Nursing: Universal Protocol and Skills Update

Nursing: Universal Protocol and Skills Update

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Description: Medication Reconciliation(MR), Medication Safety, process of comparing a patient's medication, scurrent medications, inadvertent omissions of required medications, Failure to re initiate home medication, Therapy duplication at discharge, prescribing errors, ordering incorrect doses or dosage formulations.

 
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Domain:  Medicine Category: Practice Mngmnt Subcategory: Patient Safety 
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Contents:
NURSING 2011 ONLINE SKILLS FAIR

Medication Reconciliation & Medication Safety

What is Medication Reconciliation?
Medication reconciliation (MR) The process of comparing a patient's medication orders to all of the medications that the patient has been taking Should be done at every transition of care in which new medications are ordered or existing orders are rewritten Transitions in care = changes in setting, service, practitioner, or level of care


The

Joint Commission � Goal 8 � Accurately and completely reconcile medications across the continuum of care NPSG.08.01.01 A process exists for comparing the [patient]'scurrent medications with those ordered for the[patient] while under the care of the [organization

MEDICATION RECONCILIATION Goal #8 of the Hospital National Patient Safety Goals is to accurately and completely reconcile medications across the continuum of care. There are a number of steps that medical providers must follow to assist ARMC in reaching this goal. 1. With an increasing number of sound-alike, look-alike drugs on the market, medication orders need to be written legibly, clearly specifying the dosage form, drug strength and the purpose of the medication. 2. Do not use unacceptable abbreviations (see following list). 3. When receiving telephone orders, the nurse writes and then reads the drug, dosage, etc, back to the medical provider for a final verification. 4. On admission, whether through the emergency department, same day surgery or a direct admission, the nurse and the medical provider need to reconcile the medications the patient was taking before admission to the ones to be continued in the hospital or newly added to the list. - "Meds from home" orders are not acceptable 5. Whenever a patient is transferred to another nursing unit within the facility, the nurse and the medical provider need to reconcile the medications the patient needs to be taking on the next unit before the transfer occurs. This includes: - Any transfer to a higher or lower level of care. - If the patient remains on the same unit but the status has changed, e.g., telemetry is discontinued. - Following any operative or invasive procedure. - "Resume pre-op" orders or "discontinue tele meds" are not acceptable. 6. When the patient is discharged from the inpatient unit to home, acute rehab, ECF or other outside level of care, the nurse and the medical provider need to reconcile the medications that the patient will need to take. - "Continue home meds" orders are not acceptable. Patient recovery from surgery or illness is a worthy goal, but it must be accomplished in the safest possible environment. All healthcare disciplines need to work together.

What can MR prevent?
� Inadvertent omissions of required medications � Failure to reinitiate home medication following transfer and discharge � Therapy duplication at discharge � Prescribing errors associated with ordering incorrect doses or dosage formulations

Process Overview
� Verification Collect medication history � Clarification Ensure appropriate medications, doses, routes � Reconciliation Document changes in physician orders

ORDERS
It

is ordered for you patient to receive 5 mg of Morphine every 2 hours IVP. On hand you have 2mg, 4mg or a 10mg syringe of Morphine. Rather than Waste the 5 mg of Morphine, you decide to give only 4 mg of the Morphine. What is the Medication Error?

The Error
Dispensing

order. You may not alter the dosage without an order. Even if the patient requests only half a dose, you must obtain an order to adjust a dosage.

a medication without an

ORDERED:
Give

1 to 2 tablets of Lortab 5/500 PO for pain every 4 to 6 hours as needed. What is the ERROR in this order?

ERROR
We

do not accept range orders for medications. The medication order should be written "Give 1 Lortab 5/500 mg Tablet PO every 4 hours for pain score of 1 to 4. Give 2 Lortab 5/500mg tablet PO every 4 hours for a pain score of 5 to 10.

6 Rights
Right

Patient Right Time Right Drug Right Dose Right Route Right Diagnosis

Right Patient
Tools


Available to Accomplish Goal
and Date of Birth

Two Identifiers
Name



Wrist Band

Right Time
Tools


Available to Accomplish Goal

Standard Times

Right Drug
Tools


Available to Accomplish Goal

Unit Dose Packaging

Right Dose
Tools


Available to Accomplish Goal

Unit Dose Packaging Insulin Double Check and Document
IV

Digoxin and Heparin also require a double check.

Do Not Use Abbreviations

This abbreviation ("U" for the word "unit) was misread as a zero which led to a patient receiving a ten-fold overdose of insulin.

Right Dose
Rules


of Thumb

Question dose if more than 2 tablets or capsules Question dose if more than 1 vial

ALWAYS

use leading zeros, ex: 0.5mg NEVER use trailing zeros, ex: 5.0mg

What is wrong with this order?

Resist the temptation to abbreviate drug names. In this prescription above, the common abbreviation for "hydrochlorthiazide 50 mg' was misread as "hydrocortisone 250 mg."

Right Route
Tools


Available to Accomplish Goal

Check Vial

Right Diagnosis
Question


Does the indication for this drug match a condition or diagnosis that this patient has?
Order

for insulin on a non-diabetic patient New order for furosemide on a patient with a BP of 120/75 New order for IV furosemide on a patient with a K+ of 3.5 and no additional KCL ordered

Look Alike Sound Alike Drugs
LASA

or SALADS

Drugs

with the potential to be confused because of the similarity in their names
Hydroxazine

and Hydralazine Celebrex and Celexa Zyprexa and Zyrtec

Tools
TALLman/smallMAN

Lettering Signs Listing SALADS Posted Throughout Hospital

High Alert Medications
Definition
Medications

which if given incorrectly have a high potential to cause harm to the patient
Heparin,

Insulins, Concentrated Electrolytes

Tools
Double

check dosage prior to administration Alaris Smart Pumps or Colleague Profile Standard concentrations Warning Stickers

Resources
Pharmacy Other Clerks Physician References


Nurses

Physicians Desk Reference (PDR)

Final Thoughts
Errors

are primarily caused by system failures not individuals The system can not be fixed if we do not know it is broken � report errors Nursing is the last line of defense against an error but we are all in this together DO NOT be afraid to question

Patient Education





Educate patients about their medications Purpose of each medication Name of drug, dose, how to take, etc. Provide patients with understandable written instructions Lack of involving patients in check systems Inform patients about potential for error with drugs known to be problematic

Charting Errors

Funny but Real Errors


"I just want to let you know that this lady has had decreased urinary intake." (Doctor aware) "He is allergic to wives." "No clubbing, cyanois, or extremities." "Renal insufficiency. IV Lasix was used to perfuse the kidney." order: "Incentive spriometry Q 1 hour until awake." "fibromyalgia rheumatica" "Pleasant man lying comfortably in bed. Appears somewhat uncomfortable" "Her stomach showed 3+ edema up to the knees." "Will hold glyburide for now because of reverse hypoglycemia." "pneumonia left femur" "2-4 packs of whiskey QD" "Pt is on clonidine, not"

Does this look Correct?

Correcting a Mistake
Draw

a line thru the error and date and initial the error. You do not need to WRITE ERROR.


Don't write oops or scratch out the mistake.

33

9/12/2011

Abbreviations
Abbreviations.

There is a DO NOT USE LIST per Joint Commission. Do not make up abbreviations or use symbols. While it may save time it is not the best form of documentation. Write out the drugs given in nurses notes, MARS, and flow sheets
ARMC

34

9/12/2011

Examples
DO


NOT USE THIS

Pt. given MS04 for a MG level of 1.2 PT working with Pt Pt critical value received from Larry in lab.

Write

out Patient, Physical Therapy, Magnesium Sulfate.

ARMC

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9/12/2011

Abbreviations A short cut to disaster
AFWAG
Patient

goes.

may get up as far as the wire

300

cc PWISOTF
plus what I spilled on the floor.

300cc

LGTM
Looks

good to me
ARMC

JSP
Jerry

Springer Patinet.

36

9/12/2011

DATE & TIME
It

may seem obvious but be sure to include the date and the time you wrote your entry. The date should include the year; the time should indicate am or pm by using military time. Don't chart in blocks of time such as 0700 to 1500. This makes it hard to determine when specific events occurred.
ARMC

37

9/12/2011

PIE


PIE: This is an acronym for Problems, Intervention and Evaluation of nursing care. The system consists of a 24-hour flow sheet combined with nursing progress notes. The notes are written as client problem statements using an approved nursing diagnosis. Problems are labeled "P" and given a number, nursing interventions are labeled "I" and evaluations of the nursing action or intervention are labeled "E."

ARMC

38

9/12/2011

How

you chart is as important as what you chart. Therefore, chart only what you see, hear, feel, measure and count, not what you suppose, infer, conclude or think.

ARMC

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9/12/2011

Root Causes
Root

Causes of Sentinel Events

ARMC

40

9/12/2011

Barriers to Communication
Human

Fallibility Complex Healthcare systems Limitations of learning & training Continuity gaps Negative impact of fatigue Time Constraints Volume of Information Confidentially
ARMC

41

9/12/2011

Medical Records
Tell

a story Paint a picture

ARMC

42

9/12/2011

Tools for Documentation
Kardex Care

Plans Flowsheets, checklists Monitoring stripes Report sheets

ARMC

43

9/12/2011

The Do's
Chart

solutions and problems Teaching efforts Proper spelling and grammar All referrals and support efforts All care given or supervised.

ARMC

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9/12/2011

Don't
Chart

a symptom without charting what you did. Avoid waiting till the end of a shift Write "a good shift" "ate well" "patient nervous" Avoid terms like `large amount' or `appears' or `bed soaked'. Don't make excuses "Medication not given since pharmacy did not send it"

ARMC

45

9/12/2011

KEY WORDS




There are several key words that come to mind. You might want to write them down on a note card, laminate it and carry it in your pocket. Pull the card out of your pocket periodically and use it to review and evaluate your own documentation. Here they are in alphabetical order: Chronological Comprehensive Complete Concise Descriptive Factual Legally aware Legible Relevance Standard abbreviations, symbols, and terms ARMC Thorough Timely

46

9/12/2011

Common Mistakes








Not recording pertinent heath or drug information Failing to record nursing action Failing to record medications given Charting on the wrong chart Failing to chart a discontinued medication or treatment Failing to record patients change in condition Transcribing orders incorrectly Writing illegibly or having incomplete records.

ARMC

47

9/12/2011

Tele/ Medical Surgical Charting problems
Failure

to monitor Failure to inform physicians of changes Failure to follow orders Failure to prevent falls Injury during treatment Intravenous injuries Provision of inadequate care
ARMC

What is it? How does it apply to you? Who is responsible? When should it be used? Why should you use it?

Universal Protocol for Correct Site Surgery/Procedures

What is it?
Guidelines



intended to prevent surgery/procedure errors
Wrong Site Wrong Procedure Wrong Person

Required


by TJC Applicable to ALL procedures
Not just surgery in an Operating Room
Includes

three major steps

The Three Steps Include..
The


verification processes to confirm

Correct Patient Correct Procedure Correct Site (where applicable)

The

site

marking of the operative/procedure

A

"time-out" immediately before starting the procedure

The Pre-operative Verification Process Includes...
Verification


of the correct person, procedure and site:
At the time it's scheduled At the time of admission At any time of care transfer
With

patient/family involvement



Before entering the procedure/surgical room

Marking the Operative/Procedure Site Includes...
O O

Mark ALL cases involving laterality Mark ONLY the surgical site

O
O

The mark MUST be unambiguous
The mark MUST be visible after prep and draping the patient

Marking the Operative/Procedure Site Includes, Cont'd...
The

person performing the procedure should do the marking The marking MUST occur with patient/family involvement


Involve family members or the caregiver if patient is not able to communicate

The

site MUST be verified during the final "time out"

The "Time Out" ...
O

MUST be done in the location where the procedure will be done, just prior to starting the procedure Must involve the entire operative team Must use active communication

O O O

Must be documented

The "Time Out"...Cont'd
Must


include verification of:

Correct patient identity Correct side and site Agreement on the procedure to be done Correct patient position Availability of correct implants and any special equipment or special requirements

How Does It Apply to You?
As

a staff member directly responsible for the patient


You are the patient's advocate You are responsible for making sure that the protocol is followed to protect your patient



Who is Responsible?
The

organization's policies and procedures specifically name who is responsible for each of the steps in the Universal Protocol sure to be aware of your role in the protocol

Make

When Should it be Used?
The

Universal Protocol should be used for all surgical procedures Universal Protocol should also be used for procedures done in other areas of the hospital


The

Not just those done in the OR
i.e.,

chest tubes, angiograms, etc.

Why Should You Use It?
Wrong

site, wrong procedure, wrong person surgery can be prevented. The universal protocol is intended to achieve that goal.



Remember to...
O O O O O

Review all relevant documents and studies Make sure the mark is visible after the prep and drape Involve the patient/family when marking the site Perform the "time out" for final verification Clarify all discrepancies prior to the start of the procedure
O

Have them available

Remember that YOU are a Very Important part of the process!

MODERATE SEDATION
Initial In-service 2011

Indications for Conscious Sedation


Any procedure for which increased discomfort, pain or anxiety may increase the stress or risk to the patient.

Examples include: Reduction of a dislocation Setting of a fracture Drainage of an abscess Cardioversion Endoscopic procedures

Who can provide Conscious Sedation?
Any

Licensed Independent Practitioner (LIP) with privileges at this facility. Registered Nurse's (RN) with documented competency and current ACLS. Respiratory Care Practitioner (RCP) with documented competency and current ACLS (No policy in place at this facility).

Arizona State Board of Nursing
Advisory Opinion

It is within the Scope of Practice of a Registered Nurse to administer medications to provide conscious sedation for the purposes of diagnostic or therapeutic procedures.

Four Levels of Sedation
Sedation occurs along a continuum but is generally broken into four levels
Minimal

sedation (anxiolysis) Moderate sedation (Conscious) Deep sedation General anesthesia

Minimal Sedation
A

drug-induced state during which patients respond normally to verbal commands. Cognitive function and coordination may be impaired Ventilatory and cardiovascular functions are unaffected

Moderate Sedation
A

drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation Spontaneous ventilation is adequate and no interventions are required to maintain a patent airway Cardiovascular function is usually maintained

Deep Sedation
A


drug-induced depression of consciousness during which patients:



cannot be easily aroused respond purposefully to repeated or painful stimulation respiratory effort may be impaired

Spontaneous

ventilation may be inadequate and patients may require assistance to maintain an open airway. Cardiovascular function is usually maintained.

General Anesthesia (Local Anesthesia not
included)







A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. Independent ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway. Depressed spontaneous ventilation or drug-induced depression of neuromuscular function may require the use of positive pressure ventilation. Cardiovascular function may be impaired

Requires Anesthesiologist or CRNA

Most

complications are a result of the effects medications have on the respiratory and/or central nervous system. Pre-existing conditions or medications already `on board' may also potentiate complications.

Respiratory System Review

How It Works








Increases in Carbon Dioxide levels (CO2) trigger the body to `take a breath'. The diaphragm contracts, pulling down towards the abdomen increasing the negative pressure in the chest and allowing room for the lungs to expand. Higher pressures outside the body force the air through the mouth and nasal cavity (warming, moistening and slightly filtering the air) into the trachea, down the bronchi and into the alveoli where oxygen exchange occurs. Oxygen is taken into the cells and CO2 and other byproducts are given up. As the diaphragm relaxes and begins to rise, the accessory muscles of the chest walls contract further squeezing the chest and assisting in CO2 expulsion, lowering the body's CO2 level. This constitutes a "breath". The number of "breaths" your body takes in a minute (Respiratory Rate) is controlled by your CO2 level and your autonomic nervous system.

Upper Respiratory Tract





Oral cavity Nasal cavity Nasopharynx Oropharynx Epiglottis Laryngopharynx Esophagus Vocal cords

Even partial obstruction of any of these airways can lead to hypoventilation, hypoxia and further complications. Obstruction can be from a foreign body (aspirate) or the body part itself (congenital anomaly, edema, infection)

Lower Respiratory Tract
Trachea Bronchus Bronchi

Alveoli
Accessory

muscles Diaphragm Obstruction may occur due to mucous production or allergic reaction (edema and bronchoconstriction). Decreased use of accessory muscles or the diaphragm may also lead to hypoventilation and hypoxia.

Central Nervous System Review
Brain

Spine

Brain
Cerebellum-

controls the actions of the muscular system needed for movement, balance, and posture Cerebrum- areas of higher function
Right
Art Imagination

hemisphere

Symbols

Left

Spatial

Speech

hemisphere

relations

Logic

Writing

arithmetic

Brain (cont.)


Diencephalon- consists of thalmus and hypothalmus Thalmus Relay station for sensory information Interprets sensations of pain, pressure, temperature, and touch Some influence on emotions and memory Receives information regarding sound, smell and taste Hypothalamus Control of the autonomic nervous system Controls normal body temperature Regulates the endocrine system Regulates hunger, satiation, thirst, sleep and wakefulness Involved in anger and aggression

Brain (cont.)


Brain stem Medulla oblongata Messages arriving from the spinal cord to the brain cross at the medulla causing the opposite side of the brain to control each side of the body. Controls heartbeat, respiratory rate, and diameter of the blood vessels. Helps coordinate swallowing, vomiting, hiccuping, coughing, sneezing, and other basic life functions. Helps maintain the conscious state. Pons (latin for `bridge') Conducts messages between the spinal cord and the brain and between the different parts of the brain Midbrain Conveys impulses from the hypothalmus to the pons and spinal cord Contains visual and audio reflex centers involving the movement of the eyeballs and head


Twelve pair of cranial nerves originate in the underside of the brain and brain stem. These provide information from the face, head and neck. The vagus nerve (latin for `wandering') is the only cranial nerve that also serves other areas. It branches to the larynx, heart, lungs, stomach, and intestines (helping to promote digestive activity and regulate heart activity).

Spinal Cord




Transmits sensory impulses to the brain along ascending tracts and transmits motor commands from the brain to the muscles via descending tracts. Thirty one sets of sensory neurons and motor neurons come together before they exit the vertebral column, to serve the areas of the body close by.

The Nervous System

Neuron

Neuronal Synapse

How It Works


The cells of the nervous system are comprised of three types of neurons.












Each neuron carries impulses in only one direction to prevent impulses canceling each other. Impulses are transmitted via electrochemical reactions that occur at the synapses (tiny space between the dendrite of one cell and the axon of another cell. Sodium/Potassium gates as well as neurotransmitters cause this electrochemical reaction. Many drugs effectiveness are based on their ability to mimic or block secretion/uptake of certain neurotransmitters

Sensory neurons- carry impulses or sensations from receptors (located in the skin, skeletal muscles, joints, and internal organs) to the brain or spinal cord. Motor neurons- carry impulses from the brain or spinal cord to muscles and glands, causing muscles to contract and glands to secrete. Interneurons- located in the CNS and conduct impulses from sensory to motor neurons

Contraindications for Sedation
There are many contraindications to the use of Sedation for procedures, and each patient must be assessed on an individual basis by both the RN and the Physician. Contraindications may include:
Pres-existing

cardiac condition Pre-existing pulmonary condition Medication allergies Medications currently on board Unstable vital signs (to include cardiac rhythm)

To minimize risk to the patient specific safety guidelines MUST be adhered to.
Prior


to sedation the physician must:

Physically assess the patient Verify the H&P Review any pertinent labs Assess the patient for risk (assign an ASA Classification) Assess the patient's airway (assign a Mallampati Airway Assessment Score)

American Society of Anesthesiologists (ASA) Classification
I- Normal healthy patient II-Mild systemic disease, no limitation of activity III- Severe systemic disease, limitation of activity IV- Severe systemic disease that is constant threat for life V- Moribund, patient is not expected to survive 24 hours, with or without procedure

Class I � soft palate, fauces, uvula, and tonsillar pillars visualized Class II � soft palate, fauces, and uvula visualized Class III � only soft palate and base of uvula is visualized Class IV � soft palate is not visible at all

Mallampati Airway Assessment

Class I

Class II

Class III

Class IV





Prior to sedation the RN must: Obtain consent. Make sure that patient/family received Conscious Sedation education prior to procedure. Handout is available. Ensure that all the required safety equipment is immediately available Continuous CR monitor NIBP cuff Continuous pulse oximeter (end tidal capnography not routinely used at this facility) Oxygen Suction Code Cart Patent IV access Reversal agents Two patient identifiers and Universal Protocol (Time Out) apply to all sedation procedures with reassessment immediately prior to the procedure.

As the administering RN you should:
Auscultate

procedure Confirm NPO status Confirm medication already present for possible interactions Obtain baseline vital signs Assign a baseline Modified Aldrete Score

heart and lung sounds prior to

Modified Aldrete Score
Score 2Activity Moves all extremities voluntarily/on command Respiration Breaths deeply and coughs freely Circulation BP+20mm of preanesthetic level (BP stable, HR wnl) Consciousness Fully awake Oxygen Saturation SpO2 >92% on room air

1-

Moves 2 extremities

Dyspneic, shallow or limited breathing

BP +20-50mm of preanesthetic level (BP fluctuating, HR irregular, weak)
BP +50mm of preanesthetic level (Unable to palpate BP or HR)

Arousable on calling

Supplemental O2 required to maintain SpO2 >90%
SpO2 10 hours Diphenhydramine (Benadryl�)- aids sleep Pentobarbital (Nembutal�)- preprocedural sedation Droperidol (Inapsine�)tranquilize/sedation- use with extreme caution, FDA warning Alert! There are no reversal agents for these medications

Most Common Complications and Treatments
Respiratory

Depression Hypotension Nausea and Vomiting

Respiratory Depression








Stimulate the patient Verbal Tactile Open the airway Chin lift Jaw thrust Oxygen as indicated Nasal prongs (up to 6L/min-adjust flowmeter) Venti mask (variable up to 60% FiO2- use insert and adjust flowmeter accordingly up to 10L/min) Non-rebreather (up to 100% FiO2- must run at 15L/min to clear CO2 build-up) Support the patients ventilation (Ambu bag, CPAP) Initiate Rapid Response to stabilize airway if necessary Initiate CPR if necessary

Hypotension
Leg

elevation Fluid challenge with Dr.'s order Reversal agents with Dr.'s order

Nausea and Vomiting
Side-lying

position Modified trendelenberg Suction Medicate with Dr.'s order

Cardiac Arrhythmia (Not Common)
May


be a result of:

drug interactions hypoxia over-sedation Hypotension

Treat

the reason!

Typical Arrhythmias
Tachycardia

P waves similar, 1:1 with QRS Rhythm regular Rate 100-150

Bradycardia

P waves similar, 1:1 with QRS Rhythm regular Rate Atrial, < 60 bpm

PVC's

P waves usually none seen before PVC, but normal with basic rhythm Rhythm atrial, irregular Rate variable

Recovery and Discharge




The recovery phase of sedation begins immediately after the administration of the final dose of medication (sedative or reversal agent) The RN should determine the patients Aldrete score at the end of the procedure and at the end of the recovery phase The patient must have an Aldrete score of 8 or a return to baseline before patient can be considered recovered. Discharge teaching must occur with the responsible party (whether receiving staff or family/friend). Discharge instructions must include a reminder not to perform any function which requires concentration or coordination for the next 24 hours, due to possible residual drug levels.

Documentation
It

is the RN's responsibility to complete the required documentation Moderate Sedation/Analgesia Procedure Record Moderate Sedation Log entry Moderate Sedation PI Tool Occurrence Report (if appropriate)

Summary
Goal:


To provide safe patient care




Sedation is a continuum Know how to define your role in moderate sedation (pre, intra and post procedure) Provide safe administration of medications Provide ongoing monitoring until discharged from sedation Be prepared to "rescue the patient" Complete all documentation for sedation care

PAIN MANAGEMENT
To Assess and Treat

Some Facts about Pain Management






"Unbalanced and misleading media coverage on the abuse of opioid analgesics not only perpetuates misconceptions about pain management; it compromises the access to adequate pain relief sought by over 50 million Americans living with pain." "In the past several years, there has been growing recognition on the part of health care providers, government regulators, and the public that the undertreatment of pain is a major societal problem." "Pain of all types is undertreated in our society. The pediatric and geriatric populations are especially at risk for undertreatment. Physicians' fears of using opioid therapy, and the fears of other health professionals, contribute to the barriers to effective pain management."

Source: American Medical Association, "About the AMA Position on Pain Management Using Opioid Analgesics," 2004, from the web at heep://www.ama-assn.org/ama/pub/category/11541.html, last accessed March 1, 2004.

A 2000 Gallup Poll States:
Nine

in 10 Americans aged 18 and older (89%) suffer from pain at least once a month. Forty-three percent of adults- a projected 83 millionreport that pain frequently affects their participation in some activities. Fewer than half (43%) of respondents report they have a "great deal of control" over their pain. More than 26 million Americans (15%) who suffer pain monthly have severe pain. Sixty-four percent of pain sufferers will see a doctor only when they cannot stand the pain any longer. Less than half (42%) of people who visit their doctor for pain believe that their doctor completely understands how their pain makes them feel."

How do we understand how pain makes the patient feel?
By understanding the following:


What causes pain How to properly assess it How to treat it

Three Types of Pain.

Acute

pain Chronic pain Cancer pain

Acute Pain


Begins suddenly and is usually sharp in quality. It serves as a warning of disease or threat to the body. It may be mild and last moments, or severe and last for weeks or months. In most cases it disappears when the underlying cause has been treated or has healed. Unrelieved acute pain, may lead to chronic pain. Some causes: Surgery Broken bones Dental work Burns or cuts Labor and childbirth

Chronic pain


Persists despite the fact that an injury has healed. Signals remain active in the nervous system for weeks, months, or years. Physical effects may include: Tense muscles Limited mobility A lack of energy Changes in appetite Emotional effects may include: Depression Anger Anxiety Fear of re-injury Common chronic pains may include: Headache Low back pain Cancer pain Arthritis pain Neurogenic pain (pain resulting from damage to nerves) Psychogenic pain (pain not due to past disease or injury or any visible sign of damage inside)

Cancer Pain
may

result from the tumor itself or from the surgery, radiation, and chemotherapy used during treatment. Treatment usually includes both shortacting and long-acting opioids as well as anti-inflammatories, along with possible surgical procedures to relieve pressure (debulking) or sever permanently damaged nerves (rhizotomy). Medications may be given


Intravenously (IV) Subcutaneously Transdermally Transmucosally Rectally Orally

Treatments may be individual or in combinations.
Drug


Nerve


blocks Alternative treatments


Analgesics NSAIDS Opiods

treatments

Electrical

stimulation Physical therapy Surgery Psychological counseling Behavior modification

Acupuncture Relaxation Biofeedback, etc.

Most

patients admitted to the hospital are suffering from acute pain and would benefit from multiple therapies. In order to treat the patient effectively, the patient must be assessed



On admission Every 4 hours with vital signs With changes in the patient status

Assessing the Pain
Physical
"fifth

Historical
Intensity
Quality

vital sign" Visualization of area or wound
Location

Chronology/pattern Precipitating

factors Alleviating factors Associated symptoms

Pain Scales
Non-Verbal Indicator Scale
Vocal complaints- nonverbal expression of pain demonstrated by moans, groans, grunts, cries, gasps, or sighs. Verbal expressions of pain using words, "ouch" or "that hurts"; cursing during movement, or exclamations of protest, "stop" or "that's enough" Facial Grimaces and Wincesfurrowed brow, narrowed eyes, tightened lips, dropped jaw, clenched teeth, distorted expression Bracing- clutching or holding onto side rails, bed, tray, table, or affected area during movement Restlessness- constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still

With Movement

At Rest

Wong-Baker Faces

Numerical Rating Scale
0= No pain 1-3= Mild pain 4-6= Moderate pain 7-10= Severe pain

Rubbing- massaging affected area
TOTAL SCORE

Various

pain scales are available 0-10 numerical pain scale- 0= no pain, 10= the most severe pain The Non-verbal Indicator scale- good for infants or semi-conscious/unconscious patients The Wong-Baker faces- laminated cards at the nurses station make numerical assessment possible for children and non-English speaking patients Segmented numerical pain scale- provides corresponding numbers to pain severity for medication administration.

When pain medications are indicated
Over-the-counter

(OTC) pain relievers Acetaminophen (Tylenol, Aspirin Free Excedrin) Nonsteroidal anit-inflammatory drugs (NSAIDsaspirin, Motrin, Aleve and Orudis KT) Topical Corticosteroids (Cortaid and Cortisone)



Prescription pain relievers:



Corticosteroids (Deltasone, Hydeltrasol, Solu-Medrol)
Weight gain Upset stomach Headache Mood changes Trouble sleeping Weakened immune system Drowsiness Nausea Constipation Itching Breathing problems Addiction Blurry vision Constipation Difficulty urinating Dry mouth Fatique Nausea Headache Drowsiness Dizziness Fatique Nausea





Opioids (Morphine, Fentanyl, Oxycodone, Codeine)




Antidepressants (SSRIs- Celexa, Prozac, Paxil, Zoloft; Tryclics- Elavil Norpramin Sinequan, Tofranil, Pamelor; SSNRIs- Effexor, Cymbalta)




Anticonvulsants (Tegretol, Neurontin, Lyrica)


PAIN MANAGEMENT REASSESSMENTS
Assess using a numerical value before medicating. Reassess: 15 minutes after administering IV pain medication 30 minutes after administering IM pain medication 60 minutes after administering PO pain medication

Don't Forget to Document
After each assessment After each re-assessment

ON THE PAIN SECTION OF THE FLOW SHEET!!

Sometimes alternative methods may be as or more effective than drugs. Document these interventions and their effectiveness (or lack of) also.
Physical

Interventions

Comfort

measures Repositioning (turning and elevation) Massage Heat or ice Skin and body soaks Environmental changes (dim the lights, provide quiet, provide distractions

Pain

Management is the process of providing medical care that alleviates or reduces pain. Whether it is with medications or alternative methods, the goal of medical personnel is to alleviate as much pain as possible, allowing the patient to maintain their activities of daily living (ADLs), and healing to the best of their ability.

Documentation in the Nurses Notes.






When charting pain levels and characteristics, describe the location of the pain and note if it's internal, external, localized, or diffuse. Record whether the pain interferes with the patient's sleep or activities of daily living. In the chart describe what the pain, feels like in the patient's own words. Chart the patient's description of how long the pain lasts and how often it occurs. Record the patient's ranking of his pain using a pain rating scale. Describe the patient's body language and behaviors associated with pain, such as wincing, grimacing, or restlessness. Note sympathetic responses commonly associated with mild to moderate pain, such as pallor, elevated blood pressure, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, and diaphoresis. Record parasympathetic responses commonly associated with severe, deep pain, including pallor, decreased blood pressure, bradycardia, nausea and vomiting, dizziness, and loss of consciousness. Chart situations that worsen the pain as well as interventions that relieve or decrease the pain, including heat, cold, massage, or drugs. Document interventions taken to alleviate your patient's pain and the patient's responses to these interventions. Also, note patient teaching and emotional support provided.

Preventing Contaminated Blood Cultures
A Training Guide for Collection Personnel

Objectives


To describe what constitutes a contaminated ("false positive") blood culture. To state the resulting consequences and additional costs related to contaminated blood cultures. To provide a standard framework of techniques designed to reduce contamination in the blood culture collection process.





Definitions


"blood culture" / "blood culture set" � Specimen(s) of blood collected under aseptic conditions and inoculated into test bottles to determine the presence of bacteria in the bloodstream.



"culture medium" � The material found at the bottom of the blood culture bottles that provide nutrients for bacteria to develop under laboratory-controlled conditions.

Definitions
"positive

culture" � The condition where blood inoculated into the test containers produces growth of bacteria. positive" / "contaminated" � Organisms that are not actually present in the blood sampled grow in the culture medium (Hall & Lyman, 2006).

"false

Consequences of Contaminated Blood Cultures


Lack of reliable information needed to treat the patient.
Inappropriate use of antibiotics.



Longer length of stay in the hospital.
Additional costs associated with all the above.





Unnecessary additional laboratory testing.
(Thompson & Madeo, 2009)

Associated Costs Relating to Blood Culture Contamination


Additional expenses per false-positive culture range between $1,000 to over $8,000 (Roth et. al., 2010). One ED calculated the median charge to be an additional $8,720 per patient (Gander et. al., 2009). Regardless of the specific figure, these additional costs are substantial.





Adult Standard Procedure for Blood Culture Collection
1.

Gather necessary supplies for the blood culture collection process. There should be adequate materials to perform a minimum of two successful venipunctures at different sites. If there is an anticipated need to re-palpate the vein after disinfecting the intended puncture site, it is recommended that the clinician also procure appropriate-sized sterile gloves.

Adult Standard Procedure for Blood Culture Collection
2.

A minimum of two sites should be identified for venipuncture. These sites must not be existing peripheral access sites, nor in close proximity to those sites. Sites should be free from existing skin

conditions such as those consistent with eczema,
excoriation, or any apparent underlying injury such as hematoma, scarring, or bruised areas.

Adult Standard Procedure for Blood Culture Collection
3.

Perform hand hygiene. Just prior to the procedure, it is important to wash hands using vigorous scrubbing under

soap and water. Don examination gloves.
4.

Inspect the collection bottles. Inspect each bottle for any apparent defects, and check the bottom part of the container for an intact sensor that should be a grayishgreen color. Yellow color indicates contamination of the culture medium, and these bottles should be discarded.

Adult Standard Procedure for Blood Culture Collection
5.

Prepare the collection bottles. The protective plastic covers are removed from the top of the septum. Because the septum is not sterile, it must be sterilized by cleansing with a 70% isopropyl

alcohol pad. Although bottles have been marked
with incremental levels, it is recommended to mark the desired fill level at 10 mL for adult specimens.

Adult Standard Procedure for Blood Culture Collection
6.

Prepare the site for venipuncture. This is accomplished by scrubbing the site for a minimum of 60 seconds with an

approved chlorhexidine gluconate swab. A circular area
of approximately 3 cm in all directions from the intended puncture site should be disinfected. Allow the site to airdry without assistance such as fanning. Dry times will vary according to manufacturer specifications, but typically, anywhere from 30 seconds to two minutes is recommended.

Adult Standard Procedure for Blood Culture Collection
7.

Perform the venipuncture. Secure the needle in place with tape once proper placement is indicated. Do not repalpate the vein. If there is a need to repalpate, exam gloves need to be

swapped out for sterile gloves to prevent
recontamination of the site. Do not attempt to sterilize the tips of exam gloves.

Adult Standard Procedure for Blood Culture Collection
8.

Fill the containers. Using the adapter cap, start by filling the aerobic bottle first. This requires pressing the adapter

cap straight down on the septum to initiate blood flow.
Avoid twisting or turning because this may not allow the bottle to reseal after blood capture. Fill only to the designated mark on the container, as overfilling may cause the sample to indicate a false-positive reading. After filling the aerobic container, repeat the process for the anaerobic bottle.

Adult Standard Procedure for Blood Culture Collection
9.

Additional blood collection. If required, additional blood specimens can be collected before terminating the venipuncture. Always perform blood culture collection before collecting additional blood specimens. Terminate the venipuncture. Remove the tourniquet. Activate the safety device on the needle, and dispose of the needle in the sharps container.

10.

Adult Standard Procedure for Blood Culture Collection
11.

Label the specimen bottles. Place bottles in a biohazard bag for delivery to the lab.

12.

Repeat the process for collection of a second (or

more) set(s). Starting with step 3, repeat the
process. This may be done immediately unless physician orders state a specific time interval to

elapse between specimen collection sets.

Adult Modified Procedure for Blood Culture Collection Involving an Existing Central Line
1.

Gather necessary supplies for the blood culture collection process. There should be adequate materials to perform a minimum of at least one successful venipuncture at a peripheral site. If there is an anticipated need to re-palpate the vein after disinfecting the intended puncture site, it is recommended that the clinician also procure appropriate-sized sterile gloves.

Adult Modified Procedure for Blood Culture Collection Involving an Existing Central Line
2.

The physician orders will specify a collection site (or sites), such as a central line or an implanted port. The physician's order should

specify a specific line / port to draw from, but there should also
be an order for a venipuncture site. Orders for multiple draws without any venipuncture should be done through separate lumens if possible. Venipuncture sites must not be existing

peripheral access sites, nor in close proximity to those sites. Sites
should be free from existing skin conditions such as those consistent with eczema, excoriation, or any apparent underlying injury such as hematoma, scarring, or bruised areas.

Adult Modified Procedure for Blood Culture Collection Involving an Existing Central Line
3.

Discontinue administration of all infusates via the existing line prior to obtaining blood samples. If the tubing is

disconnected, put a new sterile end cap or connecting
device on the end of the tubing. Perform hand hygiene. Just prior to the procedure, it is important to wash hands using vigorous scrubbing under soap and water. Don examination gloves.

4.

Adult Modified Procedure for Blood Culture Collection Involving an Existing Central Line
5.

Inspect the collection bottles. Inspect each bottle for any apparent defects, and check the bottom part of the container for an intact sensor that should be a grayish-green color. Yellow color

indicates contamination of the culture medium,
and these bottles should be discarded.

Adult Modified Procedure for Blood Culture Collection Involving an Existing Central Line
6.

Prepare the collection bottles. The protective plastic covers are removed from the top of the septum. Because the septum is not sterile, it must be sterilized by cleansing with a 70% isopropyl

alcohol pad. Although bottles have been marked
with incremental levels, it is recommended to mark the desired fill level at 10 mL for adult specimens.

Adult Modified Procedure for Blood Culture Collection Involving an Existing Central Line
7.

Prepare the line for drawing. Attach a blunt cannula to the syringe containing normal saline, and scrub the end cap of the lumen that will be used to obtain the blood specimen for

approximately 10 seconds. Allow the area to air dry
for approximately 30 seconds. Insert the blunt cannula into the end cap, and flush the lumen of

the line with at least 3 � 5 mL of normal saline.
Discard the flush syringe in the sharps container.

Adult Modified Procedure for Blood Culture Collection Involving an Existing Central Line
8.

Draw from the specified site / port. Sterilize the port to be used with a 70% isopropyl alcohol pad and allow for a minimum of 30 seconds drying time without assistance such as fanning. Take care when drawing from the site so as not to contaminate the tip of the syringe used to inoculate the culture bottles. Inoculate the aerobic bottle first, then the aerobic bottle, being careful not to introduce air into the second bottle. Only fill the bottles to the 10 mL mark, do not overfill. Other lab draws should be deferred to the venipuncture site if ordered.

Adult Modified Procedure for Blood Culture Collection Involving an Existing Central Line
9.

Prepare the alternate site for venipuncture (unless orders are to only draw from the central line / port, skip to step 12). This is accomplished by scrubbing the site for a minimum of 60 seconds with an approved chlorhexidine gluconate swab. A circular area of approximately 3 cm in all directions from the intended puncture site should be disinfected. Allow the site to air-dry without assistance such as fanning. Dry times will vary according to manufacturer specifications, but typically, anywhere from 30 seconds to two minutes is recommended.

Adult Modified Procedure for Blood Culture Collection Involving an Existing Central Line
10.

Perform the venipuncture. Secure the needle in place with tape once proper placement is indicated. Do not re-palpate the vein. If there is a need to re-palpate, exam gloves need to be

swapped out for sterile gloves to prevent
recontamination of the site. Do not attempt to sterilize the tips of exam gloves.

Adult Modified Procedure for Blood Culture Collection Involving an Existing Central Line
11.

Fill the containers. Using the adapter cap, start by filling the aerobic bottle first. This requires pressing the adapter cap straight down on the septum to initiate blood flow. Avoid twisting or turning

because this may not allow the bottle to reseal
after blood capture. Fill only to the designated mark on the container, as overfilling may cause the

sample to indicate a false-positive reading. After
filling the aerobic container, repeat the process for the anaerobic bottle.

Adult Modified Procedure for Blood Culture Collection Involving an Existing Central Line
12.

Additional blood collection. If required, additional blood specimens can be collected before terminating the venipuncture. Always perform blood culture collection before collecting additional blood specimens.

13.

Terminate the venipuncture. Remove the tourniquet. Activate the safety device on the needle, and dispose of the needle in the sharps container.
Label the specimen bottles. Place bottles in a biohazard bag for delivery to the lab.

14.

Pediatric / Special Population Standard Procedure for Blood Culture Collection
1.

Gather necessary supplies for the blood culture collection process. There should be adequate materials to perform a minimum of two successful venipunctures at different sites. If there is an

anticipated need to re-palpate the vein after
disinfecting the intended puncture site, it is recommended that the clinician also procure

appropriate-sized sterile gloves. In cases where less
than 10 mL of blood is to be collected per specimen, pediatric culture tubes must be used.

Pediatric / Special Population Standard Procedure for Blood Culture Collection
2.

A minimum of two sites should be identified for venipuncture. These sites must not be existing peripheral access sites, nor in close proximity to those sites. Sites should be free from existing skin

conditions such as those consistent with eczema,
excoriation, or any apparent underlying injury such as hematoma, scarring, or bruised areas.

Pediatric / Special Population Standard Procedure for Blood Culture Collection
3.

Perform hand hygiene. Just prior to the procedure, it is important to wash hands using vigorous scrubbing under soap and water. Don examination gloves.

4.

Inspect the collection bottles. Inspect each bottle
for any apparent defects, and check the bottom part of the container for an intact sensor that

should be a grayish-green color. Yellow color
indicates contamination of the culture medium, and these bottles should be discarded.

Pediatric / Special Population Standard Procedure for Blood Culture Collection
5.

Determine the amount of blood to collect. Pediatric and special populations require determination of the amount of blood to be drawn for each sample. This may be determined directly by the physician, or in the case of pediatric patients, by utilizing the following guidelines:
a. b. c.

Newborns to 1 year ( less than 4 kg.): 0.5 to 1.5 mL per tube (at least 1 mL is generally preferred) Children ages 1 to 6 years: 1 mL per year of age Children weighing 30 to 80 lbs. (13.5 � 36.5 kg.): 5-10 mL per set

Pediatric / Special Population Standard Procedure for Blood Culture Collection
6.

Prepare the collection bottles. The protective plastic covers are removed from the top of the septum. Because the septum is not sterile, it must be sterilized by cleansing with a 70% isopropyl

alcohol pad. Mark the desired fill level previously
determined.

Pediatric / Special Population Standard Procedure for Blood Culture Collection
7.

Prepare the site for venipuncture. This is accomplished by scrubbing the site for a minimum of 60 seconds with an approved chlorhexidine gluconate swab in patients over two months of age. A 70% isopropyl alcohol pad should be utilized with patients of age two months or less. A circular area of approximately 3 cm in all directions from the intended puncture site should be disinfected. Allow the site to air-dry without assistance such as fanning. Dry times will vary according to manufacturer specifications, but typically, anywhere from 30 seconds to two minutes is recommended.

Pediatric / Special Population Standard Procedure for Blood Culture Collection
8.

Perform the venipuncture. Secure the needle in place with tape once proper placement is indicated. Do not re-palpate the vein. If there is a need to re-palpate, exam gloves need to be

swapped out for sterile gloves to prevent
recontamination of the site. Do not attempt to sterilize the tips of exam gloves.

Pediatric / Special Population Standard Procedure for Blood Culture Collection
9.

Fill the containers. Using the adapter cap, start by filling the aerobic bottle first. This requires pressing the adapter cap straight down on the septum to initiate blood flow. Avoid twisting or turning

because this may not allow the bottle to reseal
after blood capture. Fill only to the designated mark on the container, as overfilling may cause the

sample to indicate a false-positive reading. After
filling the aerobic container, repeat the process for the anaerobic bottle.

Pediatric / Special Population Standard Procedure for Blood Culture Collection
10.

Additional blood collection. If required, additional blood specimens can be collected before terminating the venipuncture. Always perform blood culture collection before collecting additional blood specimens.

11.

Terminate the venipuncture. Remove the tourniquet. Activate the safety device on the needle, and dispose of the needle in the sharps container.
Label the specimen bottles. Place bottles in a biohazard bag for delivery to the lab.

12.

Pediatric / Special Population Standard Procedure for Blood Culture Collection
13.

Repeat the process for collection of a second (or more) set(s). Starting with step 3, repeat the process. This may be done immediately unless physician orders state a specific time interval to

elapse between specimen collection sets.

References
Aronson, M. D., & Bor, D. H. (1987). Blood cultures. Annals of Internal Medicine, 106, 246- 253. Retrieved from MEDLINE with Full Text. Baer, D. M. (2001). Blood culture contamination rate [Journal article - questions and answers]. Medical Laboratory Observer, 33(12), 25. Retrieved from CINAHL Plus with Full Text. Bekeris, L. G., Tworek, J. A., Walsh, M. K., & Valenstein, P. N. (2005). Trends in blood culture contamination: A college of American pathologists q-tracks study of 356 institutions. Archives of Pathology & Laboratory Medicine, 129, 1222-1225. Retrieved from CINAHL Plus with Full Text.

References
Donnino, M. W., Goyal, N., Terlecki, T. M., Donnino, K. F., Miller, J. B., Otero, R. M., & Howell, M. D. (2007). Inadequate blood volume collected for culture: A survey of health care professionals. Mayo Clinic Proceedings, 82, 1069-1072. Retrieved from MEDLINE with Full Text. Ernst, D. J. (2004). Controlling blood-culture contamination rates. Medical Laboratory Observer, 36(3), 14-18. Retrieved from CINAHL Plus with Full Text. Eskira, S., Gilad, J., Schlaeffer, P., Hyam, E., Peled, N., Karakis, I...., & Borer, A. (2006). Reduction of blood culture contamination rate by an educational intervention. Clinical Microbiology and Infectious Diseases, 12, 818-821. doi: 10.1111/j.1469-0691.2006.01446.x

References
Gander, R. M., Byrd, L., DeCrescenzo, M., Hirany, S., Bowen, M., & Baughman, J. (2009). Impact of blood cultures drawn by phlebotomy on contamination rates and health care costs in a hospital emergency department. Journal of Clinical Microbiology, 47, 1021-1024. doi: 10.1128/JCM.02162-08 Geddie, P. (2009). Blood culture contamination: Results of a performance improvement team. Oncology Nursing Forum, 36(3), 27. Retrieved from CINAHL Plus with Full Text. Hall, K. K., & Lyman, J. A. (2006). Updated review of blood culture contamination. Clinical Microbiology Reviews, 19, 788-802. doi: 10.1128/CMR.00062-05 Halm, M., Hickson, T., Stein, D., Tanner, M., & VandeGraaf, S. (2011). Blood cultures and central catheters: Is the "easiest way" best practice? American Journal of Critical Care, 20, 335-338. doi: 10.4037/ajcc2011519

References
Howanitz, P. J. (2005). Errors in laboratory medicine: Practical methods to improve patient safety. Archives of Pathology & Laboratory Medicine, 129, 1252-1261. Retrieved from MEDLINE with Full Text. Kim, J. Y., & Rosenberg, E. S. (2011). The sum of the parts is greater than the whole: Reducing blood culture contamination [Editorial]. Annals of Internal Medicine, 154(3), 202-203. Retrieved from CINAHL Plus with Full Text. Kim, N., Kim, M., Lee, S., Yun, N. R., Kim, K., Park, S. W...., & Oh, M. (2011). Effect of routine sterile gloving on contamination rates in blood culture. Annals of Internal Medicine, 154(3), 145-151. Retrieved from CINAHL Plus with Full Text.

References
Mimoz, O., Karim, A., Mercat, A., Cosseron, M., Falissard, B., Parker, F...., & Nordmann, P. (1999). Chlorhexidine compared with povidone-iodine as skin preparation before blood culture: A randomized, controlled trial. Annals of Internal Medicine, 131, 834837. Retrieved from MEDLINE with Full Text. Ogden-Grable, H., & Ernst, D. J. (2004). Blood-culture contamination tips [Letters to the editor]. Medical Laboratory Observer, 4-5. Retrieved from CINAHL Plus with Full Text. Patton, R. G., & Schmitt, T. (2010). Innovation for reducing blood culture contamination: Initial specimen diversion technique. Journal of Clinical Microbiology, 48, 4501-4503. doi: 10.1128/JCM.00910-10

References
Roth, A., Wiklund, A. E., Palsson, A. S., Melander, E. Z., Wullt, M., Cronqvist, J...., & Sturegard, E. (2010). Reducing blood culture contamination by a simple informational intervention. Journal of Clinical Microbiology, 48, 4552-4558. doi: 10.1128/JCM.00877-10 Thompson, F., & Madeo, M. (2009). Blood cultures: toward zero false positives. Journal of Infection Prevention, 10(Supplement 1), s24-s26. doi: 10.1177/1757177409342143

Tokars, J. I. (2004). Predictive value of blood cultures positive for coagulase-negative staphylococci: Implications for patient care and health quality assurance. Clinical Infectious Diseases, 39, 333341. Retrieved from MEDLINE with Full Text.
Weinstein, M. P. (2003). Blood culture contamination: Persisting problems and partial progress. Journal of Clinical Microbiology, 41, 2275-2278. doi: 10.1128/JCM.41.6.2275-2278.2003

Total Parenteral Nutrition

(see pre-printed orders)

Purpose of TPN:
TPN

A

general indication is anticipation of undernutrition (< 50% of metabolic needs) for > 7 days. TPN is given before and after treatment to severely undernourished patients who cannot ingest large volumes of oral feedings and are being prepared for surgery, radiation therapy, or chemotherapy.

is the intravenous administration of essential nutrients and is initiated when the GI tract does not provide for adequate ingestion, digestion and absorption.

Components of TPN
TPN

may include a combination of sugar and carbohydrates (for energy), proteins (for muscle strength), lipids (fat), electrolytes, and trace elements. A TPN solution may contain all or some of these substances, depending on client's condition.

Nutritional

content: TPN requires water (30 to 40 mL/kg/day), energy (30 to 60 kcal/kg/day, depending on energy expenditure), amino acids (1 to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty acids, vitamins, and minerals

Fluid.

Fluid is an essential component of parenteral nutrition. Calories. Carbohydrate. Glucose is the main source Protein. This is delivered as a synthetic crystalline amino acid solution. Adverse effects of excess protein include a rise in urea and ammonia Intralipid. An oil-in-water emulsion derived from egg phospholipid, soyabean and glycerol. Minerals. Sodium, potassium, chloride, calcium, magnesium and phosphorus levels need to be closely monitored Trace Elements. Zinc, copper, manganese, selenium, fluorine and iodine are provided in a number of commercial TPN preparations. Vitamins. The daily requirements for both water and fat soluble vitamins can be provided in TPN

When

hanging TPN, confirm the TPN bag label with the original order form Standardized Bag Prescribing
Solutions

may be modified based on laboratory results, underlying disorders, hypermetabolism, or other factors.

Lipids:

Commercially available lipid emulsions are often added to supply essential fatty acids and triglycerides; 20 to 30% of total calories is usually supplied as lipids.

TPN Administration
Before

you administer TPN, look at the solution closely. It should be clear and free of floating material. Gently squeeze the bag or observe the solution container to make sure there are no leaks. Do not use the solution if it is discolored, if it contains particles, or if the bag or container leaks.

Tubing/Line: Because of high infection risk and compatibility issues, TPN is infused only through a dedicated lumen. CDC Guidelines state, "Designate one port exclusively for TPN if a multi-lumen catheter is used to administer parenteral nutrition." Label the lumen used for TPN to ensure that it is not used for other medications/fluids.

Because

TPN solutions are concentrated and can cause thrombosis of peripheral veins, a central venous catheter is usually required The solution is started slowly at 50% of the calculated requirements usually 1st 24hrs Insulin: The amount of regular insulin given (added directly to the TPN solution) depends on the blood glucose level

TPN

lines shall be used exclusively to administer TPN/PPN and shall not be accessed for any other reason (e.g., blood draws, piggybacking meds or other fluids) compatible medication is sometimes piggybacked with TPN (check policy) PPN may be infused through a peripheral or central VAD.

TPN

with or without lipid admixture administration sets changed Q48hrs (check policy) Filters for TPN (check policy) Filtration is aimed at filtering out particulate matter and microbes from infusates. (changed Q24hrs check policy) Lipid administration sets changed Q24hrs.

Patients

receiving TPN shall have their intake and output, blood glucose, and weight monitored according to physician order, or at least daily. A weaning period is necessary for all TPN infusions (does not include PPN). If TPN runs out, is not available, or the TPN line becomes dysfunctional, D10W shall be infused at the previously ordered TPN rate (check policy) A blood glucose level shall be checked 1 hour after D10W is started (check policy)

Prep

all TPN connections with alcohol vigorously for 510 seconds prior to entering Connect filter to the end of the TPN tubing, below the pump; change filter daily. Infuse TPN via infusion pump.

Monitoring
Progress

should be followed on a flowchart. Weight, CBC, electrolytes, and BUN should be monitored often (eg, daily for inpatients). Blood glucose should be monitored q 6 h until stable. Fluid intake and output should be monitored continuously. When the patient becomes stable, blood tests can be done much less often LABS: Monitor:



Na, K, Cl, HCO3, BUN, CR, Gluc, Mg, PO4, AST, ALT, alkaline phosphatase, triglycerides.

LABS:

Monitor:
Na, K, Cl, HCO3, BUN, CR, Gluc, Mg, PO4, AST, ALT, alkaline phosphatase, triglycerides. Liver function tests should be done. Protime Plasma proteins (eg, serum albumin)



(See individual facility protocol for lab and frequency)

Signs of infection
symptoms of a catheterrelated infection tenderness warmth irritation drainage redness swelling pain

PATIENT/CAREGIVER

Explain rationale for TPN therapy. Instruct patient/caregiver to report: �loose, wet or soiled IV dressing �pain at IV site �redness/swelling of IV site

The following symptoms may occur with TPN administration feet, fever or chills swelling of the hands,








stomach pain difficulty breathing rapid weight gain or loss increased urination upset stomach vomiting confusion or memory loss muscle weakness, twitching, or cramps





or legs thirst fatigue changes in heartbeat tingling in the hands or feet jumpy reflexes convulsions or seizures

Complications of TPN Therapy
Glucose

abnormalities are common. Hyperglycemia can be avoided by monitoring blood glucose often Abnormalities of serum electrolytes and minerals should be corrected by modifying subsequent infusionsVolume overload (suggested by > 1 kg/day weight gain) may occur when high daily energy requirements require large fluid volumes. Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in some patients receiving TPN for > 3 mo. The mechanism is unknown Adverse reactions to lipid emulsions (eg, dyspnea, cutaneous allergic reactions, nausea, headache, back pain, sweating, dizziness) are uncommon but may occur early

Hepatic

complications include liver dysfunction, painful hepatomegaly, and hyperammonemia Gallbladder complications include cholelithiasis, gallbladder sludge, and cholecystitis

Central Line Dressing Change

Central Line Dressing Change
Central


Venous Access Device: Dressing Change:
permanent tunneled long-term (Hickman, Broviac, Groshong) temporary non-tunneled single/multilumen (Arrow, Hohn, Cook) accessed subcutaneous implanted ports

non-tunneled long-term (PICC)

At

least every four (4) days for transparent dressings (Tegaderm, Sorbaview, and Opsite) At least every day, for any gauze dressing.
An

immediate dressing change is required for a wet, soiled or loose dressing. An occlusive dressing must be intact at all times. Do not reinforce loose dressings with tape; the dressing must be changed. Gauze may be added for patients who are diaphoretic or when there is bleeding or oozing at the catheter insertion site.

Assess

site and change dressing within 24 hours of catheter placement. For patients admitted with existing catheters, dressing change and site care must be done within 24 hours of hospital admission. DO NOT USE SITE UNTIL PLACEMENT HAS BEEN CONFIRMED

**Please see individual facility protocol**

STEPS KEY POINTS
1.

Explain procedure to patient/caregiver. 2. Perform hand hygiene and put on clean gloves. Place patient in supine position with head turned away from dressing site. 3. Remove dressing carefully and discard with gloves.

STEPS KEY POINTS
Never

use scissors when removing the dressing. Observe the site for redness, swelling or discharge, and integrity of any sutures.

4.

4.

Report signs of infection to MD.

5.

Repeat hand hygiene. --Alcohol-based foam may be used. 6. Open the sterile dressing change kit --Mask patient if indicated 7. Put on mask. 8. Put on sterile gloves.

9.

Use first alcohol swab stick to cleanse the skin around the catheter or needle insertion site. Use firm circular motion beginning at the insertion site and moving outward. X3, Include the entire area to be covered by the dressing. 2-3 inches. (apply friction and pressure)

10.

Repeat cleansing in the same manner with second alcohol swab. 11. Use third swab stick to cleanse any catheter or tubing that will be covered by the sterile dressing. Allow to dry.

12.

Use chlorhexidine applicator to cleanse skin around catheter or needle insertion site. Use firm circular motion beginning at the insertion site and moving outward to include entire area to be covered by the dressing

--Chlorhexidine should not be used for patients < 2 months of age or chlorhexidine-allergic patients.
13.

Allow chlorhexidine to air dry (at least 30 seconds, may take up to 2 minutes).

14.

Apply transparent (Tegaderm, Sorbaview, Opsite) occlusive dressing and change weekly. Must change immediately if wet, soiled or loose. --May use gauze dressing (gauze and tape or Mefix� or transparent dressing over sterile 2 X 2 gauze) as an alternative only if patient has an allergy to the transparent occlusive dressing.

Change

at least every other day or three times per week, (usually Monday, Wednesday and Friday). May use 2 x 2 gauze, folded, under port needle to prevent rocking. 15. Pleat transparent dressing around the tubing to insure occlusive dressing. 16. Change catheter cap

16.

Remove gloves. 17. Anchor catheter with tape to skin. --This helps prevent tension on insertion site and accidental dislodgement of catheter.

18.

Label dressing with date and nurse's initials.

DOCUMENTATION:

Record on Flow Sheet:

procedure site observations patient's tolerance patient instruction/understanding.

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