OPERATING INSTRUCTIONS - Texas State University



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About this Manual:

Many factors contribute to providing the best care possible for our patients. One of these factors includes understanding the proper use of medical tools. In many cases, a patient needs continuous services from medical tools for a successful diagnostic and recovery. Healthcare providers must be able to distinguish the purpose of the medical equipment and identify which patients are in need of the equipment. Most importantly, healthcare providers must be aware of the necessary steps to successfully operate the medical equipment to ensure the patient’s safety as well as their own. This manual includes details to certain medical equipment necessary for patients of the Stroke Center.

Table of Contents

Quick Pressure Monitor Set

Sterile Procedures…..…………………………………..……….....4-6

Indwelling Slit Catheter……………………………..……………..7-9

Fluid Warmer for

Hypothermic Patients …………………..………..…...…………….10

Basic Fluid Warmer Instructions…………………………..…....10-11

Transferring Hovermatt..……………………………………….......12

Using/Cleaning Hovermatt………………………………...…....12-13

Bair Hugger Warmer..………………………………………...….…15

Bair Hugger Warmer Use……………………………………….15-17

Peripherally Inserted Central

Catheter (PICC)………………………………………...…….…......18

PICC Instruction Use…………………………………...….………..19

Taking Care of PICC…………………………………..….……..19-20

CAT Scan………………………………………………………..21-22

Heart CT Scan…………………………………………………...22-23

EKG Machine………………..…...………….………....….………..24

EKG 5-Step……………………………...………………………25-26

Holter Monitor……………………………...………………………27

Holter Monitor Exam…………………..………………….…….27-28

Treadmill Stress Machine…………………….………….…………30

Stress Test………………………………………………….……30-33

Ultrasound Machine…………………………………….…….....34-35

Quick Pressure Monitor Set Sterile Procedures

The Stryker Intra-Compartmental Pressure Monitor System is a convenient, self-contained, reliable unit for an immediate or continuous reading of compartment pressure.

Instructions

1.     First you must turn unit on.

2.     Remove contents of disposable pouch.

3.     Place needle firmly on the tapered chamber stem.

4. Remove cap on pre-filled syringe and twist the syringe against remaining chamber stem without contaminating the fluid.

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Figure 1

5.    Open the monitor’s cover and place slot in well, gently pushing it until disposable settles in.

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Figure 2

6.    Snap cover closed without forcing it.

7.    Pull cap off syringe and attach needle rod.

8.    Slowly force fluid through the disposable to flush out air without allowing saline to pour down the needle.

9. Fix the intended angle of insertion of the needle into the skin. Press the zero button and wait 2 seconds. The display should read 00.

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Figure 3

10.  Insert needle into body. Slowly inject less than 3/10cc of saline into the compartment.

11.     Wait for the display to reach equilibrium before reading pressure.

12.     For additional measurements, make sure to reset unit and repeat steps 9-12.

Indwelling Slit Catheter

Sterile Procedures

1.     Turn on the monitor. (Make sure to start procedure with a full syringe)

2.     Remove the needle from the monitor.

3.     Attach the slit catheter to the tapered chamber stem. Make sure the fit is snug.

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Figure 4

4.     Remove the needle protector from the removable needle. Push the catheter in until it is only slightly visible at the end of the needle.

5.     Slowly force the disposable to remove air.

6.     Bring the catheter tip to the same height as the diaphragm chamber.

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Figure 5

7.     Press the zero button and wait until display reads 00 before proceeding.

8.     Hold the catheter and the needle together and push into the compartment.

9.     Push the catheter forward as you pull back on the needle. Once the need is out of the skin, tape the catheter in place.

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Figure 6

10. Remove the detached needle.

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Figure 7

11.     Keep the chamber in the monitor at the same height as the slit tip of the catheter in the body.

12.     Inject less than 3/10 cc of saline into the compartment to balance with interstitial fluids.

13.     Wait for the display to reach equilibrium.

14.     Document the pressure reading at the appropriate times. Repeat step 12 to ensure patency for successive measurements.

Fluid Warmer for Hypothermic Patients

Fluid warmer must be used by trained professional and for patients who are in severe state of hyperthermia. It is important to be trained in using the Intravenous Fluid Warmer to ensure patient’s safety. It is also important to consider that because there are different types of fluid warmers, each one operates differently and according specific instructions. Note: Some fluid warmers operate in conjunction with additional machinery and tools.

Basic Fluid Warmer Instructions

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Figure 1

1. First you must read the instructions for the specific unit you will be operating.

2. Ensure that you have the proper power supply.

Note: Most portable fluid warmers operate on 12 volts.

3. Ensure heat fluids are between 104 and 108 F˚ for hypothermia patients.

Note: Fluids should never be cooler than the patient’s core temperature.

4. Attach IV needle to the fluid warmer pipe.

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Figure 2

5. Prepare to insert needle to administer fluid to the hypothermic patient.

6. Be cautions when inserting the IV needle into the vein. Note: In some hypothermic patients, blood vessels can become constricted, thus making the vein difficult to find.

7. Fix the intended angle of insertion of the needle into the skin.

8. Slowly administer warmed dextrose in water or saline solution.

9. When infusion fluid passes through this device, it will be heated to the right temperature for human bodies. Note: Reducing temperature difference between infusion fluid and human body can avoid adverse reactions and improve drug assimilation by human body.

10. Because most hypothermic victims are dehydrated, it is important to administer about 300 to 500 ccs of dextrose in water or saline rapidly, followed by 75 to 100 cc per hour.

Transferring Hovermatt

The Hovermatt is an inflatable mattress used to relocate patients. Hovermatt has no weight limit and is appropriate for all patients. Patients may remain on the Hovermatt for all necessary, secondary procedures.

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Figure 1

Instructions in using the Hovermatt

1. Place the hovermatt mattress underneath patient using

2. Patient should be in a horizontal position for

transfer/repositioning.

3. Plug the electric cord into the outlet.

4. Be sure transfer surfaces are as close as possible.

5. Log-rolling technique and attach patient safety straps.

6. Attach the flexible hose end to the mattress, parallel to the foot end, and snap in place.

7. Transfer from a higher surface to a lower surface.

8. Turn on air supply.

9. If the width of the equipment receiving the patient is less

than the width of the transfer pad, ensure that the patient is

centered on the receiving equipment prior to deflation.

10. Grasp handles and pull patient on an angle, either head

first or feet first, until patient is in desired position.

Note: Be careful not to pull on the patient safety straps, but use the handles for pulling.

11. Turn off air supply and employ the bed/stretcher rails.

Note: Never leave the patient unattended on an inflated transfer mattress and always use bedrails for safety.

Instructions to properly clean the Hovermatt

It is crucial to ensure that the matt is properly cleaned and disinfected prior to using it with the next patient.

In cleaning the matt make sure to:

1. Wiped down with phenolic disinfectants, quaternaries, or other similar type solutions, as per hospital protocol for stretchers and mattresses.

Note: If mattress becomes extremely soiled, it can be laundered in a washing machine with a 150 degree Fahrenheit maximum water temperature. If bleach us used, direction are 10 parts water, one part bleach.

2. Mattress should be air dried.

Note: Air drying can be expedited by using the air supply unit to circulate air through the inside of the mattress.

3. Drying temperature should never exceed 115 degrees Fahrenheit.

Note: The double-Coated Hovermatt should not be put in

the dryer.

4. To help keep it clean, a bed sheet may also be used.

Bair Hugger Warmer

The Bair Hugger warmer is intended to prevent and treat hyperthermia. Because patients under anesthesia cannot control their body temperature, this equipment provides warmth before, during, and after surgery to help prevent and/or treat Hypothermia. The Bair Hugger blanket is not to be used with any other devices not pertaining to the Bair unit. The Bair Hugger blanket is not to be used with hose alone as thermal injury may result.

Bair Hugger Warmer Safety Use

1. Ensure that Bair Hugger hose is attached to the blanket before providing therapy.

2. Do not allow the patient to lie on the warming unit hose or allow the hose to directly contact the patient’s skin during patient warming; thermal injury may result.

3. Do not use a forced-air warming device over trans-dermal medications; increased drug delivery, patient injury, or death may occur.

4. Do not use Bair Hugger blanket to transfer or move the patient

5. This blanket is intended for single patient ONLY and needs to be disposed after a single use.

6. Using a sheet between Bair Hugger blanket and patient does not prevent contamination of the product.

7. Do not leave pediatric patients unattended during therapy

8. Notify physician of vital sign instability immediately.

9. Do not apply heat to lower extremities during aortic cross-clamping. Thermal injury may occur if heat is applied to ischemic limbs.

10. Do not leave patients with poor perfusion unmonitored during prolonged warming therapy sessions.

Bair Hugger Warmer Instructional Use

1. Open and unfold blanket.

2. Locate the white product label on the blanket. Note: Make sure the product label is facing the patient.

3. Position the blanket onto the surface of the patient footboard or onto the surface of the sling assembly.

4. Using the tape strip on the underside of the blanket, secure

the blanket to the table to prevent it from slipping.

5. Pass the blanket between the patient footboard and the patient top thigh set through the frame to the underside of the frame of the spinal surgery table.

6. Unfold the blanket under the top thigh pad set top hip pad set, patient chest pad, and under the patient head support plate.

4. Draw the end of the blanket to the end of the spinal surgery table and secure it to the end of the table frame using the tie strips located at the end of the blanket.

5. Open the four perforations on both sides of the blanket and position the blanket around the edges of the spinal surgery frame.

6. Before the patient has been positioned, draw tie strips across the top of the frame of the spinal surgery table and around each side of the patient chest pad or directly to the frame.

7. Pillows and other positioning modalities used for the lower extremities should be positioned under the blanket. Optional: Tear out the circular (face) section at the head the blanket to visualize the patient’s eyes and airway from under the table.

8. Insert the end of the Bair Hugger warming unit hose into the hose port.

9. Support hose to insure secure attachment.

Note: If the patient is intubated and ventilated, position the head drape over the patient’s head and neck.

10. Monitor the patient’s temperature every 10 to 20 minutes or according to

institutional protocol.

Note: Make sure to monitor the patient’s vital signs regularly.

Peripherally Inserted Central Catheter (PICC)

A Peripherally Inserted Central Catheter (PICC) is similar to an IV line or catheter. The PICC is inserted through an arm vain, and then pushed into a larger vein in the chest area for the purpose of placing the PICC near the heart.

The PICC can stay in place for several weeks or months at a time. One of the purposes for this is so that patients won’t need to have an IV line replaced every few days. As a result, the PICC is used to give IV medicines or fluids to the patient, sometimes used when IV medicines or fluids are irritating to small arm or hand veins. Some of the types of medicines administered through a PICC are antibiotics, chemotherapy, blood products, IV nutrition and other IV medicines can be given through the PICC. In addition, blood can be drawn from the PICC.

ONLY certified healthcare professional may insert a PICC line.

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PICC Instructions Use

1. When PICC line is being placed make sure patient in lying flat with arm straight-out.

Note: Nurse may administer a numbing medicine to the top layer of the skin to decrease discomfort where the PICC will be placed.

2. Make sure PICC has appropriate needle before beginning the procedure.

3. Use an ultrasound machine to see the vein on which the PICC will be inserted.

4. Push the catheter into the vein.

Note: If necessary, to ease the procedure, ask the patient to move their arm and wrist as this will help the catheter move into the vein.

5. After the catheter is in place, out on a sterile dressing and prepare patient for a chest X-ray.

Note: An X-ray is necessary to check the position of the PICC.

Taking Care of Your PICC

After the PICC is inserted, healthcare provider will need to help patient care for the PICC line. Caregiver will need to change the dressing, flush each opening of the catheter with fluids, and change the cap on the end of each lumen of the. Caregiver needs to instruct patients on how to further care for the catheter, such as:

1. To avoid activities with repetitive motion such as golfing, tennis or pushing a vacuum that could cause the catheter end to move.

2. To avoid swimming or other activities that place water over the site because it may cause the dressing to loosen, putting you at risk for infection.

3. To cover the site with plastic wrap to keep the dressing and site dry when taking a shower.

4. To notify the doctor if:

• Increased bruising, swelling or tenderness Any problems with your catheter

• Warmth or drainage from your PICC site

• Fever or chills

• More redness at your site where the PICC was placed

Additional Care Instructions for Caregiver

1. Make sure to apply warm compresses to your shoulder above the dressing for the first 2 to 3 days to reduce the chance of vein irritation.

2. Place the warm compress on your shoulder above the dressing where

your catheter goes into your vein.

3. Do not place the compress on your dressing as this can create moisture under it.

4. Leave the compress on the shoulder for 20 minutes then remove it.

Note: Repeat this 4 times each day for the first 48 to 72 hours after the catheter is put in.

Cat scan

A CT scan is used to take cross-sectional X-ray pictures of the body. CT scans use an X-ray technology and powerful computers to function. The CT scan is used for many purposes; some of these purposes include looking for:

• Broken bones

• Cancers

• Blood clots

• Signs of heart disease

• Internal bleeding

The procedure is painless and rarely do patients feel any discomfort while the procedure is taking place. During the scan, patient will feel the table move inside a donut-shaped scanner. The high-speed CT scan captures multiple images, synchronized with the heartbeat. ONLY a cardiovascular radiologist may perform a CT scan. After the CT scan, patient may continue all normal activities and eat as usual after the heart CT scan.

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Heart CT Scan

The Heart CT scan is an exam used to look directly at the arteries of the heart to detect calcium deposits found in atherosclerotic plaque in the coronary arteries of heart disease patients. The more coronary calcium detected, the more coronary atherosclerosis, which suggests a greater higher risk of future cardiovascular problems.

From the Heart CT Scan, the following information will be obtained:

• The number and density of calcified coronary plaques in the coronary arteries.

• Calcium score.

Heart CT scan Procedure

1. Provide patient with a hospital gown.

2. Record vital signs—i.e. blood pressure, height, and weight. Note: It is necessary to draw blood for lipid analysis.

3. Properly clean three small areas on the patient’s chest and attach the, sticky electrode patches on these areas.

Note: Men may expect to have their chest partially shaved to help the electrodes stick.

5. Attach the electrodes to an electrocardiograph (ECG) monitor. Note: ECG charts your heart's electrical activity during the test.

6. Make sure patient has received contrast dye before the initiation of the procedure.

Note: Contrast dye makes parts of the body show up better in the image.

7. Patient should be lying flat and still on the scanning table.

Note: Patients should avoid caffeine and smoking hours before the exam.

8. For safety reasons, make sure radiation exposure is kept to a minimum.

Note: Patients who are pregnant or undergoing radiation therapy should not undergo the CT scan procedure as this can be harmful.

EKG Machine

An EKG machine is a voltmeter that reads electrical energy from the body to help detect steady or irregular heartbeat, heart disease, as well as identify heart problems before a patient experiences chest pains. By placing electrical sensors (leads) on the patient’s chest the nurse is able to read the electrical energy of the heart—the heart uses electrical energy to cause muscle cells to contract. Often, 12 leads are used to look at the heart from different angles; however, the EKG machine only views one angle at a time. The EKG machine is used as a diagnostic tool to record heart activity and to diagnose a variety of heart conditions. The heart’s electrical impulses are transferred to paper by the EKG machine.

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EKG Basic Instructions

1. Provide patient with a hospital gown.

2. Record vital signs—i.e. blood pressure, height, and weight.

Note: It is crucial to obtain information on family history to determine patient’s personal risk factors.

3. Position metal sensors on the patient’s ankles, wrists, and various places on the chest.

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Using the 5-step method

To recognizing normal and abnormal heart rhythms, the EKG uses a 5-step method. Throughout this 5-step method it is important to consider:

• Is the speed of the rhythm between 60-100?

• Is it regular?

• Is the complex narrow?

• Is it preceded by a P-wave?

• Do all the complexes look the same?

If all five questions were answered with a “yes”, then this signifies that there was a normal sinus rhythm. Although a normal sinus rhythm is usually associated with normal hemodynamics, it is important to check blood pressure to validate stability.

5-step Reading Method

1. Evaluate the speed of the rhythm— too slow or too fast—to determine if it is normal. Note: A speed between 60-100 maintains the best hemodynamic stability. Rates less than 60 or greater than 100, can lead to hemodynamic instability and become symptomatic.

2. Determine whether the rhythm is regular. Note: Rhythms originating from the normal pacemakers in the heart will be regular. Irregular rhythms indicate extra beats or abnormal rhythms.

3. Assess the shape of the complex. Note: A narrow complex is normal. A wide complex indicates conduction abnormalities.

4. Asks if a P-wave precedes the QRS complex. Note: This represents normal conduction from the atria to the ventricles. If the P-wave is absent, the impulse is being generated from elsewhere in the heart.

5. Assess whether all the complexes look the same. Note: Normal conduction follows the same pathway with each beat. Different looking complexes indicate the some impulses are following alternative or aberrant pathways.

Holter Monitor

A Holter monitor, or an ambulatory electrocardiography device, is used to continuously—24hr. — monitor recording of a patient's EKG (heart activity). A patient wears the Holter monitor throughout their daily activities to help the physician correlate symptoms of dizziness, palpitations (a sensation of fast or irregular heart rhythm) or black outs. Because patient will use the Holter monitor throughout their regular daily activities, any abnormality of the heart will likely be detected. The Holter monitor also helps evaluate the patient's EKG during episodes of chest pain.

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Preparing a Patient for the Holter Monitor Exam

• Patients should wear loose-fitting clothes

• Patient should unbutton their shirt or blouse so that the EKG electrodes can be conveniently applied.

• Patients should carry the monitor in a relatively discreet manner

• Patients should wear the recording device can be worn on a belt or in a case on a strap worn across the chest. Note: Individuals who want to minimize the visibility of the device can wear layers or bulky clothes so the case is not as obvious.

• Patient wearing the monitor should carry out their daily activities as they normally would. Note: The purpose of the monitoring in normal life style conditions is necessary for a successful reading.

• Patients can remove the Holter monitor when engaging in any activities associated with water such as showering. Note: Device can also be removed during the batteries or electrodes change.

Performing the Exam

1. Clean the patient’s chest with alcohol solution to ensure good attachment of the EKG electrodes. Note: Men may expect to have their chest partially shaved to help the electrodes stick.

2. Connect electrodes to a small tape recorder using thin wires.

3. Secure tape recorder to the patient's belt or it can be slung over the shoulder and neck with the use of a disposable pouch. Note: It takes approximately 10 to 15 minutes to apply the monitor and less than 5 minutes to remove it.

4. Patient will wear the recorder for 24 hours and should be instructed to carry on with their regular daily activities.

5. Instruct patient to remove recorder when taking a shower to avoid getting the setup wet and damaging.

6. Patient should keep a diary or log to record activity: i.e. walking, running, emotional changes, as well as heart activities such as skipped heartbeats, chest discomfort, dizziness, etc.

7. After 24 hours, the Holter monitor needs to be returned to the laboratory.

8. After the Holter monitor is returned to the physician or hospital lab, the tape is removed from the recorder and scanned by a technician.

9. Multiple EKG strips are recorded on paper together with a computer-generated summary that provides details about the patient's heart activity during the recording.

10. Physicians will then need to check the results of the exam. Note: Physician will determine whether patient will need a signal analysis

Treadmill Stress Machine

Because patients with coronary artery blockages may have minimal symptoms and an unremarkable or unchanged EKG while at rest, symptoms and signs of heart disease may become visible by exposing the heart to the stress of exercise. During exercise, healthy coronary arteries dilate (develop a more open channel) than an artery that has a blockage. Most commonly, a motorized treadmill is used for exercise, while a stationary bicycle is used in some exercise laboratories.

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Regular Stress Test

A regular stress test is considered in the following circumstances:

• Patients with symptoms or signs that suggest a coronary artery diseases (CAD).

• Patients with significant risk factors for CAD.

• To evaluate exercise tolerance when patients have unexplained fatigue and shortness of breath.

• To evaluate blood pressure response to exercise in patients with borderline hypertension.

• To look for exercise-induced serious irregular heart beats.

A regular stress may be sufficient in stable patients or those with a low suspicion of coronary artery disease who are being assessed for exercise tolerance. However, it is important to remember that the regular stress test is heavily dependent upon interpretation of EKG changes produced by exercise.

Preparing for the Regular Stress Test

To better prepare patients for the Regular Stress Test, patients should:

1. Not eat or drink for three hours prior to the procedure as this reduces the likelihood of nausea that may accompany strenuous exercise after a heavy meal. Note: Diabetics, particularly those who use insulin, will need special instructions from the physician's office.

2. Not take specific heart medicines one or two days prior to the test.

3. Not wear tight clothes, but rather wear comfortable clothing and shoes that are suitable for exercise.

4. Not sign the consent form until an explanation of the test is provided to them.

A patient should allow approximately one hour for the entire test, including the preparation. Experienced medical staff should be in attendance at all times to manage any rare complications: i.e. irregular heart beats, unrelieved chest pain or even a heart attack. If a patient is able to achieve the target heart rate, a regular treadmill stress test is capable of diagnosing important disease in approximately 67% or 2/3 rd of patients with coronary artery disease.

Performing a Regular Treadmill Stress Test

1. Take patient to the exercise laboratory.

2. Record the heart rate and blood pressure at rest.

3. Attach electrodes to the chest, shoulders and hips.

4. Connect electrodes thin wires to the EKG portion of the Stress test machine.

5. Record a 12-lead EKG on paper. Note: Each lead of the EKG represents a different portion of the heart, with adjacent leads representing a single wall.

5. After patient gets on the treadmill start it at a relatively slow speed to allow patient to warm-up.

6 Increase treadmill speed every three minutes and according to a preprogrammed protocol. Note: Each three minute interval is known as Stage 1, Stage 2, and Stage 3, etc.

6. The EKG results are constantly displayed on the monitor and recorded on paper at one minute intervals.

7. Pay close attention to the heart rate, blood pressure, changes in the EKG pattern, irregular heart rhythm, and the patient's appearance and symptoms.

7. Stop the treadmill when the patient achieves a target heart rate. Note: If the patient is doing well at peak exercise, the treadmill test may be continued further.

8. Stop the treadmill if the patient develops significant chest discomfort, shortness of breath, dizziness, unsteady gait, or if the EKG shows alarming changes or serious irregular heart beats, or if the blood pressure (BP) rises or falls beyond acceptable limits.

Ultra Sound Machine

The ultrasound machine allows seeing the inside of the heart to identify abnormal structures or functions measuring blood flow through the heart and major blood vessels. This equipment transmits high-frequency (1 to 5 megahertz) sound pulses into your body using a probe. The central processing unit (CPU) does all of the calculations and contains the electrical power supplies for itself and the transducer probe. The sound waves travel into your body and hit a boundary between tissues.

The machine calculates the distance from the probe to the tissue or organ (boundaries) using the speed of sound in tissue (5,005 ft/s or1,540 m/s) and the time of the each echo's return (usually on the order of millionths of a second). The distances and intensities of the echoes are displayed on the screen, forming a two dimensional image. In a typical ultrasound, millions of pulses and echoes are sent and received each second.

Maintaining the Ultrasound Machine

Maintaining an ultrasound machine is vital for continued and accurate use in patient diagnostic testing. Because the ultrasound equipment is necessary for a smoothly functioning medical lab, the care, prevention and maintenance of the machine should be strictly followed on a routine basis. It is important to consider that a maintenance agreement will be necessary, as well as an ultrasound cleaner.

1. Schedule preventative machine maintenance and cleaning by a service representative on a quarterly basis.

2. Check the ultrasound equipment daily.

3. Make sure that all of the connections are plugged in properly.

4. Look carefully at the integrity of the wiring, cables and transducers.

3. Wipe down the transducers and patient physiology cables—cables that monitor the heart rate and vital signs—after each patient exam using an ultrasound cleaner.

4. Follow any rigid cleaning protocols, such as sterilization for certain types of transducers used for specific procedures.

5. Wipe down the machine thoroughly at the end of each shift and write down any glitches or problems that you may have noticed during any of the exams done during your shift.

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