ADULT AND PEDIATRIC



LONG BEACH CITY COLLEGE

Associate Degree Nursing Program

ADN 22AL

Advanced Nursing Critical Care Life Span

COURSE SYLLABUS

for

ADULT LABORATORY

\

Edited by:

Sigrid Sexton, RN, MSN, FNP

( 2011 Long Beach City College Associate Degree Nursing Program, Long Beach CA 90808

ADN 22AL: ADVANCED NURSING CRITICAL CARE LIFESPAN SYLLABUS

ADULT LABORATORY BEHAVIORAL OBJECTIVES

Lab Content: ENDOTRACHEAL TUBES AND SUCTIONING 21.0

Suctioning the Ventilated Patient: Skill Lab Overview 21.1

Skill Assessment: Suctioning the Patient on a Ventilator 21.2

Lab Content: CLIENTS WITH MECHANICAL VENTILATION 22.0

Endotracheal Tube Guidelines 22.2

Mechanical Ventilation Vocabulary 22.4

Skill Lab Overview: Mechanical Ventilation 22.6

Skill Assessment: Mechanical Ventilator 22.7

Lab Content: MEDICATION ADMINISTRATION IN THE ICU 23.0

Medication Administration Procedures 23.1

IV Drip Calculation Practice 23.2

Lab Content: ARTERIAL, PULMONARY ARTERY AND CVP LINES 24.0

Arterial, Pulmonary Artery and Central Venous Pressure Lines 24.2

Review of Pathophysiology of the Left Ventricle 24.2

Lab Content: PHYSICAL ASSESSMENT OF THE CHEST 25.0

Physical Assessment Lab Notes 25.1

Lab Content: CHEST TUBES 26.0

Chest Tubes Lab Notes 26.1

Lab Content: PERFORMING A 12 LEAD ELECTROCARDIOGRAM 27.0

Skill Assessment: Obtaining a 12 Lead EKG 27.2

12 Lead EKG Lab Notes 27.3

Lab Content: MOCK CODE... ...28.0

Mock Code Exercise 28.1

Evaluation of Mock Code 28.2

Lab Content: EKG MONITORING SUBMODULE 29.0

Behavioral Objectives 29.1

Correlating the Conduction System with the Rhythm Strip 29.4

The EKG Paper 29.5

Identifying Waveforms 29.6

Counting Heart Rate 29.7

Placing EKG Leads 29.7

Cardiac Monitor Vocabulary 29.8

i.

Lab Content:

Orientation Behavioral Objectives for Intensive Care 30.0

Baseline Assessment of Universal Self-Care Requisites 30.1

Orientation to Critical Care Checklist 30.2

Behavioral Objectives for Group Leader Role 30.4

Critical Elements for Group Leader Role 30.5

Group Leader Worksheet for Intensive Care 30.6

Peer Evaluation Sheet 30.7

Nursing Care Plan 30.8

Medication and Laboratory worksheet 30.9

Behavioral Objectives: PACU/Cath Lab Experience 30.10

Behavioral Objectives: Emergency Department Experience 30.11

Guidelines for Case Study 30.12

Case Study Style 30.13

Case Study Rubric 30.14

ii.

LAB CONTENT: ENDOTRACHEAL TUBES/ TRACHEOSTOMIES AND SUCTIONING

1. Review concepts related to tracheostomies and suctioning from previous nursing courses including: cuffed and fenestrated tracheostomies, hazards associated with tracheostomies, principles and goals of suctioning, and methods of oxygen delivery.

2. Describe the similarities and differences between an endotracheal tube (ETT) and a tracheostomy tube.

3. Describe the care of the patient with an ETT, including precautions to be observed.

4. Discuss the hazards of instilling saline into the ETT or tracheostomy.

5. Demonstrate the proper techniques for suctioning patients on ventilators using an in-line closed suctioning system.

6. In the learning center, independently practice tracheostomy care of the ventilated patient. Be prepared to perform tracheostomy care in the clinical area.

7. Describe the rationale and the method for hyper-oxygenating a patient on a ventilator requiring suctioning.

8. Demonstrate suctioning of a ventilated patient using sterile technique according to the critical elements in the syllabus on page 22.1 and 22.2

REQUIRED ASSIGNMENTS:

Text: Brunner: 11th Edition pages 735-754

Urden, Stacy & Lough:5th Edition Chapter 16

Syllabus: Guidelines for caring for patients with Endotracheal Tubes

Article: Harm, M. “Instilling Normal Saline With Suctioning: Beneficial Technique or Potentially Harmful Sacred Cow?” American Journal of Critical Care. (2008). 17(5) 469-472

Video: Acute Care Skills: Suctioning Part 1 and 2

21.0

SKILL LAB OVERVIEW: SUCTIONING THE CLIENT ON A VENTILATOR

CRITICAL ELEMENTS:

1. Set correct pressure on suction source.

2. Verify patency of suction catheter.

3. Assure hyper-oxygenation of patient before and after suctioning.

4. Apply suction continuously only when withdrawing catheter for a maximum of fifteen seconds.

5. Protect patient and self from contamination.

6. Suction oral cavity as necessary

7. Complete all critical elements within two minutes.

HOW THIS SKILL WILL BE LEARNED:

1. Review of skill from previous coursework.

2. Read Brunner and Critical Care Text regarding care of ventilated patient and suctioning patient on the ventilator.

3. Participate in class discussion and demonstration.

TEACHER RESPONSIBILITIES:

1. In lab, demonstrate suctioning a client on a ventilator with an endotracheal tube or tracheostomy tube and be available for questions.

2. Test students according to critical elements.

STUDENT RESPONSIBILITIES:

1. Practice procedure in lab and independently asking for help as needed.

2. Perform procedure with 100% accuracy according to critical elements during clinical laboratory or in the clinical setting. The suction catheter kit rather than the in-line suction catheter is to be used for testing.

HOW THIS PROCEDURE WILL BE TESTED:

During on campus lab, student will demonstrate suctioning the ventilated patient with an ET or tracheostomy tube according to critical elements with 100% accuracy.

This is a previously learned skill. If the skill is failed, a progress note will be given. If the skill is failed a second time, the student will receive a mid-course clinical marginal. The clinical marginal will be removed if the skill is passed on the next attempt.

21.1

Skill Assessment: Suctioning the Client on a Ventilator

Name: _______________________________________________ Date ____________

Evaluator: ______________________________________________________________

|CRITICAL ELEMENTS |SAT |UNSAT |COMMENTS |

|1. Set correct pressure on suction source. | | | |

|2. Provide 100% FiO2 to patient before and after | | | |

|suctioning. | | | |

|3. Prepare suction equipment without contaminating | | | |

|catheter. | | | |

|3. Verify functioning of suction and patency of suction | | | |

|catheter. | | | |

|4. Apply suction continuously only when withdrawing the | | | |

|catheter for a maximum of 10 seconds. | | | |

|5. Protect patient and self from contamination. | | | |

|6. Suction oral cavity as necessary. | | | |

| | | | |

|7. Complete all critical elements within two minutes. | | | |

| | | | |

Retest: Pass ____________________ Fail ____________________

Evaluator: _________________________________ Date ____________________

21.2

LAB CONTENT: CLIENTS WITH HEALTH DEVIATIONS REQUIRING MECHANICAL VENTILATORS

1. Describe health deviations requiring mechanical ventilation. Describe the effect of ventilatory support on the universal self-care requisites of normalcy and the prevention of hazards.

2. Demonstrate knowledge of oxygen delivery systems including nasal cannula, non-rebreather mask, and venturi-mask.

3. Demonstrate ventilating a non-intubated patient with a Bag Valve Mask (BVM) device (ambu-bag) using one-person and two-person methods.

4. Compare and analyze the differences between the following ventilator modes: Assist-Control, IMV/SIMV, CPAP, and Pressure Control. Explain the following ventilator settings: Pressure Support, Inverse Ratio, and PEEP.

5. Describe the reasons for the high-pressure and low-pressure alarms to sound and the nursing interventions to correct them.

6. Describe the communication deficits associated with the patient on a ventilator and describe methods used to assist communication.

7. List the conditions required and the steps taken in weaning a patient from a ventilator. Describe the assessments found indicating that the patient is weaning successfully.

8. In the clinical setting, describe the ventilator settings of your assigned patient.

9. Describe the common complications of patients on mechanical ventilation and the prevention of those complications.

10. Describe the indications for and use of Bi-Pap as a means of avoiding the need for endotracheal intubation.

11. Be prepared to discuss the factors contributing to the high incidence of Ventilator Associated Pneumonia in the critical care unit. Describe the nurse’s role in preventing this complication.

12. Describe the effects of poor nutrition on the ventilated patient. Compare the nutritional needs of a cardiac patient with those of a patient with COPD.

13. Discuss the collaborative care required to manage the ventilated patient including the role of the Respiratory Therapist, Nutritionist, and Physician.

22.0

REQUIRED ASSIGNMENTS

Text: Brunner, 11th edition, pp. 735-754, and as needed

Urden, Stacy & Lough, 5th edition, Chapter 16

Syllabus: Mechanical Ventilators Worksheet

Mechanical Ventilation Vocabulary

Skill Lab Overview

Skill Assessment: Mechanical Ventilator

Learning Center:

CD-Rom: “Auscultation of Normal Breath Sounds”

Article: Garcia, R. “Reducing Ventilator-Associated Pneumonia Through Advanced Oral-Dental Care: A 48-Month Study” American Journal of Critical Care. (2009). 18(6) 523-534

22.1

Guidelines for Caring for Intubated and Ventilated Patients

Nursing Assessments:

1. Respiratory rate and character, breath sounds, use of accessory muscles. Skin color/ signs of cyanosis. Pulse oximetry readings.

2. Ventilator settings: Mode, Rate, Tidal Volume, and FiO2, Pressure Support, PEEP.

3. Depth of ET tube as measured by markings on ETT. (Ex: 23 cm at lipline) Notify the RN or RT immediately if this distance changes since it may indicate that the tube is coming out or is inserted too far.

4. Condition of tape securing the endotracheal tube.

5. Presence of a bite block or airway. If the patient bites on the tube, an oral airway may be used as a bite block. Care must be taken to give good mouth care and remove the bite block as soon as possible.

6. Condition of oral mucous membranes and lips. Observe for open areas and broken teeth.

7. ABG results and trends. Go back several days to gain understanding from the trends in ABGs. ABGs are to be interpreted as a group and not read as isolated values.

Nursing Care:

1. Cuff remains inflated at all times. If an air leak is heard, notify the RN or RT immediately.

2. Orally or nasally intubated patients are always NPO. They may be fed by an NG or Gastrostomy tube.

3. Frequent mouth care is necessary for these patients, at least every four hours. Lack of mouth care contributes to Ventilator Associated Pneumonia.

4. The ETT tape is changed as needed. The ETTis changed from one side of the mouth to the other on a regular basis to avoid erosion of the mucous membranes. The Respiratory Therapist changes the tape and the position of the ETT.

22.2

5. When tube feedings are ordered, precautions are taken to minimize the risk of aspiration:

a. Aspirate and measure the stomach contents every four hours. Chart the residual on the flow sheet. If this residual is high the tube feedings may be held.

b. The head of the bed must be elevated while tube feedings are running. If the patient’s head must be lowered, the tube feeding is to be turned off prior to lowering the head of the bed.

6. The endotracheal tube goes between the vocal cords, so the patient will not be able to speak. The patient can write, use hand signals, answer with yes or no, or mouth words to communicate.

22.3

Mechanical Ventilation Vocabulary

Modes:

CMV or A/C: (Controlled Mandatory Ventilation or Assist/Control) Every breath is controlled by the machine, even the breaths initiated by the patient. The ventilator will be set at a certain rate, but the patient can breathe faster than this and each time he initiates a breath over this set rate, the ventilator will deliver a breath.

IMV (Intermittent Mandatory Ventilation) This mode also delivers a set number of machine-volume breaths, however if the patient initiates breaths at a rate higher than this set rate, the patient will be allowed to take breaths at his own volume. You can remember this by saying that the machine delivers breaths intermittently.

CPAP (Continuous Positive Airway Pressure) The machine is providing some support pressure (measured as Pressure Support), but is basically letting the patient breathe and is measuring the rate and volume of these breaths.

Other settings:

Rate The set rate of mechanical ventilation. The patient can breathe faster than this rate. The patient’s total rate of breathing will be counted by the ventilator, so you will see the set rate and the patient’s respiratory rate as separate readings.

Tidal Volume: The volume of air delivered to the patient with each machine breath, expressed in ml. ex: 700 ml of tidal volume.

FiO2: The percentage of oxygen delivered to the patient. This stands for Fraction of Inspired Oxygen.

PEEP (Positive End Expiratory Pressure) The pressure kept in the lungs by the ventilator at the end of expiration.

Pressure Support: The supporting pressure given to a patient to back up each patient breath. This setting does not apply to machine breaths and is only relevant for the patient on IMV or CPAP.

Peak Inspiratory Pressure: A measure of the highest pressure in the lungs during a ventilator breath. This pressure will go up suddenly if there is a pneumothorax or a tracheal tube blockage or gradually in the case of ARDS or abdominal compartment syndrome.

T-piece: An adapter used to deliver oxygen and humidification to a patient with an endotracheal tube or tracheostomy. It consists of ventilator tubing attached to the endotracheal tube (ETT) or tracheostomy from the side. The end is left open and the ventilator is not connected.

Intubate, extubate: To insert an endotracheal tube or remove an endotracheal tube.

22.5

SKILL LAB OVERVIEW: MECHANICAL VENTILATION

CRITICAL ELEMENTS:

1. Identify the ventilator mode, compare the different modes.

2. Identify the FiO2.

3. Identify the respiratory rate setting and the patient’s respiratory rate.

4. Identify the tidal volume setting.

5. Identify the presence of PEEP and give the setting.

6. Identify high and low pressure indicators an describe possible causes of each.

7. Complete all critical elements within five minutes.

HOW THIS SKILL WILL BE LEARNED:

Reading Assignments from Course Syllabus. Discussion of ventilator settings with clinical instructor and RN on the intensive care unit.

STUDENT RESPONSIBILITIES:

1. Practice procedure in lab and independently on own time asking for help as needed.

2. Perform procedure with 100% accuracy according to critical elements in the clinical setting.

22.6

Long Beach Community College District

LONG BEACH CITY COLLEGE

Associate Degree Nursing Program

SKILL ASSESSMENT: MECHANICAL VENTILATOR

Student(print): Date:

Evaluator:

Identify a patient in the ICU on a ventilator. Be prepared to review the patient’s ventilator setting with your clinical instructor and demonstrate understanding of the following modes and settings.

|CRITICAL ELEMENTS |SAT |UNSAT |COMMENTS |

|Identify the ventilator mode and describe. | | | |

| | | | |

|Identify the FiO2. | | | |

| | | | |

|Identify the ventilator respiratory rate setting. | | | |

| | | | |

|Identify the patient’s respiratory rate. | | | |

| | | | |

|Identify the Tidal Volume setting. | | | |

| | | | |

|Identify the presence of PEEP. | | | |

|Identify low and high pressure alarms and describe likely causes of | | | |

|each. | | | |

|Complete all critical elements within five minutes. | | | |

| | | | |

RETEST: Date: Evaluator:

Comments:

22.7

LAB CONTENT: BEHAVIORAL OBJECTIVES FOR MEDICATION ADMINISTRATION IN CRITICAL CARE

1. Come to class prepared to demonstrate knowledge of the following drugs commonly given as drips in the critical care unit. Include effects on preload, afterload, blood pressure, and heart rate when applicable.

Dopamine Nitroglycerin

Dobutamine Sodium Nitroprusside (SNP)

Levophed Morphine

Heparin Versed, Ativan

2. Review IVP administration from previous courses. Be familiar with “Procedure for administering bolus (IVP) medication” before coming to class. Describe potential hazards to life and well-being associated with IV push infusions.

3. Demonstrate a method of calculating IV infusion rates in the critical care unit according to milligrams or micrograms per kilogram per minute (mg/kg/min or mcg/kg/min). Demonstrate the ability to determine infusion rates in mL/hr based on medication concentration and kilogram weight of the patient.

4. Discuss the health deviations associated with stopping or infusing into a line containing the drugs listed in behavioral objective 1.

5. Discuss the collaborative role nursing has with medicine in regulating IV vasopressors according to vital signs and pressure line readings. Describe the development of protocols in establishing titration limitations for vasopressor drugs.

ASSIGNMENTS:

Text:

Davis’s Drug Guide for Nurses

23.0

Procedure for administering bolus (IVP) medication

1. Determine expected reaction and any potential side effects or adverse reactions.

2. Determine amount of time over which the medication is to be pushed, port to be used to give medication, type of vein, and compatibility with existing IV fluids and medications.

3. Prepare medication in syringe and a syringe(s) of normal saline to flush before and after if the drug is not compatible with running fluids and medications.

4. Consider implications of IV rate if medication is to be infused into a running IV line.

5. Determine incremental rate of infusion of medication and give medication slowly while watching a clock with a second hand or seconds in digital.

6. Observe for the expected reaction and stop infusion appropriately.

7. Flush line before and after with normal saline or appropriate flush and clamp the line above the port being used if the drug is not compatible. Consider that the line does not have a flowing IV when administering the medication and flush.

Calculation of IV drip medication

Mcg/kg/minute

1. Determine concentration of medication. Example Dopamine 400 mg/ 500 mL.

2. Determine micrograms in each mL by determining the mcg in the IV fluids and then dividing this number by the mL volume of the IV.

(A handy trick: If you determine the number of mg of medication in a full liter of fluids, this will give you the mcg in 1 mL.)

3. Divide this number by the weight in kilograms. (1 kg = 2.2 lbs = 1 liter)

4. Divide this by 60 to give the rate per minute. The resulting number is the drip factor or X factor. This number represents the dose of drug at a rate of one mL per hour.

5. Multiply by the cc/hr rate to determine the mcg/kg/minute rate.

6. If the drug is not to be given by kilograms, skip step 3. If given “per hour” instead of “per minute”, skip step 4. If given in mg instead of in mcg, determine the mg in a mL and not the mcg in a mL.

23.1

IV drip dose calculations practice

1. You need to administer 800 U/hr of Heparin. The label states there are 25,000 U/500 ml of fluid. Calculate the rate you will set on the IV pump.

2. At the beginning of your shift, you note that Theophylline 1gm/ 500ml is infusing at 20 ml/hr. You have an order to administer Theophylline at 40 mg/hr. Is the rate correct?

3. Your patient has been having chest pain and is receiving 30 ml/hr of Nitroglycerine 50 mg / 250 ml of D5W. You are going to notify the physician that the Nitroglycerine is not controlling the chest pain. You need to calculate the dose (mcg/min) the patient is receiving.

4. Your patient's blood pressure has been unacceptably low (70's/40's). He is receiving dopamine 800 mg/D5W 250 ml at a rate of 5 ml/hr. You have increased the dopamine to 12 ml/hr and need to talk to the physician. In order to discuss the dopamine, you need to know the dose the patient is receiving. (Note: weight is 70 kg. and you will need conversion from hours to minutes.)

5. The physician orders you to start dobutamine at 10 mcg/kg/min. You have a premixed bag with 1000 mg/500 ml D5W. What rate will you infuse the dobutamine?  Your client weighs 50 kg.

23.2

Answers to 1st six questions:

1. 16 ml/hr (Use D/H times Q)

2. 20 ml/hr (the correct rate) (D/H times Q works to calculate this)

3. 100 mcg/min (Figure out the mcg/ml (divide then convert from mg to mcg), then divide by 60 for the minutes to get the drip factor and multiply this by the ml/ hr rate.)

4. 9.14 mcg/kg/min (Calculate the mcg/ml, divide by kg, divide by 60 for minutes, then multiply by the cc/hr rate.)

5. 15 ml/hr (Calculate mcg/ml, divide by kg, divide by 60, then divide this drip factor into the desired dose to get the cc/hr rate.)

|Another set of questions: |

|Ms. Pibb was admitted to ICU with renal failure and has developed multiorgan system dysfunction. Her dry weight* was 60 kg. She is |

|receiving the following medications: |

|Nitroglycerine 50 mg/250 ml D5W at 20 mcg/min |

|Dopamine 800 mg/250 ml D5W at 8 mcg/kg/min |

|[pic] |

|What rate (ml/hr) do you expect the Nitroglycerine to be infusing? |

|What rate (ml/hr) do you expect the Dopamine to be infusing? |

|The physician orders Amrinone loading dose of 0.75 mg/kg to be given over 3 minutes. What dose of Amrinone will Ms. Pibb receive? |

|After the loading dose you start the Amrinone at 5 mcg/kg/min.  If you have 250 mg/50 ml NS, what rate (ml/hr) will you start the |

|Amrinone infusion? |

|The physician orders the Dopamine to be decreased to a renal dose of 2 mcg/kg/min. What rate (ml/hr) will you infuse the Dopamine? |

|The Amrinone is increased to 5 ml/hr. You know the maximum dose of Amrinone is 10 mcg/kg/min. What is the maximum rate (ml/hr) you |

|can infuse the Amrinone? |

|23.3 |

| |

|Two hours later, you need to notify the physician of the Ms. Pibb's condition.  The Amrinone is now infusing at 17 ml/hr. What dose|

|will you tell the physician she is receiving? |

|Ms. Pibb begins complaining of chest pain. You increase the Nitroglycerine to 15 ml/hr. What dose (mcg/min) is she now receiving? |

| |

| |

| |

| |

| |

| |

|Answers to above set of questions: |

|6 ml/hr |

|9 ml/hr |

|45 mg |

|3.6 ml/hr |

|2.3 (2) ml/hr |

|7.2 (7) ml/hr |

|23.6 mcg/kg/min |

|50 mcg/min |

*Dry weight is the patient’s weight without extra fluids from their illness in their bodies. We use the admission weight for non-CHF patients and the known dry weight of the patient for CHF patients and renal patients. Dry weight is the weight that should be used when calculating doses.

Some IV pumps deliver fluid in 10ths, which means we can give a fluid at 13.2 ml/hr. If the pumps only deliver in ml/hr and not in 10ths, then you need to round the dose. We will assume that pumps deliver rounded to the whole number on our quizzes.

23.4

LAB CONTENT: HEMODYNAMIC HEALTH DEVIATIONS: ARTERIAL, PULMONARY ARTERY AND CENTRAL VENOUS PRESSURE LINES

1. Review the similarities and differences between short and long-term central venous catheters. Describe the complications associated with central venous catheters and the measures used to prevent them.

2. Describe the hazards associated with Peripherally Inserted Central Catheters (PICC) and the procedures used to prevent these hazards. Discuss the frequency and method used to flush PICC catheters.

3. Describe the use of transducers including the equipment needed, preparation before insertion of catheters into high pressure vessels, and the maintenance of transducer systems including leveling, zeroing, and frequency of line and site changes.

4. Describe the arterial catheter, including sites of insertion, normal values, and level of the transducer. Identify two uses for the arterial line.

5. Describe Central Venous Pressure monitoring including sites of insertion and normal pressure readings. Describe implications of high and low readings.

6. Describe the pulmonary artery (Swan Ganz) catheter including ports, pressure and cardiac output readings and normal values for the cardiac output and various pressures.

7. Describe the hemodynamic changes and health deviations commonly associated with congestive heart failure, cardiac tamponade, and septic shock.

8. Identify the student nurse’s role in maintaining and working with patients who have central, arterial and/or pulmonary artery catheters. Include the educative/ supportive role of the nurse.

9. Describe the hazards to life and well-being associated with central lines including pulmonary artery catheters and arterial lines.

24.0

ASSIGNMENTS:

Text: Brunner, 11th edition,: pp. 790-792, and as needed.

Urden, Stacy & Lough, 5th edition, pp. 134-150, and as needed.

Syllabus: Worksheet:

Arterial and Central Venous Catheters

Learning Center: Video #74: Cardio Vascular Nursing Principles of Hemodynamics Monitoring

24.1

PERIPHERAL ARTERIAL, PULMONARY ARTERY

AND CENTRAL VENOUS ACCESS DEVICES

|Peripheral Arterial |Pulmonary Artery |Central Venous Access Devices |

|WHAT |Catheter tip in pulmonary artery. Proximal |Catheter in a central vein. |

|Catheter in peripheral artery. |port reads CVP. |Examples: Triple Lumen, PICC |

|Pressure in artery read by transducer, |Distal port reads the pulmonary artery |Tunneled: Groshong, Porta- |

|displays on monitor. |pressure, and when balloon inflated, the |cath, Broviac, Hickman |

| |wedge. | |

|WHY |CVP (proximal port): Detects high central |Can be used to give IV fluids, meds, TPN, |

|1.To read B/P continuously |venous pressure: CHF or tamponade |blood. |

|2. To draw ABGs frequently |Wedge: determines left ventricular end |Also used to obtain CVP pressure reading, |

| |diastolic pressure: high = heart failure or|detects hyper/hypo-volemia |

| |tamponade | |

| |Measures Cardiac Output | |

|WHERE IT ENTERS |Internal jugular or subclavian through the |PICC: large veins of arm |

|Peripheral Artery: radial, femoral, or |superior vena cava, right atria, right |Triple lumen catheter: Subclavian or |

|dorsalis pedis (foot). |ventricle, to the pulmonary artery |Internal Jugular |

| | |Tunneled catheters: Subclavian |

|KIND OF BLOOD | | |

|Arterial - Oxygenated |Mixed venous - from distal port |Venous |

|NORMS |PA systolic = 20-30 mm Hg |CVP Pressures: |

|same as cuff pressure |Diastolic = 10-15 mm Hg |SVC - 6-12 cm H20 |

| |Wedge (PWP, PAW, PCWP) |(Superior Vena Cava) |

| |= 8 to 12 mm Hg |RA - 0-5 cm. H20 |

| |CVP: 2 to 6 mm Hg |(Right Atria) |

|EQUIPMENT |Same as the arterial line, plus lines to |IV solution and tubing |

|Heparinized IV solution (lOOOu/500cc D5W) |keep prox and cordis ports open. |Same as arterial line if used to measure |

|Or Normal Saline |Distal - Pulmonary Artery |CVP. |

|Pressure cuff (to 300 mm/Hg.) |Balloon – reads Wedge through the distal | |

|Pressure tubing with transducer |port when inflated. | |

| |Thermistor – needed to read CO | |

| |Proximal – reads CVP, used for fluids | |

| |Cordis (Introducer catheter)-superior vena | |

| |cava, used for fluids, not used for | |

| |pressure readings. | |

|KEY NURSE TASKS |NO MEDS in distal port of the PA catheter, |Consent must be signed |

|1. Monitor B/P |(only proximal port or cordis) |X-ray check for placement |

|2. Change dressings daily to prevent |Monitor for a wedge wave form. |Possible complications: |

|infection. |The catheter can be in a wedge | |

|3. Prevent disconnection, clotting, |position without the balloon being |1. Sepsis |

|bleeding-keep the catheter visible. |inflated. In the wedge position a segment |2. Air embolism |

|4. Keep level of the transducer at the site|of lung is getting no blood flow and can |3. Venous thrombosis |

|of entry. |infarct the area causing severe hemoptysis.|4. Catheter rupture. |

|When discontinuing the art line hold FIRM | | |

|pressure for 5-15 minutes followed by a | | |

|pressure dressing. | | |

24.2

LAB CONTENT : PHYSICAL ASSESSMENT OF ICU PATIENT

1. Describe different methods for assessing patients including head-to-toe, systems approach, and Orem’s Universal Self-Care Requisites as organizing frameworks. Describe the advantages and disadvantages of the use of each method in medical/surgical, critical care, and the emergency department.

2. Describe the order of assessment (observation, auscultation, percussion, palpation, and deep palpation) and the rationale for this order.

3. Independently review prior to class the physical assessment of the following systems:

Neurological

Cardiovascular

Respiratory

Integumentary

Gastrointestinal

Urinary

Musculoskeletal

4. Be prepared to chart normal findings and health deviations on the flow sheet of the assigned critical care unit.

5. Be prepared to demonstrate the correct location for auscultation of various heart and lung sounds.

6. Document the physical assessment on Nursing Care Plans daily using “Baseline Assessment of Universal Self-Care Requisites” (p. 30.1) as a format. Chart appropriately on the ICU flow sheet under the guidance of the assigned RN.

7. Describe methods of assessing pain in the intubated, pharmacologically paralyzed, confused, or semi-conscious patient.

ASSIGNMENTS:

Brunner 11th Edition pp 798-804 and as needed

Urden, Stacy & Lough, 5th edition pp85-89, 121-133, 255-267, 327-354, 379-385, 419-423

CD-Rom: “Auscultation of normal breath sounds”

Videos: “Assessing Breath Sounds” (#17)

“Assessment Review Series: Cardiac System” (#21)

25.0

LAB CONTENT: CHEST TUBES

1. Independently review the anatomy and physiology of pneumothorax, hemothorax, and cardiac/thoracic surgery. Describe the clinical manifestations and health deviations indicating the need for a chest tube.

2. Independently review the components of an underwater seal chest tube drainage system. Be prepared to discuss the three chambers of a chest tube drainage system.

3. Compare normal chest tube drainage in various situations including cardiothoracic surgery, hemothorax, pneumothorax and empyema.

4. Demonstrate knowledge of chest tubes in the clinical area.

5. Discuss the educative/ supportive role of the nurse for the patient with a chest tube including during insertion and removal.

REQUIRED ASSIGNMENTS:

1. Text: Brunner 11th Edition: 758-763, and as needed

Urden, Stacy & Lough, 5th edition, as needed.

2. Videos: Airway Management: Chest Tubes

Basic Clinical Skills: Insertion and Management of chest tubes.

26.0

LONG BEACH CITY COLLEGE

Associate Degree Nursing Program

ADN 22AL – Advanced Nursing Critical Care Life Span

SKILL LAB: PERFORMING A 12 LEAD ELECTROCARDIOGRAM

BEHAVIORAL OBJECTIVES

1. Review the topographical anatomy of the chest wall, identifying specific landmarks and reference lines used to locate the six chest leads (V1 through V6) of the standard electrocardiogram.

2. Describe the position of the patient for a resting ECG, including environmental factors that may affect the quality of the tracing.

3. Discuss the importance of correct placement of the 12 ECG leads. Discuss the importance of having clean equipment for the test and common ways to clean the equipment.

4. Describe placement of the 12 leads of the ECG.

5. Following the operating instructions for the specific ECG machine, run a 12 lead ECG strip.

6. Describe the qualities of a good ECG tracing including how to recognize and correct a wandering baseline and artifact associated with muscular movement. Bring examples of artifact on EKG tracings from the clinical setting. Be prepared to identify artifact on an EKG tracing.

7. State the rationale for and describe methods of removal of pads from the client’s skin when the tracing has been completed.

HOW THIS SKILL WILL BE LEARNED

1. Discussion and demonstration of a procedure for obtaining a 12 lead ECG strip in campus lab.

2. Practice in the skills lab in teams of three students, under skills lab monitor supervision, to obtain one acceptable 12 lead ECG tracing.

3. Assignments:

Brunner and Suddarth, 11th edition, p. 824-828.

27.0

TEACHER RESPONSIBILITIES

1. Describe and demonstrate the skill of obtaining a 12-lead ECG.

2. Be available for questions during practice lab.

STUDENT RESPONSIBILITIES

1. Form groups of three students to practice the skill of obtaining a 12 lead ECG.

2. Sign up for practice time when the skills lab teacher is available. The ECG machine is expensive and must be kept in locked storage when the skills lab teacher is not present.

3. Assist each other to practice placing ECG leads to obtain an acceptable ECG strip.

HOW THIS PROCEDURE WILL BE TESTED

No formal testing will be done. Each group of three students must submit one acceptable ECG tracing within one week after the 12 lead ECG content presentation in the Lab section of the class.

27.1

Long Beach Community College District

LONG BEACH CITY COLLEGE

Associate Degree Nursing Program

SKILL ASSESSMENT: OBTAINING A 12 LEAD ELECTROCARDIOGRAM

Student name: Date:

Student name: _____________________________

Student name:_____________________________

| CRITICAL ELEMENTS |SAT |UNSAT | COMMENTS |

|Explains procedure to client and assures that equipment is clean. | | | |

|Places four limb leads correctly. | | | |

|Places six chest leads, V1 through V6, correctly, using bony | | | |

|landmarks. | | | |

|Following the instructions on the 12 lead ECG machine, runs a 12 lead| | | |

|ECG strip that does not have a wandering baseline or muscle movement | | | |

|artifact. | | | |

|Cleans the client's skin after removing the ECG leads. | | | |

|Cleans the ECG machine and replaces neatly. | | | |

Skills Lab Instructor:___________________

27.2

Lab Content: BEHAVIORAL OBJECTIVES FOR TREATMENT OF CARDIAC ARREST

1. Identify criteria for assessing for presence of cardiac and/or respiratory arrest.

2. Demonstrate appropriate safety measures when using the cardiac defibrillator. Describe health deviations associated with incorrect use.

3. Demonstrate the ability to prioritize interventions during the initial stages of a code.

4. Identify on a rhythm strip the following life threatening arrhythmias:

Symptomatic bradycardia

Symptomatic tachycardia

Ventricular tachycardia

Ventricular fibrillation

Asystole

5. Demonstrate the appropriate interventions for the dysrhythmias listed in behavioral objective #4.

REQUIRED ASSIGNMENTS:

Text: See Cardiopulmonary Resuscitation lecture.

Syllabus: Mock Code Exercise

Evaluation of Mock Code

Web sites:

28.0

MOCK CODE EXERCISE

The problem: You are making rounds on your patients. You enter Mrs. Smith’s room and note that she is pale and unresponsive. Prioritize the following activities. You will work with the other lab students to post these activities on the whiteboard in the correct order.

The Choices: Rank:

Read and interpret the rhythm __________

Press the code blue button __________

Move the patient in the next bed out of the room __________

Check the pulse __________

Prepare for intubation __________

Start the resuscitation record __________

Call for help __________

Get the Ambu-bag and ventilate the patient __________

Call the attending physician and family __________

Check for respirations __________

Attach the EKG leads __________

Start an IV (if one isn’t already in) __________

Set up the suction __________

Start Compressions __________

Bring Crash Cart into the room __________

Start Ventilations __________

Give medications __________

Place the backboard under the patient __________

Connect the oxygen to the ambu-bag __________

28.1

EVALUATION OF MOCK CODE

Observer:__________________________

Student Nurses in the scenario: ____________________

In the debriefing after the Mock Code, you will be asked to discuss the following aspects of the code.

Effective evaluation and treatment:

Did students recognize changes in symptoms needing immediate attention and respond efficiently and effectively to assess and treat the patient?

Were standing orders followed in treating the patient?

Safety measures:

Were signs and symptoms of changes in condition noticed quickly and responded to?

Did students recognize potential hazards and respond appropriately?

Were gloves and protective equipment worn appropriately?

Were actions by the team so chaotic that team member safety was at risk? Was the room free of trip hazards? Was patient safety maintained at all times?

Were correct safety measures taken when using the defibrillator?

Communication:

Was the level of assertiveness and assuredness adequate for effective communication?

Were there instances of a team member taking over to the point of not listening to other team members?

Was there good team work? Did members work together for a common goal?

Was the full nursing process followed at each stage of decision making?

Was there adequate assessment before treatment was initiated including carotid pulse checks, blood pressure, and assessment of respirations?

Do you have any suggestions for improvement for the code team?

28.2

|Expected Behaviors |What Actually Happened |Suggestions for Improvement |

|First Student on Scene: | | |

|Assessed unresponsiveness | | |

|Called for help after appropriate | | |

|assessments | | |

|Crash Cart moved to room after cord | | |

|unplugged from wall | | |

|Patient positioned flat, furniture cleared | | |

|away as necessary | | |

|Backboard placed under patient | | |

|Airway opened and presence of ventilation | | |

|assessed | | |

|Ventilatory Assistance started by ambu-bag | | |

|as soon as possible | | |

|Carotid or femoral pulse checked initially,| | |

|at intervals, and after each change in | | |

|rhythm | | |

|Compressions started after pulse absence | | |

|confirmed, compressions continued with | | |

|minimal interruptions | | |

|Technique for compressions adequate, | | |

|confirmed by pulse check during | | |

|compressions | | |

|EKG leads placed as soon as possible | | |

28.3

|Rhythm assessed efficiently while | | |

|compressions stopped | | |

|Rhythms correctly identified | | |

|The treatment for each dysrhythmia was | | |

|correct | | |

|Peripheral line started, fluid hung before | | |

|medications given. | | |

|Code recorder established; time, rhythms, | | |

|medications, defibrillation with joules | | |

|recorded. | | |

|Defibrillations given safely: | | |

|Gel pads used. | | |

|“All Clear” command given | | |

|All students responded to all clear | | |

|including student with Ambu-bag. | | |

|Group dynamics were satisfactory: Everyone | | |

|felt they were heard, no input was ignored,| | |

|chaos was minimal. | | |

28.4

Long Beach Community College District

LONG BEACH CITY COLLEGE

Associate Degree Nursing Program

Cardiac Monitor Submodule Behavioral Objectives

I. INTRODUCTION

A. Purpose

This submodule is designed to guide the student in acquiring the basic knowledge needed to read and interpret cardiac rhythm strips.

B. Method

It is recommended that the student first review the behavioral objectives and the submodule content along with the web resources. Video #215 in the Learning Center, “Reading ECG Rhythm Strips” can also be viewed. It is only necessary to view the section that covers the basics of reading rhythm strips and the beginning of the process for reading the strips, the first 15 minutes or so. This basic content is also presented in the textbooks. The courseware developed by Sigrid Sexton can be used to practice what has been learned.

It is important to concentrate on learning the basics at this stage in learning how to read EKG rhythm strips. Once you can recognize the parts of the rhythm strip, it will be much easier to recognize abnormal rhythms. If there are any questions or concerns, Sigrid can be contacted by email at ssexton@lbcc.edu.

II. RESOURCES

A. Cardiac Monitoring Submodule, pp. 17.4 to 17.8 of this syllabus.

B. Learning Center:

• Video #215: "Reading ECG Rhythm Strips”: The first 15 minutes are the most important content for the submodule.

• Computer Assisted Instruction: "EKG Rhythm Strip Recognition Courseware" written by Sigrid Sexton

C. Textbooks:

Brunner, Textbook of Medical-Surgical Nursing, (12th ed), pp. 721-727 (through Sinus Arrhythmia).

Urden, Stacy & Lough, 5th ed, pp. 137-142

D. Web Sites (these sites are linked on the 22A web page)

Wikipedia: Electrical conduction system of the heart

YouTube videos:



29.0

III. BEHAVIORAL OBJECTIVES

A. Describe the location and function of the parts of the cardiac conduction system:

a. SA node (Sino-atrial node)

b. Atrial Conduction Tissue

c. AV node (Atrioventricular node)

d. Ventricular Conduction Tissue

i. Bundle of His

ii. Bundle Branches

iii. Purkinje fibers

B. Describe the relationship between the conduction of electricity through the heart and the mechanical event of cardiac contraction.

C. Describe depolarization and repolarization. Relate depolarization and repolarization to systole and diastole.

D. Describe the EKG paper markings and their values:

a. The distance between the vertical lines and along the horizontal axis (time)

b. The distance between the horizontal lines and along the vertical axis (amplitude or voltage)

c. Small light-lined squares

a. Horizontal Axis: 0.04 seconds

b. Vertical Axis: 0.5 millivolts

d. Large heavy-line squares

a. Vertical Axis: 0.20 seconds (1/5 of a second)

e. Three-second time segment

f. Six-second time segment

E. Identify the following parts of the EKG Rhythm and correlate them to the parts of the conduction system described in Behavioral Objective A. State the normal interval for the PR interval and the QRS complex.

a. P wave

b. PR interval

c. QRS complex

d. T wave

e. Isoelectric line

F. Identify the waveforms on an EKG strip.

G. List three different methods for counting heart rate on EKG paper and count the heart rate on sample strips.

29.1

H. Demonstrate the ability to measure PR intervals and QRS complexes on an EKG strip.

I. Systematically evaluate EKG rhythm strips. Be prepared to identify normal sinus rhythm, sinus tachycardia and sinus bradycardia.

IV. EVALUATION OF SELF-LEARNING MODULE

A. The criteria for successful completion of this submodule is the submodule test. A score of 85% or better is required to pass the test on the first try.

B. An appointment to take the exam is made in the Learning Center. The submodule test may be taken three times with the required scores on the second and third attempts being 88% and 90% (see Submodule policy).

a) A student who fails the Self-Learning module test for the third time

b) Will be given a progress note

c) Must complete the behavioral objectives in writing and turn them in to the instructor at a time specified by the instructor.

d) The submodule test must be taken until successfully completed.

C. A student who does not take a submodule test within the time frame will receive a progress note indicating a course of action to be determined by the teaching team.

D. If the submodule is not passed, a course grade of “incomplete” will be given.

29.2

Correlating the Conduction System with the Rhythm Strip

The whole process of cardiac contraction starts with firing of the SA node, the pacemaker of the heart. Electricity is then conducted through the atrial conduction tissue resulting in contraction of the atria, then through the AV node where the process is slowed a bit before it hits the ventricular conduction system and causes the ventricles to contract. What we see on the EKG rhythm strip correlates with this process of cardiac conduction. The P wave is produced by electricity coming from the atrial conduction system and the QRS complex is produced by electricity coming from the ventricular conduction system. This electrical event causes the mechanical event of cardiac contraction.

[pic]

[pic]

29.3

The EKG Paper

Both time and voltage are measured by using grids lines on the EKG paper. Time is measured along the horizontal axis. You could say that it is measured by looking at the intervals between two vertical lines. Voltage is measured along the vertical axis (the distance between horizontal lines).

By measuring time on the EKG rhythm strip, we can tell exactly how long it takes for the impulse to get through the AV node (the PR interval) and through the ventricles (the QRS complex). We can also measure the heart rate.

The large thick-lined boxes are 0.2 seconds each. It takes five 0.2 second intervals to make one second, so there are 5 large boxes in one second and 15 in 3 seconds. The paper has notches at the top that show you 3-second intervals (15 large boxes).

[pic]

[pic]

29.4

Identifying Waveforms

Once you have learned the information on the previous pages, you are ready to practice identifying the parts of the rhythm on a real rhythm strip. First look for the QRS. It’s always the tallest complex. The bump before the QRS complex is the P wave. The wave after the QRS complex is the T wave. The most important parts of the rhythm strip to pick out are the P wave and the QRS complex. The PR and QRS complex intervals are given under each strip.

[pic]

PR: 0.16 QRS: 0.08 Rate: 50

[pic]

PR: 0.16 QRS: 0.06 Rate: 130

[pic]

PR: 0.18 QRS: 0.12 Rate: 42

[pic]

PR: 0.16 QRS: 0.08 Rate: 88

[pic]

PR: 0.12 QRS: 0.08 Rate: 94

29.5

Counting Heart Rate

There are three methods of counting heart rate.

1) The simplest and the one that works for both regular and irregular rhythms: Identify a six-second strip and count the QRS complexes in that section. Multiply that number by 10 and you will have a rough count of the heart rate.

2) Count the number of small boxes between the R waves and divide that number into 1500. This is the most accurate method. It only works for rhythms that are regular. (The R waves are the top points of the QRS complexes.)

3) Count off the number of large boxes between two R waves using the sequence: 300, 150, 100, 75, 60, 50. This works because a rhythm with a rate of 300 has one large box between the R waves, one with a rate of 150 has two large boxes between the R waves, etc.

Placing EKG Leads

The most common system you will see is the five lead system. There is a little saying that may help you remember where the leads go on your patients in ICU and telemetry. It goes,

“White on the right, smoke over fire, snow on the mountain top.”

White goes by the right arm. Black goes over red on the left side and green goes on the right leg under the “snow”. Brown goes in the middle. Brown is a combination of all colors, or you can use your own little thought to remember where to place it.

[pic]

29.6

Cardiac Monitor Vocabulary

Cardiac Monitor: The system of electrodes, leads, and machine with monitor screen that allows us to continuously monitor the heart’s cardiac activity.

Electrocardiograph: The machine used to record the electrical activity of the heart.

Electrocardiogram: The reading of electrical activity printed on paper.

A good way to remember the difference between an electrocardiograph and electrocardiogram is to think of telegraph and telegram. The stem -graph means the instrument, the stem -gram means the paper.

Electrodes: The pads with gel that are attached to the patient. To obtain a clear reading the skin should be dry and clean and should have minimal hair (shaving may be necessary). Pick a site between ribs rather than on top of them and in areas of decreased muscle tissue. There must be adequate gel on the pad. These pads may also be called leads.

Leads: 1) The wires that run from the electrodes to the monitor cable or telemetry unit. 2) An electrical view of the heart. A lead consists of a positive and negative electrode.

Telemetry: A system that consists of a small box called a telemetry unit with leads and electrodes that transmits the electrocardiogram to a central monitoring station. These systems are used on step-down units to monitor patients that no longer need critical care. There is no cable running up to a monitor, so the patient is free to move about.

29.7

LAB CONTENT: CLINICAL ORIENTATION BEHAVIORAL OBJECTIVES FOR INTENSIVE CARE

1. Identify the physical arrangement of the clinical area.

2. Identify the role of staff members.

3. Identify and prepare to use emergency equipment including the crash care, ambu-bag, fire alarms, and fire equipment.

4. Assess one patient as assigned and/or attend agency orientation and conferences.

5. Review attachment of cardiac monitoring electrodes and identify lines on assigned patients.

6. Run rhythm strips and label them with the PR, QRS, rate, and interpretation.

7. Review the medication record and identify the method of confirming unclear orders with the medical orders.

8. Identify and locate the sections of the patient chart.

9. Identify charting procedures used at the assigned agency including vital signs, narrative notes, and physical assessment.

30.0

Long Beach City College

Division of Nursing and Health Technologies

ADN Program

Baseline Assessment of Universal Self-Care Requisites

Critical Care Unit

|SOLITUDE and SOCIAL INTERACTION |INTAKE of FOOD, Elimination Process |

|(Neurological and Psychosocial) |(GI, Metabolic) |

|Appearance, behavior (Calm vs. Anxious) Orientation to time, |Diet: NPO, type, amount eaten |

|place, person and environment Response to verbal commands |NG or GT: feedings: type, rate |

|Pupil size and reaction to light |Height, weight: gain, loss |

|Strength and Sensation of Extremities |Abdominal distention: Nausea, Vomiting |

|Response to Pain |Gastric suction: Gravity, intermittent, continuous |

|Glasgow Coma Scale |Gastric output: color, amount |

|Speech: ETT, Trach, dominant language |Tubes: Type, location, patency, drainage |

|Method of Communication if intubated |Bowel Sounds |

|Head Dressings |Stool: Last BM, amount, character |

|Cervical Collar | |

|Significant Others | |

|Spiritual Concerns |INTAKE OF WATER elimination process |

| |(Bowel, Bladder, and Skin) |

|INTAKE OF AIR |Skin Turgor |

|(Cardiac) |Intake and Output for 24 hours |

|Vital Signs (pain scale under comfort) |Dialysis: Access site, type, bruit |

|EKG Strip Interpretation, Ectopics |IV sites: appearance, patency, solution and rate |

|Pacemaker |Skin:Color, rashes, breakdown, temperature, moist or dry. |

|Heart Sounds, S1, S2 |Urine output: amount, color, characteristics |

|Jugular vein distention (JVD) |Catheter: Foley, Condom, Suprapubic |

|Peripheral Pulses, Capillary Refill | |

|Lines: list lines and PA catheter/CVP readings | |

|Chest dressings |ACTIVITY AND REST |

| |(Musculoskeletal and Comfortt) |

|(Respiratory) |Activity Level |

|Respiratory pattern, rate, depth |Presence of casts, splints, traction, dressings |

|Lung Sounds |Bed: Type |

|Sputum: color, amount, consistency |Pain scale, location |

|Chest tubes: Color, amount of drainage, fluctuation, air leak |Sleep pattern |

|Ventilator: ETT or trach, mode, rate, tidal volume, FiO2 |Restraints |

|Oxygen: method, liter flow or percentage |Assistive devices |

|ABG results | |

30.1

Long Beach City College

ADN Nursing Program

Orientation to Critical Care

Find the location of the following equipment in supply cabinets and in the patient rooms.

|Patient Care Items: |In an empty room identify: |

| |__Monitor cables |

|__Basin |__EKG lead patches |

|__Soap |__Oxygen, Air outlets |

|__Disposable washcloths |__Suction |

|__Shampoo, rinse free |__Ambu-bag location |

|__Razors and shaving cream |__Code Blue button |

|__Linen | |

|__Chuxs | |

|__Foley Catheter | |

|Medications: |Charting: |

|__IVPB medications |__Physical Assessment |

|__IV fluids |__Vital Signs |

|__IV tubing |__Intake and Output |

|__Method of charting medications |__IV drips |

|__IV pumps: if you have not used this pump, please ask your |__EKG strips |

|instructor to go over the pump with you. |Where are EKG strips posted? |

| |Print 3 EKG strips: find one normal sinus rhythm strip and two |

|__Syringes |with an abnormal rhythm or ectopics. Measure the PR and QRS |

|__Alcohol swabs |intervals and heart rate for each strip. Place these on the |

|__IV tubing |reverse side of a care plan. Ask your instructor for assistance |

|__Method of ordering medications not available on the unit. |as needed. |

| | |

| |__Laboratory studies: Locate at least one patient with |

| |respiratory problems, find ABG results for this patient and |

| |interpret the ABGs. Ask for assistance as needed. |

30.2

Long Beach City College

ADN Program

Orientation to Critical Care (cont)

Who draws blood for laboratory studies? ___________________________

By venipuncture ___________________________

By arterial or central venous line ___________________________

Who draws arterial blood gases? ___________________________

Who obtains 12 lead EKGs? How would you call for one? _______________________

Locate the Crash Cart.

Is an ambu-bag on the crash cart? ______________________________

Who checks the crash cart daily? _______________________________

Where is the log of crash cart checks? ___________________________

On your assigned patient, list all the drips and lines that your patient has on the assessment section of the care plan. List any drainage tubes including the Foley catheter.

If your patient is on the ventilator, write out the settings under the assessment for Maintenance of Sufficient Intake of Air.

When charting ventilator settings, chart the mode, the set rate, the FiO2, the set tidal volume, PEEP and pressure support. For example: CMV 8, FiO2 40%, TV 700 mL, peep 5, pressure support 12)

Locate the Fire Response Alarms and Equipment

Locate the fire alarms on the unit.

Locate the map showing fire exits.

Locate fire extinguishers on the unit. Identify the type of fire the extinguisher is appropriate for.

Locate the oxygen shut off valves on the unit.

30.3

BEHAVIORAL OBJECTIVES FOR GROUP LEADER

A. Preparation for Group Leader role:

1. On the day before clinical, communicate with each student member to obtain assignment information. Familiarize yourself with all diagnoses.

B. Start of shift:

1. Identify self as group leader to the staff on the unit. Wear Group Leader tag.

2. Verify that patients are still in the unit. Assist students in finding a new assignment if the patient is no longer on the unit or if the assigned RN requests a change.

3. Verify correct posting of assignments.

4. Determine the presence of each peer in the assigned clinical areas. Notify instructor if any student is tardy.

C. During the shift:

1. Receive report on assigned patients from students and/or listen in on report from RN as able.

2. Confer with the instructor to make plans for the day.

3. Assess each patient, make brief baseline assessment, identify nursing diagnosis or self-care deficits and set priorities using the Group Leader worksheet.

4. Collect care plans at designated time. Review each care plan and write in suggestions. Review careplans with the instructor.

5. Alert group members to special procedures and learning experiences present on unit.

6. Assist group members with patient care as needed. Each patient should be bathed and linens changed. Mouth care should be completed every four hours if intubated and patients must be turned and correctly positioned every two hours. Be sure to let the Instructor know if students are having difficulty with time management.

7. Act as liaison for instructor and alert to:

Group member's supervision and instruction needs.

Problems as they occur.

8. Periodically, make rounds on assigned students and patients.

9. Assign breaks. Students should not be leaving the unit at the same time as their assigned nurse. Assure that each student returns from their break in a timely manner (15 minutes for AM break, 30 minutes for lunch break).

10. Review medication administration records for accuracy and completeness at mid shift and at end of shift.

D. End of shift responsibilities:

1. Check peer's assignments for completeness.

2. Complete evaluation of each team member.

3. Report any problems to instructor. Check for the completion of peer assignment and check off each peer from unit.

4. Turn in completed ICU Group Leader Worksheet

30.4

.

ICU GROUP LEADER WORKSHEET Group Leader Name:_________________________________

|Room number: |Key Findings of Physical Assessment: |VS: |Priority Nursing Diagnosis: |Nursing Interventions: |Flow sheets |IV and Medication Times |

| | | | | |complete ____ | |

|Initials: | | | | | | |

| | | | | | | |

|Age and Sex: | | | | |Med Charting Complete | |

| | | | | |____ | |

|Date admitted: |Therapies: (vent settings, lines, drip | | | | | |

| |medications, Foley, tubes) | | | | | |

|Dx: | | |Priority Collaborative Problem: |Signs and Symptoms to monitor for: |AM/PM Care Completed | |

| | | | | |and Charted: _____ | |

|Hx: | | | | | | |

| | | | | |Turns completed and | |

| | | | | |charted: ___________ | |

| | | | | | | |

|Primary Nurse: | | | | | | |

|M F Age: |Key Findings of Physical Assessment: |VS: |Priority Nursing Diagnosis: |Nursing Interventions: |Flow sheets |IV and Medication Times |

|Room number: | | | | |complete ____ | |

| | | | | | | |

|Initials: | | | | | | |

| | | | | |Med Charting Complete | |

|Age and Sex: | | | | |____ | |

| |Therapies: (vent settings, lines, drip | | | | | |

|Date admitted: |medications, Foley, tubes) | | | | | |

| | | |Priority Collaborative Problem: |Signs and Symptoms to monitor for: |AM/PM Care Completed | |

|Dx: | | | | |and Charted: _____ | |

| | | | | | | |

|Hx: | | | | |Turns completed and | |

| | | | | |charted: ___________ | |

| | | | | | | |

| | | | | | | |

|Primary Nurse: | | | | | | |

|Room number: |Key Findings of Physical Assessment: |VS: |Priority Nursing Diagnosis: |Nursing Interventions: |Flow sheets |IV and Medication Times |

| | | | | |complete ____ | |

|Initials: | | | | | | |

| | | | | | | |

|Age and Sex: | | | | |Med Charting Complete | |

| | | | | |____ | |

|Date admitted: |Therapies: (vent settings, lines, drip | | | | | |

| |medications, Foley, tubes) | | | | | |

|Dx: | | |Priority Collaborative Problem: |Signs and Symptoms to monitor for: |AM/PM Care Completed | |

| | | | | |and Charted: _____ | |

|Hx: | | | | | | |

| | | | | |Turns completed and | |

| | | | | |charted: ___________ | |

| | | | | | | |

|Primary Nurse: | | | | | | |

|Room number: |Key Findings of Physical Assessment: |VS: |Priority Nursing Diagnosis: |Nursing Interventions: |Flow sheets |IV and Medication Times |

| | | | | |complete ____ | |

|Initials: | | | | | | |

| | | | | | | |

|Age and Sex: | | | | |Med Charting Complete | |

| | | | | |____ | |

|Date admitted: |Therapies: (vent settings, lines, drip | | | | | |

| |medications, Foley, tubes) | | | | | |

|Dx: | | |Priority Collaborative Problem: |Signs and Symptoms to monitor for: |AM/PM Care Completed | |

| | | | | |and Charted: _____ | |

|Hx: | | | | | | |

| | | | | |Turns completed and | |

| | | | | |charted: ___________ | |

| | | | | | | |

|Primary Nurse: | | | | | | |

|Room number: |Key Findings of Physical Assessment: |VS: |Priority Nursing Diagnosis: |Nursing Interventions: |Flow sheets |IV and Medication Times |

| | | | | |complete ____ | |

|Initials: | | | | | | |

| | | | | | | |

|Age and Sex: | | | | |Med Charting Complete | |

| | | | | |____ | |

|Date admitted: |Therapies: (vent settings, lines, drip | | | | | |

| |medications, Foley, tubes) | | | | | |

|Dx: | | |Priority Collaborative Problem: |Signs and Symptoms to monitor for: |AM/PM Care Completed | |

| | | | | |and Charted: _____ | |

|Hx: | | | | | | |

| | | | | |Turns completed and | |

| | | | | |charted: ___________ | |

| | | | | | | |

|Primary Nurse: | | | | | | |

|Room number: |Key Findings of Physical Assessment: |VS: |Priority Nursing Diagnosis: |Nursing Interventions: |Flow sheets |IV and Medication Times |

| | | | | |complete ____ | |

|Initials: | | | | | | |

| | | | | | | |

|Age and Sex: | | | | |Med Charting Complete | |

| | | | | |____ | |

|Date admitted: |Therapies: (vent settings, lines, drip | | | | | |

| |medications, Foley, tubes) | | | | | |

|Dx: | | |Priority Collaborative Problem: |Signs and Symptoms to monitor for: |AM/PM Care Completed | |

| | | | | |and Charted: _____ | |

|Hx: | | | | | | |

| | | | | |Turns completed and | |

| | | | | |charted: ___________ | |

| | | | | | | |

|Primary Nurse: | | | | | | |

PEER EVALUATION SHEET

Group Leader Name ____________________ Date __________________________

|Student __________________________ |Student __________________________ |

|Strengths: |Strengths: |

| | |

| | |

|Areas to improve: |Areas to improve: |

| | |

| | |

|__________________ ______________________ |__________________ ______________________ |

|Evaluator Student Signature |Evaluator Student Signature |

|Student __________________________ |Student __________________________ |

|Strengths: |Strengths: |

| | |

| | |

|Areas to improve: |Areas to improve: |

| | |

| | |

|__________________ ______________________ |__________________ ______________________ |

|Evaluator Student Signature |Evaluator Student Signature |

|Student __________________________ |Student __________________________ |

|Strengths: |Strengths: |

| | |

| | |

|Areas to improve: |Areas to improve: |

| | |

| | |

|__________________ ______________________ |__________________ ______________________ |

|Evaluator Student Signature |Evaluator Student Signature |

|Student __________________________ |Student __________________________ |

|Strengths: |Strengths: |

| | |

| | |

|Areas to improve: |Areas to improve: |

| | |

| | |

|__________________ ______________________ |__________________ ______________________ |

|Evaluator Student Signature |Evaluator Student Signature |

|Student __________________________ |Student __________________________ |

|Strengths: |Strengths: |

| | |

| | |

|Areas to improve: |Areas to improve: |

| | |

| |__ |

|__________________ ______________________ |________________ ______________________ |

|Evaluator Student Signature |Evaluator Student Signature |

30.7

Long Beach City College ADN Program

Nursing Care Plan, ADN 22A

Student_____________Date_________Pt Initials________ RM/Bed#__________Adm Date___________

Coassigned Nurse_____________ Medical Dx____________________Allergies_____________________

Age______Sex____Religion________________Occupation______________Ethnicity________________Family Role___________________________Developmental Level _______________________________

Code Status___________Predisposing Factors/Hx_____________________________________________

|Universal Self-Care|Structural and Functional |Self-Care Deficits | |Nursing Interventions |Nsg Agency |

|Requisites |Assessment |Nursing Dx/ |Goals |Dependent and Independent Nursing Actions| |

| | |Collaborative Problems | | | |

|Maint. of Balance | | | | | |

|between Solitude | | | | | |

|and Social | | | | | |

|Interaction | | | | | |

|Maint. Of | | | | | |

|Sufficient Intake | | | | | |

|of Air | | | | | |

|Maint. Of | | | | | |

|Sufficient Intake | | | | | |

|of Food | | | | | |

|Maint. Of | | | | | |

|Sufficient Intake | | | | | |

|of Water | | | | | |

|Maint. Of Balance | | | | | |

|between Activity & | | | | | |

|Rest | | | | | |

Put a star next to any priority problems*

Diagnostic Tests

| | | |

|Test Name |Latest Result |Implications including possible causes and effects |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

Tape an EKG strip for your patient in the space below. Determine the following:

PR interval:_______________QRS interval: _____________Rate:________________

Interpretation:_____________________________________

DRUG WORKSHEET

| | | | |

|DRUG |CLASS |Why is THIS patient receiving this drug? | |

|(Include all drugs, not just | | |Nursing Responsibilities |

|those given by student.) | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

LONG BEACH CITY COLLEGE

ASSOCIATE DEGREE NURSING PROGRAM

Behavioral Objectives for 22A Cath Lab Experience

On a separate sheet, answer the following objectives and submit them to your instructor by the Monday after the experience.

1) Describe the role of the nurses in the Cardiac Cath Lab.

2) Describe the critical thinking necessary to work in this specialty.

3) Give a summary of the types of patients you cared for and the procedures you observed.

4) Describe two specific patients and give a priority nursing diagnosis or collaborative problem for each patient.

5) State whether or not the experience was valuable and why.

Have your co-assigned nurse write his/her name and sign below.

Date ________________

Name of co-assigned nurse Signature of co-assigned nurse.

Name of Student Signature of Student

Signatures confirm that the student was present in the cath lab for the full 8 hour shift. Please feel free to call the instructor if there are concerns.

30.11

LONG BEACH CITY COLLEGE

ASSOCIATE DEGREE NURSING PROGRAM

Behavioral Objectives for 22A Emergency Department Experience

On a separate sheet, answer the following objectives and submit them to your instructor by the Monday after the experience.

1) Describe the various roles of the nurses in the Emergency Department. Describe the role of the triage nurse.

2) Describe the critical thinking necessary to work in Emergency Department nursing. How is nursing different in the Emergency Department as compared with other areas?

3) Give a summary of the types of patients you cared for and the procedures you observed.

4) Describe three specific patients and give a priority nursing diagnosis or collaborative problem for each patient.

5) Describe any procedures you performed such as medication administration, assessment, catheterization, etc.

6) State whether or not the experience was valuable and why.

Have your co-assigned nurse write his/her name and sign below.

Date ________________

Name of co-assigned nurse Signature of co-assigned nurse.

Name of Student Signature of Student

Signatures confirm that the student was present in the cath lab for the full 8 hour shift. Please feel free to call the instructor if there are concerns.

30.12

LONG BEACH CITY COLLEGE

Associate Degree Nursing (RN) Program

ADN 22AL – Critical Care through the Life Span

GUIDELINES AND FORMAT FOR ADULT CASE STUDY

A. Policy for written work in the nursing program:

1. Eight and 1/2” by 11” standard size white paper is to be used for all written assignments. Paper torn out of spiral bound notebooks is not acceptable.

2. All written assignments are to be printed on one side of the paper only.

3. APA format is to be used for all written work.

B. Select one of your assigned patients to present in the case study. Discuss the selection with your clinical teacher during the hospital day. This patient must be approved by your instructor.

C. The case study will be submitted in writing to your clinical instructor and will be presented orally to your clinical group on an assigned day. Limit your oral presentation to 10 minutes. A visual aid must be used for your presentation.

D. Format for the case study

I. Basic conditioning factors

Include all information from the top of your nursing care worksheet, including the developmental level. Provide a rationale for why you think the patient has achieved or failed to achieve resolution of the appropriate Erikson developmental level.

II. Physiology of the Involved Organs

A brief statement, paraphrased (in your own words) from references, about the structure and function of each of the involved organs. Do not copy sections directly from textbooks or articles! Ideally, you will read several sources on the physiology of the organ and write a section about the organ(s) in your own words.

III. Pathophysiology

This section must include general information regarding the disease condition, predisposing and/or precipitating factors, and the most common causes of the selected pathophysiology. Describe what went wrong for your particular patient, the cause (if known), and any signs and symptoms that your patient exhibited. Discuss diagnostic tests such as laboratory values (including ABGs) and radiology studies. Include your interpretation of the cardiac rhythm strip. If more than one system is involved discuss the effects of one dysfunction on the other

30.13

system and the cumulative effect of dysfunction. For example, many chronic illnesses affect the immune system, which can result in infection and sepsis.

IV. Medical Orders

List the orders in effect for your patient when you were assigned to that patient. Include diagnostic tests, including normal values and interpretation not included in the Pathophysiology section.

V. Health Deviations

Under each Universal Self-Care Requisite section, describe the health deviations that were:

a) Brought about by illness.

b) Brought about by diagnostic tests and/or treatments.

VI. Nursing Diagnoses/ Collaborative Problems

Identify priority Nursing Diagnoses and Collaborative Problems. Include supporting physical assessment data, goals, and interventions.

VII. Nursing Care Plan

Prepare a clean, correct copy of your NCP for the day you cared for this patient. Star the two priority nursing diagnoses.

VIII. Teaching Plan

Include a plan for teaching the patient, family members, or nursing staff. Include your behavioral objectives, the method you used to teach (verbally, in writing, through pamphlets) and a method of validating that learning has taken place (ex: family member explained the concepts taught to another family member).

IX. References

Include and attach a copy of one nursing research article. Many journal articles do not directly report on research and though they are good information articles, the intent of this portion of the assignment is to have you gain awareness of nursing research. It is strongly suggested that you review past issues of Nursing Research (available in the LBCC or CSULB library) or the American Journal of Critical Care to find an article relevant to your patient.

Nursing Research:



American Journal of Critical Care:



This paper must be written in APA format.

30.15

LONG BEACH CITY COLLEGE

Associate Degree Nursing Program

ADN 22AL – Critical Care Through the Life Span

CASE STUDY STYLE

APA Style is the accepted format to be used for the case study and is used by most schools of nursing. When looking for appropriate articles and using references, remember that sources more than five years old are considered outdated. Older sources are only to be used if they have historical importance. The standard reference work of APA is Publication Manual of the American Psychological Association (6th ed.). Washington DC: APA.

Citations

You are required to cite each source that is used to write your case study. If you open a book or Internet site and refer to it while you are writing, you should cite the reference in that section and include it in the reference list. It is not necessary to cite common knowledge such as, “The heart has four chambers.” The citation format must include the author’s last name and date of publication. If the citation includes a specific excerpt from the source then the actual page numbers should be given and the quoted material should be in quotations. If the quote is over 40 words long, it should be placed in an indented paragraph. It is best to avoid long quotes taken directly from a source. If you paraphrase (rewrite the section in your own words), you still need to cite the reference, but quotation marks aren’t used. Quoting is best reserved for phrases that would lose accuracy or aesthetics by paraphrasing. For example, one would not paraphrase a quote by Florence Nightingale.

Examples of referencing within text:

1. All information required (year and author) is in the sentence:

As stated in the 2000 edition of Smeltzer & Bare, the liver is the largest gland of the body.

2. Only the author’s name is in the referencing sentence. The year must be included in parentheses:

Dr. Richard Smith (1996) describes a standard hiatal hernia repair.

3. Information is not cited in the text and therefore is placed in parentheses.

The most recent statistical information (Adams, 1998) reveals an increase in the incidence of breast cancer.

30.16

4. Quoted information:

(Note that this quotation is from a theorist. These words are very carefully chosen and therefore would not lend themselves to paraphrasing.)

According to Orem (1995, p.17), “to support another person means to ‘sustain in an effort’ and thereby prevent the person from failing or from avoiding an unpleasant situation or decision”.

List of References

The articles, textbooks, Internet information and other resources are listed on a separate piece of paper with the centered title “References”. This list is intended to provide all of the information needed to locate the source of information. The list should not be numbered and should be alphabetically organized by the author’s last name. Format the list using a hanging indentation, that is, the author’s name is at the left margin and the remaining lines are indented 5 spaces. Some examples follow:

Book

Smeltzer, S & Bare, B.(2010). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins.

Article from a journal

Kendall, H. (2010, April). Cardiac Amyloidosis. Critical Care Nurse, 30(2), 16-23.

Electronic sources: include the URL

American Psychological Association Electronic reference formats recommended by the american psychological association. (n.d.). Washington, DC: American Psychological Association. Retrieved March 27, 2002 from

Note: The initials (n.d.) stands for no date. If a date that the site was last updated is displayed, it should be included in place of these initials. The retrieval date should be the date the student down-loaded the information from the net. No period is used at the end of the citation.

30.17

Articles taken from an electronic source

Most articles found on the web were originally published in print. The article should be referenced as any other print article would be referenced. If you have only seen the article in its Internet or electronic version, the words [Electronic version] in brackets should go after the article name.

VandenBos, G., Knapp, S., & Doe, J. (2001). Role of reference elements in the selection of resources by psychology undergraduates [Electronic version]. Journal of Bibliographic Research, 5, 117-123.

30.18

LONG BEACH CITY COLLEGE

Associate Degree Nursing Program

ADN 22AL: Critical Lifespan Laboratory

GRADING CRITERIA FOR CASE STUDY

Attach this page to the back of your case study.

Student Name Date

| | |Not | |

|ITEM TO BE EVALUATED |Correct |Correct |Comments |

| 1. Assignment is typed or word processed on one side of clean | | | |

|8 1/2” by 11” white paper. The font is readable and text is double spaced. | | | |

| 2. A title page is present. Student’s name, date and clinical instructor’s name is | | | |

|in the center. | | | |

|√ All pages are numbered starting on the second page. | | | |

|√ Pages are bound together by staples or other device | | | |

|√ Each section of the case study is identified by title. | | | |

| 3. The format and content is college level. | | | |

|√ Documentation style is APA | | | |

|√ Paragraphs are organized and logical | | | |

|√ No plagiarism is present, information is paraphrased rather than copied directly | | | |

|from sources, correct citations are present | | | |

|√ Sentences are complete and grammatically correct | | | |

|√ Style is appropriate for a documented essay | | | |

|√ Spelling is correct | | | |

| 4. The client selected was approved by the clinical teacher. | | | |

| 5. The oral presentation contained new information for fellow students and used | | | |

|teaching principles appropriate to an adult learner. A visual aid was utilized in the| | | |

|oral presentation. | | | |

| 6. Basic Conditioning Factors included all information. Erikson's developmental | | | |

|level is included and thorough. | | | |

| 7. Physiology of the involved organ is accurate and properly referenced and cited. | | | |

|More than one source is used. | | | |

| 9. Pathophysiology of the client’s health deviations: | | | |

|√ Statistics regarding incidence and predisposing and/or precipitating factors are | | | |

|listed | | | |

|√ If more than one disease is present, the relationship between and the effects of | | | |

|one disease on the other is thoroughly explained | | | |

|√ If Reference source of the information is cited | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|30.19 | | | |

| |Correct |Not |Comments |

| | |Correct | |

| 10. Pathophysiology of the selected patient: | | | |

|√ The cause, precipitating factors, and clinical manifestations for this particular | | | |

|patient’s pathology are listed | | | |

|. 11. Medical orders in effect are listed: | | | |

|√ Medications are listed along with expected | | | |

|therapeutic affect | | | |

|√ Diagnostic tests are listed with an explanation of | | | |

|implications of any abnormal findings (Only include information not present in the | | | |

|Pathophysiology section.) | | | |

| 12. Health deviations are formatted by Universal Self-Care Requisites and are listed| | | |

|according to: | | | |

| | | | |

|Health deviations caused or associated with the illness | | | |

|Health deviations associated with the diagnostic tests or treatments | | | |

| 13. The listed nursing diagnoses and collaborative problems are priority problems. | | | |

|√ Goals are specific for the client and the nursing | | | |

|diagnosis or collaborative problem. | | | |

|√ Interventions are specific for the client and the | | | |

|nursing diagnosis or collaborative problem. | | | |

| 14. The nursing care plan is attached. If the original care plan had feedback, the | | | |

|care plan is rewritten. | | | |

| 15. The teaching plan is relevant to the client’s problems: | | | |

|√ If the patient is too incapacitated to learn, the family members or nurses on the | | | |

|unit are included in the teaching plan | | | |

|√ A method of teaching is included. | | | |

|√ A method of validating that learning has taken place is included. | | | |

| 16. The list of references is included: | | | |

|√ On a separate, last page | | | |

|√ In APA style | | | |

| 17. A copy of a nursing article is attached: | | | |

|√ The article reports on nursing research. | | | |

|√ The article is related to the client’s problems | | | |

|√ The article is from a refereed professional journal | | | |

|√ The article was cited once in the body of the paper | | | |

30.20

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