Have the patient lie in bed for a few hours

 NURSING RESPONSIBILITIES

WATCH FOR:

· Chills or a fever.· A stiff neck. This may be a sign of a developing infection.· Any drainage or bleeding from the puncture site.· A severe headache.· Any numbness or loss of strength below the puncture site.

If any of these signs shows up, inform the doctor immediately.

PERITONEAL CATHETER INSERTION

Indications for Peritoneal Catheter Insertion

Peritoneal dialysis is an alternative to haemodialysis and is usually used to treat patients with end-stage renal disease. Peritoneal dialysis involves infusing fluid into the peritoneal cavity via a catheter and leaving it for sufficient time to allow exchange of metabolic waste products through the peritoneal membrane into the dialysis fluid. In continuous ambulatory peritoneal dialysis, the patient manually drains and replaces the dialysis fluid several times a day. Another form of peritoneal dialysis is automated peritoneal dialysis, which obviates the need for more frequent exchanges of fluid bags.

Equipments

1. 1 Pleurx Peritoneal Catheter2. 1 Drainage line3. 1 Valve cap4. 1 16 Fr. peel-away introducer5. 1 J-tip guidewire6. 2 Small safety syringes7. 1 Large safety syringe8. 1 Tunneler9. 1 Safety scalpel10.1 Silk suture, 3-0 straight needle11.1 Silk suture, 3-0 curved needle12.1 Forceps13.2 Scrub sponge with handle14.1 Guidewire introducer with needle15.1 22 ga. needle, 1.5 in.16.1 25 ga. needle, 1.0 in.17.1 17 ga. needle, 1.0 in.18.3 5 cc ampule lidocaine HCl 1%19.1 Filter straw20.1 Foam catheter pad21.1 5-in-1 adapter22.6 Gauze pads, 4 in. x 4 in.23.1 Self-adhesive dressing24.1 Fenestrated drape25.1 CSR wrap26.1 Package povidone iodine swabs

PROCEDURE

Laparoscopic insertion of a peritoneal dialysis catheter is usually performed under general anaesthesia. The abdomen is insufflated and several small incisions are made. In one variation of the technique, the lateral inferior edges of the omentum are fixed onto the parietal peritoneum with sutures. The tip of the catheter is advanced through the abdominal cavity into the pelvic cavity and is sometimes held in place by sutures. The distal end of the catheter is then tunneled subcutaneously to an exit site incision in the

abdomen. Use of the laparoscope allows complete visualization of the catheter’s location and configuration during the procedure, potentially facilitating more accurate placement within the pelvis.NURSING RESPONSIBILITIES

The nurse should listed potential adverse events as bowel perforation, fluid leaks, infection, catheter migration, catheter blockage and bleeding. Two nursess noted that potential adverse events were mainly adverse events of laparoscopic surgery, common to all procedures. They noted that the adverse events for this procedure would also be found in the open procedure for catheter insertion. None of the specialist advisers considered there to be uncertainties or concerns regarding the safety of this procedure.

CT SCAN

INDICATION

CT scanning of the head is typically used to detect:

bleeding, brain injury and skull fractures in patients with head injuries. bleeding caused by a ruptured or leaking aneurysm in a patient with a sudden severe headache. a blood clot or bleeding within the brain shortly after a patient exhibits symptoms of a stroke. a stroke, especially with a new technique called Perfusion CT. brain tumors. enlarged brain cavities (ventricles) in patients with hydrocephalus. diseases or malformations of the skull.

CT scanning is also performed to:

evaluate the extent of bone and soft tissue damage in patients with facial trauma, and planning surgical reconstruction.

diagnose diseases of the temporal bone on the side of the skull, which may be causing hearing problems. determine whether inflammation or other changes are present in the paranasal sinuses. plan radiation therapy for cancer of the brain or other tissues. guide the passage of a needle used to obtain a tissue sample (biopsy) from the brain. assess aneurysms or arteriovenous malformations through a technique called CT angiography.

EQUIPMENT

Ct scan

PROCEDURE

The technologist begins by positioning you on the CT examination table, usually lying flat on your back or possibly on your side or on your stomach. Straps and pillows may be used to help you maintain the correct position and to hold still during the exam.

For children who cannot hold still for the examination, sedation may be needed. Motion will degrade the quality of the examination the same way that it affects photographs.

If contrast material is used, it will be swallowed, injected through an intravenous line (IV) or administered by enema, depending on the type of examination.

NURSING RESPONSIBILITIES

The nurse must know the risk of serious allergic reaction to the patient to contrast materials that contain iodine is extremely rare, and radiology departments are well-equipped to deal with them.

CHEST ULTASOUND

PROCEDURE

INDICATION

 A chest ultrasound may used to assess the presence of excess fluid in the pleural space or other areas of the chest, especially when the amount of fluid is small. If excess fluid is present, ultrasound may be useful to determine the type of fluid, exudate (seen in inflammatory, cancerous, or infectious conditions) or transudate (fluid that has leaked from blood or lymph vessels for various reasons).

Chest ultrasound may be performed to guide a needle during thoracentesis (puncture of the chest wall for the removal of fluids) or biopsy. Another use of chest ultrasound is to assess the movement of the diaphragm.

Chest ultrasound may be used to locate lung tumors, to assess the extent of tumor infiltration into nearby tissues and structures, to evaluate pain in the chest, or to diagnose pneumothorax (air becomes trapped in the pleural space, causing the lung to collapse). Conditions such as pneumonia, abscesses, infection, and pulmonary embolism may be assessed with chest ultrasound.

EQUIPMENT

Chest Ultrasonography, Chest Wall Ultrasonography, Chest Sonography

PROCEDURE

A chest ultrasound may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your physician's practices.

Generally, a chest ultrasound follows this process:

1. You will be asked to remove any clothing, jewelry, or other objects that may interfere with the scan.2. If you are asked to remove clothing, you will be given a gown to wear.3. You will be positioned on an examination table, either lying on your back or side, or sitting up with your

arms raised and your hands clasped behind your neck, depending on the specific area of the chest to be examined.4. A clear gel will be placed on the skin over the area to be examined.5. The transducer will be pressed against the skin and moved over the area being studied.6. You may be asked to shift positions so that the technologist can obtain other views. You also may be asked

to cough or sniff during the procedure, so that the movement of certain structures within the chest cavity can be observed.

7. If blood flow is being assessed, you may hear a "whoosh, whoosh" sound when the Doppler probe is used.8. Once the procedure has been completed, the gel will be wiped off.

While the chest ultrasound procedure itself causes no pain, having to remain still for the length of the procedure may cause slight discomfort, and the clear gel will feel cool and wet. The technologist will use all possible comfort measures and complete the procedure as quickly as possible to minimize any discomfort.

 NURSING RESPONSIBILITIES

Contraindicated on pregnant woman.

Generally, there is no special care following a chest ultrasound. However, your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.

KIDNEY URETER BLADDER ULTRASOUND

INDICATION

A KUB x-ray may be performed to diagnose the cause of abdominal pain, such as masses, perforations, or obstructions. A KUB x-ray may be taken to evaluate the urinary tract before other diagnostic procedures are performed. Basic information regarding the size, shape, and position of the kidneys, ureters, and bladder may be obtained with a KUB x-ray. The presence of calcifications (kidney stones) in the kidneys or ureters may be noted.

EQUIPMENT

Renal Ultrasound, Kidney Ultrasonography, Kidney Echography

PROCEDURE

KUB x A -ray may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your physician's practices.

Generally, a KUB x-ray follows this process:

1. You will be asked to remove any clothing, jewelry, or other objects that might interfere with the procedure.2. If you are asked to remove clothing, you will be given a gown to wear.3. You will be positioned in a manner that carefully places the part of the abdomen that is to be x-rayed

between the x-ray machine and a cassette containing the x-ray film. You may be asked to stand erect, to lie flat on a table, or to lie on your side on a table, depending on the x-ray view your physician has requested. You may have x-rays taken from more than one position.

4. Body parts not being imaged may be covered with a lead apron (shield) to prevent exposure to the x-rays.5. Once you are positioned, the radiologic technologist will ask you to hold still for a few moments while the

x-ray exposure is made.6. It is extremely important to remain completely still while the exposure is made because any movement may

distort the image and even require another x-ray to be done to obtain a clear image of the body part in question.7. The x-ray beam will be focused on the area to be photographed.8. The radiologic technologist will step behind a protective window while the image is taken.

While the x-ray procedure itself causes no pain, the manipulation of the body part being examined may cause some discomfort or pain, particularly in the case of a recent injury or invasive procedure, such as surgery. The radiologic technologist will use all possible comfort measures and complete the procedure as quickly as possible to minimize any discomfort or pain.

NURSING RESPONSIBILITIES

Ask the patient to notify the radiologic technologist if he is pregnant or suspected to be pregnant.

Generally, there is no special type of care following a KUB x-ray. However, your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.

ABDOMINAL ULTRASOUND

INDICATION

Your health care provider may order this test to:

Determine the cause of abdominal pain Learn why there is swelling of an abdominal organ Look for stones in the gallbladder or kidney

EQUIPMENT

Abdominal Ultrasound Imaging

PROCEDURE

For most ultrasound exams, the patient is positioned lying face-up on an examination table that can be tilted or moved.

A clear water-based gel is applied to the area of the body being studied to help the transducer make secure contact with the body and eliminate air pockets between the transducer and the skin. The sonographer (ultrasound technologist) or radiologist then presses the transducer firmly against the skin in various locations, sweeping over the area of interest or angling the sound beam from a farther location to better see an area of concern.

Doppler sonography is performed using the same transducer.

When the examination is complete, the patient may be asked to dress and wait while the ultrasound images are reviewed. However, the sonographer or radiologist is often able to review the ultrasound images in real-time as they are acquired and the patient can be released immediately.

This ultrasound examination is usually completed within 30 minutes.

NURSING RESPONSIBILITIES

Tell your patient to wear comfortable, loose-fitting clothing for the ultrasound exam. The patient may need

to remove all clothing and jewelry in the area to be examined.

Patient may be asked to wear a gown during the procedure.

Instruct your patient to tell doctor if he have had a barium enema or a series of upper GI (gastrointestinal)

tests within the past two days. Barium that remains in the intestines can interfere with the ultrasound test.

DEFIBRILLATION

INDICATIONS:

         ventricular arrhythmia (ventricular tachycardia or ventricular fibrillation) and associated cardiac arrest (unresponsive patient without a pulse)

EQUIPMENTS

         defibrillator

         many different machines/models

         become familiar with equipment where you are practicing

         paddles

         adult size (8-9cm diameter) for patient weight > 10 kg.

         pediatric size ( 2.2 cm diameter) for patient weight < 10 kg.

         Electrode pads

         Self – adhesive

         Conductive material

         Gel, paste or pads

 

PROCEDURE/TECHNIQUE:

         Sudden death/cardiac arrest patients in VF or VT without a pulse should be defibrillated as soon as possible (even before CPR, medications or advanced airway procedures)

         Initiate CPR/ACLS protocols until defibrillator available

         Power on the defibrillator and select “unsynchronized/defibrillation” mode

         turn monitor selector to “paddles”

         Apply conductive materials (depends on what is available) before paddle placement

         Apply defibrillator monitor cables, pads, or “quick-look” paddles to patient in cardiac arrest to determine rhythm

         Paddle placement: 

         First (“sternum”) paddle:  to the right of the upper sternum and below the clavicle

         Second (“apex”) paddle:  to the left of the nipple in the midaxillary line, centered in the 5th intercostal space

         Avoid placing both paddles next to one another on the anterior chest wall

         Lead placement:

         “White-on-the-right” will help you to remember the white electrode is placed on the right side of the chest just below the right clavicle

         “smoke over fire” will help you to remember that the black lead is placed  on the left chest just below the left clavicle, and the red lead is placed in the left midaxillary line below the expected  PMI of the heart

         electrode pad placement:

         can be placed as described above for paddles, or

         anterior pad just to the left of the sternum, and posterior pad on the patient’s back to the left of the spine.  (This technique “sandwiches” the heart between the pads)

         assess rhythm to confirm VF/VT:

         if you see a flatline, turn up the gain to rule out fine VF, if flatline remains (and you have checked monitor, connections, and the patient) rotate paddles 90 degrees and re-assess rhythm to assure VF or (pulseless) VT remains

         choose energy level and charge defibrillator (“charge” buttons may be located on the paddles or on the machine itself)

         deliver shock(s) by simultaneously pressing the discharge buttons located on the paddles (or on the monitor for electrode pads) after ensuring “all clear” from the patient for equipment and providers

         re-assess patient, consider recommended medications, further management

NURSING RESPONSIBILITIES

It’s the nurse responsibility to know that it is contraindicated to a patient that is awake, responsive patients and any arrhythmias in a patient with a pulse.

ELECTROCARDIOGRAM

Indications:                                                              

      Known or Suspected Cardiac Patient

      Known or Suspected Tricyclic Overdose

      Electrical Injuries

      Syncope

Equipment:

Electrocardiogram

Procedure:

a.       Assess patient and monitor cardiac status.

b.      Administer oxygen per patient condition as tolerated.

c.       If patient is unstable, definitive treatment is the priority.  If the patient is stable or stabilized after treatment, perform a 12-lead ECG.

d.      Prepare ECG monitor and pre-cordial lead cables.

e.       Enter patient demographic data.

f.        Expose the chest and prep as necessary.  Modesty should be considered.

g.       Apply chest leads and limb leads as follows:

     RA----right arm

     LA----left arm

     RL----right leg

     LL----left leg

     V1----4th intercostal space at right sternal border

     V2----4th intercostal space at left sternal border  

     V3----Directly between V2 and V4

     V4----5th intercostal space at midclavicular line

     V5----Level with V4 at the left anterior axillary line

     V6----Level with V5 at the left midaxillary line

h.       Instruct patient to remain still.

i.         Press the 12 lead acquisition button on the monitor.

j.        If the monitor detects a problem, such as loose leads, bad connection, noisy data, the monitor will alarm.  The EMT-P should address the problem.

k.      Once acquired, transmit to the appropriate receiving facility.

l.         Contact the receiving facility to notify them of the patient and the incoming 12-lead.

m.     Monitor and reassess the patient enroute and continue treatment protocol.

n.       Attach a copy of the 12-lead with the patient’s record at the hospital.

o.      Document the procedure, time, results and findings on the ACR.

Nursing Responsibilities:

Nursing Responsibility for a certain risk factors or conditions may interfere with or affect the results of the test. These include, but are not limited to, the following:

1. obesity, pregnancy, or ascites (accumulation of fluid in the abdomen) 2. anatomical considerations, such as the size of the chest and the location of the heart within the

chest 3. exercise, intake of high-carbohydrate meal, and/or smoking prior to the procedure 4. Electrolyte abnormalities, such as too much or too little potassium, magnesium, and/or calcium in

the blood.

SUCTIONING

INDICATION

1. Visible presence of secretions in tube orifice 2. Coarse tubular breath sounds on auscultation in patient unable to cough or without artificial airway in place. 3. Patient with an artificial airway.

Equipment

Clean suction catheter (Make sure you have the correct size)Distilled or sterile waterNormal salineSuction machine in working orderSuction connection tubingJar to soak inner cannula (if applicable)Tracheostomy brushes (to clean tracheostomy tube)Extra tracheostomy tube

PROCEDURE

1. Wash your hands.2. Turn on the suction machine and connect the suction connection tubing to the machine.3. Use a clean suction catheter when suctioning the patient. Whenever the suction catheter is

to be reused, place the catheter in a container of distilled/sterile water and apply suction for approximately 30 seconds to clear secretions from the inside. Next, rinse the catheter with running water for a few minutes then soak in a solution of one part vinegar and one part distilled/sterile water for 15 minutes. Stir the solution frequently. Rinse the catheters in cool water and air-dry. Allow the catheters to dry in a clear container. Do not reuse catheters if they become stiff or cracked.

4. Connect the catheter to the suction connection tubing.5. Lay the patient flat on his/her back with a small towel/blanket rolled under the shoulders.

Some patients may prefer a sitting position which can also be tried.6. Wet the catheter with sterile/distilled water for lubrication and to test the suction machine

and circuit.7. Remove the inner cannula from the tracheostomy tube (if applicable). The patient may

not have an inner cannula. If that is the case, skip this step and go to number 8.

a. There are different types of inner cannulas, so caregivers will need to learn the specific manner to remove their patient's. Usually rotating the inner cannula in a specific direction will remove it.

b. Be careful not to accidentally remove the entire tracheostomy tube while removing the inner cannula. Often by securing one hand on the tracheostomy tube?s flange (neck plate) one can/ will prevent?accidental removal.

c. Place the inner cannula in a jar for soaking (if it is disposable, then throw it out).8. Carefully insert the catheter into the tracheostomy tube. Allow the catheter to follow the

natural curvature of the tracheostomy tube. The distance to the location of catheter becomes easier to determine with experience. The least traumatic technique is to pre-measure the length of the tracheostomy tube then introduce the catheter only to that length. For example if the patient?s tracheostomy tube is 4 cm long, place the catheter 4 cm into the tracheostomy tube. Often, there will be instances when this technique of suctioning (called tip suctioning) will not clear the patient?s secretions. For those situations, the catheter may need to be inserted several mm beyond the end of the tracheostomy tube (called deep suctioning). With experience, caregivers will be able to judge the distance to insert the tracheostomy tube without measuring.

9. Place your thumb over the suction vent (side of the catheter) intermittently while you remove the catheter. Do not leave the catheter in the tracheostomy tube for more than 5-10 seconds since the patient will not be able to breathe well with the catheter in place.

10. Allow the patient to recover from the suctioning and to catch his/her breath. Wait for at least 10 seconds.

11. Suction a small amount of distilled/sterile water with the suction catheter to clear any residual debris/secretions.

12. Insert the inner cannula from extra tracheostomy tube (if applicable).13. Turn off suction machine and discard catheter (clean according to step 3 if to be reused).14. Clean inner cannula (if applicable).

NURSING RESPONSIBILITIES

The nurse responsible to gather equipment that is needed in suctioning. You may explain to the family and relatives what each piece of equipment is for, and how it is used during the procedure of suctioning.

  2D ECHO

Indication for 2D Echo

1. Assess the heart’s function

2. Determine the presence of disease of the heart muscle, valves and pericardium, heart tumors,

and congenital heart disease

3. Evaluate the effectiveness of medical or surgical treatments

4. Follow the progress of valve disease

Equipment

Echocardiogram

PROCEDURE

Before the echocardiogram test, a cardiac sonographer (an allied health professional who has been

trained specifically to perform ultrasound examinations), nurse or physician will explain the procedure in

detail, including possible complications and side effects. They will be available to answer any questions

you may have. You will be given a gown to wear for your echocardiography procedure. You will be asked

to remove your clothing from the waist up. A cardiac sonographer will place three electrodes (small, flat,

sticky patches) on your chest. The electrodes are attached to an electrocardiograph monitor (ECG) that

charts your heart’s electrical activity.The sonographer will ask you to lie on your left side on an exam

table. The sonographer will place a wand (called a sound-wave transducer) on several areas of your

chest. The wand will have a small amount of cool gel on the end, which will not harm your skin. This gel

helps get clearer pictures. Sounds are part of the Doppler signal. You may or may not hear the sounds

during the test. You may be asked to change positions during the exam in order to take pictures of

different areas of your heart. You may be asked to hold your breath at times. You should feel no major

discomfort during the test. You may feel coolness from the gel on the transducer and a slight pressure of

the transducer on your chest.The echo test takes about 40 minutes. After the echocardiogram test, you

may get dressed and go home or go to your other scheduled appointments.

Nursing Responsibilities

Echocardiography is extremely safe. As a nurse tell your patient that there are no known risks from the clinical use of 2D echo during this type of testing.

COLLEGE OF OUR LADY OF MOUNT CARMEL

PAMPANGA

PROCEDURES

IN THE INTENSIVE CARE UNIT

 

SUBMITTED BY:

JOYCE B. CRUZ

SUBMITTED TO:

MRS. LILIBETH NUCUM