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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.
2.
3.
4.
Set correct pressure on suction source.
Verify patency of suction catheter.
Assure hyper-oxygenation of patient before and after suctioning.
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
1. Set correct pressure on suction
source.
SAT UNSAT
COMMENTS
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 machinevolume 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
1. Identify the ventilator mode and
describe.
2. Identify the FiO2.
3. Identify the ventilator respiratory rate
setting.
4. Identify the patient’s respiratory rate.
5. Identify the Tidal Volume setting.
6. Identify the presence of PEEP.
7. Identify low and high pressure alarms
and describe likely causes of each.
8. Complete all critical elements within
five minutes.
RETEST:
Comments:
Date:
Evaluator:
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
Dobutamine
Levophed
Heparin
Nitroglycerin
Sodium Nitroprusside (SNP)
Morphine
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
1. What rate (ml/hr) do you expect the Nitroglycerine to be infusing?
2. What rate (ml/hr) do you expect the Dopamine to be infusing?
3. 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?
4. 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?
5. 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?
6. 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
7. 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?
8. 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:
1.
2.
3.
4.
5.
6.
7.
8.
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
WHAT
Catheter in peripheral artery.
Pressure in artery read by
transducer, displays on monitor.
WHY
1.To read B/P continuously
2. To draw ABGs frequently
WHERE IT ENTERS
Peripheral Artery: radial, femoral,
or dorsalis pedis (foot).
KIND OF BLOOD
Arterial - Oxygenated
NORMS
same as cuff pressure
EQUIPMENT
 Heparinized IV solution
(lOOOu/500cc D5W)
Or Normal Saline
 Pressure cuff (to 300 mm/Hg.)
 Pressure tubing with transducer
KEY NURSE TASKS
1. Monitor B/P
2. Change dressings daily to
prevent infection.
3. Prevent disconnection, clotting,
bleeding-keep the catheter visible.
4. Keep level of the transducer at
the site of entry.
When discontinuing the art line
hold FIRM pressure for 5-15
minutes followed by a pressure
dressing.
Pulmonary Artery
Catheter tip in pulmonary artery.
Proximal port reads CVP.
Distal port reads the pulmonary
artery pressure, and when balloon
inflated, the wedge.
CVP (proximal port): Detects
high central venous pressure:
CHF or tamponade
Wedge: determines left
ventricular end diastolic pressure:
high = heart failure or tamponade
Measures Cardiac Output
Internal jugular or subclavian
through the superior vena cava,
right atria, right ventricle, to the
pulmonary artery
Central Venous Access Devices
Catheter in a central vein.
Examples: Triple Lumen, PICC
Tunneled: Groshong, Portacath, Broviac, Hickman
Mixed venous - from distal port
PA systolic = 20-30 mm Hg
Diastolic = 10-15 mm Hg
Wedge (PWP, PAW, PCWP)
= 8 to 12 mm Hg
CVP: 2 to 6 mm Hg
Same as the arterial line, plus
lines to keep prox and cordis
ports open.
Distal - Pulmonary Artery
Balloon – reads Wedge through
the distal 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.
NO MEDS in distal port of the
PA catheter, (only proximal port
or cordis)
Monitor for a wedge wave form.
The catheter can be in a wedge
position without the balloon
being inflated. In the wedge
position a segment of lung is
getting no blood flow and can
infarct the area causing severe
hemoptysis.
Venous
CVP Pressures:
SVC - 6-12 cm H20
(Superior Vena Cava)
RA - 0-5 cm. H20
(Right Atria)
IV solution and tubing
Same as arterial line if used to
measure CVP.
24.2
Can be used to give IV fluids,
meds, TPN, blood.
Also used to obtain CVP pressure
reading, detects hyper/hypovolemia
PICC: large veins of arm
Triple lumen catheter: Subclavian
or Internal Jugular
Tunneled catheters: Subclavian
Consent must be signed
X-ray check for placement
Possible complications:
1. Sepsis
2. Air embolism
3. Venous thrombosis
4. Catheter rupture.
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, 419423
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:
Brunner 11th Edition: 758-763, and as needed
Urden, Stacy & Lough, 5th edition, as needed.
1.
Text:
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
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
UNSAT
COMMENTS
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: http://www.madsci.com/manu/indxacls.htm
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
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
Suggestions for
Improvement
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 [email protected].
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: http://www.youtube.com/watch?v=te_SY3MeWys&feature=related
http://www.youtube.com/watch?v=htPIqn-kP08&feature=related
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.
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).
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.
PR: 0.16
QRS: 0.08
Rate: 50
PR: 0.16
QRS: 0.06
Rate: 130
PR: 0.18
QRS: 0.12
Rate: 42
PR: 0.16
QRS: 0.08
Rate: 88
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.
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
INTAKE of FOOD, Elimination Process
INTERACTION
(GI, Metabolic)
(Neurological and Psychosocial)
Diet: NPO, type, amount eaten
Appearance, behavior (Calm vs. Anxious) NG or GT: feedings: type, rate
Orientation to time, place, person and
Height, weight: gain, loss
environment Response to verbal commands Abdominal distention: Nausea, Vomiting
Pupil size and reaction to light
Gastric suction: Gravity, intermittent,
Strength and Sensation of Extremities
continuous
Response to Pain
Gastric output: color, amount
Glasgow Coma Scale
Tubes: Type, location, patency, drainage
Speech: ETT, Trach, dominant language
Bowel Sounds
Method of Communication if intubated
Stool: Last BM, amount, character
Head Dressings
Cervical Collar
Significant Others
INTAKE OF WATER elimination
Spiritual Concerns
process
(Bowel, Bladder, and Skin)
Skin Turgor
INTAKE OF AIR
Intake and Output for 24 hours
(Cardiac)
Vital Signs (pain scale under comfort)
Dialysis: Access site, type, bruit
EKG Strip Interpretation, Ectopics
IV sites: appearance, patency, solution and
Pacemaker
rate
Heart Sounds, S1, S2
Skin:Color, rashes, breakdown,
Jugular vein distention (JVD)
temperature, moist or dry.
Peripheral Pulses, Capillary Refill
Urine output: amount, color, characteristics
Lines: list lines and PA catheter/CVP
Catheter: Foley, Condom, Suprapubic
readings
Chest dressings
ACTIVITY AND REST
(Respiratory)
(Musculoskeletal and Comfortt)
Respiratory pattern, rate, depth
Activity Level
Lung Sounds
Presence of casts, splints, traction,
Sputum: color, amount, consistency
dressings
Chest tubes: Color, amount of drainage,
Bed: Type
fluctuation, air leak
Pain scale, location
Ventilator: ETT or trach, mode, rate, tidal
Sleep pattern
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 instructor to go
over the pump with you.
__EKG strips
Where are EKG strips posted?
Print 3 EKG strips: find one normal
sinus rhythm strip and two with an
abnormal rhythm or ectopics.
Measure the PR and QRS intervals
and heart rate for each strip. Place
these on the reverse side of a care
plan. Ask your instructor for
assistance as needed.
__Syringes
__Alcohol swabs
__IV tubing
__Method of ordering medications not
available on the unit.
__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.
B.
C.
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.
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.
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.
9.
D.
Periodically, make rounds on assigned students and patients.
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.
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
Room number:
Key Findings of Physical Assessment:
Group Leader Name:_________________________________
VS:
Priority Nursing Diagnosis:
Nursing Interventions:
Flow sheets
complete ____
IV and Medication Times
Initials:
Age and Sex:
Date admitted:
Med Charting Complete
____
Therapies: (vent settings, lines, drip
medications, Foley, tubes)
Dx:
Priority Collaborative Problem:
Signs and Symptoms to monitor for:
Hx:
AM/PM Care
Completed and Charted:
_____
Turns completed and
charted: ___________
Primary Nurse:
M F Age:
Room number:
Key Findings of Physical Assessment:
VS:
Priority Nursing Diagnosis:
Nursing Interventions:
Flow sheets
complete ____
IV and Medication Times
Initials:
Med Charting Complete
____
Age and Sex:
Date admitted:
Therapies: (vent settings, lines, drip
medications, Foley, tubes)
Priority Collaborative Problem:
Signs and Symptoms to monitor for:
Dx:
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
complete ____
Initials:
Age and Sex:
Date admitted:
Dx:
Hx:
Med Charting Complete
____
Therapies: (vent settings, lines, drip
medications, Foley, tubes)
Priority Collaborative Problem:
Signs and Symptoms to monitor for:
AM/PM Care
Completed and Charted:
_____
Turns completed and
charted: ___________
Primary Nurse:
IV and Medication Times
Room number:
Key Findings of Physical Assessment:
VS:
Priority Nursing Diagnosis:
Nursing Interventions:
Flow sheets
complete ____
IV and Medication Times
Initials:
Age and Sex:
Date admitted:
Med Charting Complete
____
Therapies: (vent settings, lines, drip
medications, Foley, tubes)
Dx:
Priority Collaborative Problem:
Signs and Symptoms to monitor for:
Hx:
AM/PM Care
Completed and Charted:
_____
Turns completed and
charted: ___________
Primary Nurse:
Room number:
Key Findings of Physical Assessment:
VS:
Priority Nursing Diagnosis:
Nursing Interventions:
Flow sheets
complete ____
IV and Medication Times
Initials:
Age and Sex:
Date admitted:
Med Charting Complete
____
Therapies: (vent settings, lines, drip
medications, Foley, tubes)
Dx:
Priority Collaborative Problem:
Signs and Symptoms to monitor for:
Hx:
AM/PM Care
Completed and Charted:
_____
Turns completed and
charted: ___________
Primary Nurse:
Room number:
Key Findings of Physical Assessment:
VS:
Priority Nursing Diagnosis:
Nursing Interventions:
Flow sheets
complete ____
Initials:
Age and Sex:
Date admitted:
Dx:
Hx:
Med Charting Complete
____
Therapies: (vent settings, lines, drip
medications, Foley, tubes)
Priority Collaborative Problem:
Signs and Symptoms to monitor for:
AM/PM Care
Completed and Charted:
_____
Turns completed and
charted: ___________
Primary Nurse:
IV and Medication Times
PEER EVALUATION SHEET
Group Leader Name ____________________
Date
__________________________
Student __________________________
Strengths:
Student __________________________
Strengths:
Areas to improve:
Areas to improve:
__________________
______________________
Evaluator
Student Signature
Student __________________________
Strengths:
__________________
______________________
Evaluator
Student Signature
Student __________________________
Strengths:
Areas to improve:
Areas to improve:
__________________
______________________
Evaluator
Student Signature
Student __________________________
Strengths:
__________________
______________________
Evaluator
Student Signature
Student __________________________
Strengths:
Areas to improve:
Areas to improve:
__________________
______________________
Evaluator
Student Signature
Student __________________________
Strengths:
__________________
______________________
Evaluator
Student Signature
Student __________________________
Strengths:
Areas to improve:
Areas to improve:
__________________
______________________
Evaluator
Student Signature
Student __________________________
Strengths:
__________________
______________________
Evaluator
Student Signature
Student __________________________
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
Requisites
Structural and Functional
Assessment
Self-Care Deficits
Nursing Dx/
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*
Goals
Nursing Interventions
Dependent and Independent
Nursing Actions
Nsg
Agency
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
(Include all drugs,
not just those given
by student.)
CLASS
Why is THIS patient
receiving this drug?
Nursing Responsibilities
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:
www.nursingresearchonline.com
American Journal of Critical Care:
http://ajcc.aacnjournals.org/
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
http://www.apastyle.org/elecref.html
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 __________________________________________________
ITEM TO BE EVALUATED
Correct
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
Date ________________
Not
Correct
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:
a) Health deviations caused or associated with the illness
b) 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
Not
Correct
Comments