Critical Care Nursing Manuall I

An Najah Antional UniversityFaculty of NursingDr. Aidah Abu El Soud Alkaissi

An-Najah National UniversityFaculty of Nursing

Critical Care NursingProcedures Manuell

Aidah Abu El Soud Alkaissi

BS Law, BSN, MSN, PhD

2006


CONTENTS1. THE NURSING PROCESS

2. UNIVERSAL TO ALL NURSING PROCEDURES

3. ELECTRICITY IN ICU/CCU

4. HOW TO PERFORM A HEAD TO TOE

5. DRESSING CHANGES TO RADIAL/FEMORAL ARTERIAL LINES

6. REMOVAL OF ARTERIAL LINE

7. CENTRAL VENOUS CATHETER SITE DRESSING

8. CENTRAL VENOUS CATHETER LINE CHANGE

9. CENTRAL VENOUS CATHETER PORT DESIGNATION

10. DRAWING BLOOD FROM A CENTRAL LINE

11. DRAWING BLOOD FROM A CENTRAL VENOUS CATHETER

12. HEPARIN LOCK FOR CENTRAL VENOUS CATHETER LINES

13. REMOVAL OF CENTRAL VENOUS LINE

14. CHEST PAIN

15. EMERGENCY DEFIBRILLATION

16. CARDIOVERSION

17. EMERGENCY INTUBATION (E. I.)

18. SECURING AND CARE OF ENDOTRACHEAL TUBES (ETT's)

19. SUCTIONING A PATIENT WITH AN ENDOCTRACHEAL TUBE (ETT)

20. ENDOTRACHEAL TUBE SUCTIONING PROCEDURE (Infant)

21. SUCTIONING A PATIENT WITH A TRACHEOSTOMY TUBE

22. TRACHEOSTOMY DRESSING

23. CLEANING OF ELECTRICAL EQUIPMENT CONTAMINATED WITH BODY PRODUCTS

24. COOLING OF PATIENTS

25. CPAP FACE MASKS

26. NURSING MANAGEMENT: CONTINUOUS POSITIVE AIRWAY PRESSURE OXYGEN THERAPY (CPAP )

27. COMPLETING THE NEUROLOGIC EXAMINATION


28. DRAWING BLOOD SAMPLES FROM A RADIAL/FEMORAL ARTERIAL LINES ON ADULT PATIENTSCONTENTS29. DRAWING ABG's/ANALYSIS

30. DRAWING BLOOD CULTURES

31. HEAD INJURY PRINCIPLES

32. HUMIDIFICATION - AEROSOL AND NEBULISER

33. LATEX POLICY

34. PULMONARY CAPILLARY WEDGE PRESSURE MEASURE

35. PULSE OXIMETRY

36. ENTERAL FEEDING

37. TOTAL PARENTERAL NUTRITION

38. TRANSFER OF PATIENTS TO OTHER WARD AREAS

39. UNDERWATER SEAL DRAINAGE

40. VENTILATOR CIRCUIT SETUPS AND ASSEMBLY

41. VENTILATOR EMERGENCY

42. PATIENT RECEIVING VENTILATORY ASSISTANCE

43. SENGSTAKEN-BLAKEMORE TUBE


1. The NURSING PROCESS

The nursing process is based on a nursing theory developed by Ida Jean Orlando. She developed this theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing. From her observations she learned that the patient must be the central character. Nursing care needs to be directed at improving outcomes for the patient, and not about nursing goals. The nursing process is an essential part of the nursing care plan.

The nursing process is perhaps one of the most misunderstood nursing theories, and yet one of the most effective as well as practical. It takes time for students and new nurses to get the hang of this process, and many fight it every step of the way, until one day a light bulb begins to burn brightly.

The nursing process is really not as complicated as it seems.

It is basically five steps. Originally, Ms. Orlando had four, but through practical application over the past 40 years, one step became two and now we have five. All nursing personnel take part in the nursing process. The RN has the primary responsibility however.

The Five Steps Assessment

Diagnosis

Planning

Implementation

Evaluation

AssessmentThis is the data collection step. For RNs it also entails analyzing the data.

Assessment involves taking vital signs, performing a head to toe assessment, listening to the patient's comments and questions about his health status, observing his reactions and interactions with others. It involves asking per tenant questions about his signs and symptoms, and listening carefully to the answers.

Once you have collected the data, the process moves on to analysis of the data to determine the health status, the patient's coping mechanisms or lack thereof, his ability to use these mechanisms and to identify his problems related to his health status.

DiagnosisNurses only make nursing diagnoses. Once you have identified the patient's problems related to his health status, you formulate a nursing diagnosis for each of them. You will also prioritize the problems in formulating your plan and goals. The nursing diagnoses are categorized by a system


commonly referred to as NANDA.

The North American Nursing Diagnosis Association (NANDA) has now become an international group who works to classify nursing diagnoses, and to review and accept new diagnoses as needed. The RN chooses a nursing diagnosis from the NANDA list which most closely describes the patient's problem related to his health status. This might be a current problem or a potential problem which needs to be addressed. It can even be a problem that relates to his family rather than to him alone such as the family's inability to cope with life style changes necessitated by the patient's illness.

PlanningSetting goals to improve the outcomes for the patient are a primary focus of the nursing process. Based on the nursing diagnoses, what are the expectations for this patient? This is not about nursing goals. This is about improving the quality of life for your patient. This is about what your patient needs to do to improve his health status or better cope with his illness.

Planning also involves making plans to carry out the necessary interventions to achieve those goals.

ImplementationSetting your plans in motion and delegating responsibilities for each step. Communication is essential to the nursing process. All members of the health care team should be informed of the patient's status and nursing diagnosis, the goals and the plans. They are also responsible to report back to the RN all significant findings and to document their observations and interventions as well as the patient's response and outcomes.

EvaluationThe nursing process is an ongoing event. Evaluation involves not only analyzing the success of the goals and interventions, but examining the need for adjustments and changes as well. Evaluation leads back to Assessment and the whole process begins again. The evaluation incorporates all input from the entire health care team, including the patient.

The Whole PatientThe nursing process involves looking at the whole patient at all times. It personalizes the patient. He is not "the CVA in 214B." It also forces the health care team to observe and interact with the patient, and not just the task they are performing such as a dressing change, or a bed bath. The process provides a roadmap that ensures good nursing care and improves patient outcomes.


2. UNIVERSAL TO ALL NURSING PROCEDURES

There are certain things that are universal to all nursing procedures whether they are performed in a hospital, clinic, physician's office or home health care setting.

Verify the physician's order

Gather all necessary equipment (charge it out as appropriate)

Identify the patient

Introduce yourself and explain the procedure to the patient

Wash your hands

Don necessary protective equipment (gloves, gown, goggles, etc.)

Provide for patient privacy including draping as necessary

Perform procedure according to protocol

Utilize proper body mechanics

Position patient for comfort

Explain each step to the patient

Observe patient's response to all steps

Clean and position patient for comfort. Return bed to original position and adjust side rails.


3. ELECTRICITY IN ICU/CCU

Electricity in ICU/CCU plays a vital role in lighting, powering equipment, defibrillation and monitoring.

STANDARDS:

* All cardiac protected areas are marked with the appropriate sign.* Cardiac procedures are only carried out in the specified areas. * All patients in ICU/CCU will be protected from both macro electrocution and micro electrocution by use of cardiac protected wiring.* All patients having an invasive procedure with risk of micro electrocution e.g. pulmonary artery catheters, temporary pacing wires should have earthing cables attached between equipotential junction (green earth outlets) and the patients bed.* If electrical equipment is on an IV pole not attached to the bed it also must be earthed to the equipotential junction.* The ICU power supply is covered by an uninterupted power supply. The power outlets that access this are the green power switch on the right side of each patient column. The ventilator should be plugged into this at all times. No other electrical equipment should be plugged into this power point.* All other power points are covered by the hospital generator in the event of a power failure.

NB: There will be a 20 second delay before the power is restored.* There is a risk that mobile phones may interfere with the function of sensitive electrical equipment and as such no mobile phones are to be used within the ICU/CCU.* In the event of a circuit breaker tripping, the electrical equipment protected by the circuit breaker should be removed, the circuit breaker reset and each piece of equipment replaced one at a time. If the circuit breaker retrips, the faulty piece of equipment should be removed and sent for checking by the electrical service dept.

OUTCOMES: Patients undergoing procedures and ongoing treatment in ICU/CCU will be protected from electrocution in both micro and macro forms.


4. HOW TO PERFORM A HEAD TO TOE

A head to toe assessment is a vital aspect of nursing. It should be done each time you encounter a patient for the first time each shift or visit. It includes assessment of the physical, emotional and mental aspects of all body systems as well as the environmental issues affecting the patient.

Here's How: Wash your hands and assemble equipment. Greet the patient and explain what you need to

do.

Provide for privacy.

Begin with the 5 vital signs: Temperature, Pulse, Respirations, BP and Pain. Ask the patient how he feels and observe the environment. As you assess the body by systems observe for mobility and ROM.

HEENT

Head: shape and symmetry; condition of the hair and scalp

Eyes: conjunctiva and sclera, pupils; reactivity to light and able to follow a finger or light

Ears: hearing aids, pain, hears whispers, comprehension

Nose: drainage, congestion, difficulty breathing or with sense of smell

throat and mouth: mucous membranes, any lesions, teeth or dentures, odor, swallowing, trachea, lymph nodes

As you examine all body systems observe the integumentary system for any breaks in the skin, scars, lesions, wounds, redness or irritation. Also note turgor, the color, temperature, and moisture of the skin.

Thoracic region. Assess lung sounds and cardiac sounds. Front and back: assess for character and quality as well as the presence or absence of appropriate sounds. Palpate the chest wall and breasts for any tenderness, lumps.

Abdomen: Listen to bowel sounds throughout the four quadrants. Palpate for tenderness or lumps. Palpate the bladder. Ask about Intake and appetite, and output both urinary and bowels

Genetalia: assess for tenderness, lumps or lesions

Extremities: Assess for temperature, capilary fill and ROM. Palpate pulses. Note any edema, lesions, lumps, pain.

Ask the patient how he feels. Has anything changed recently? Any pain, burning, SOB, chest pains, change in bowel or bladder habits, change in sleep habits, cough, discharge from any orafice, depression, sadness, change in appetite.

Wash your hands. Document your findings. Report any significant changes or findings to


the MD.

What You Need: Pen

Assessment forms or note paper

Thermometer

Watch with second hand

Stethoscope

Sphygmomanometer

Penlight

Tape measure


5. DRESSING CHANGES TO RADIAL/FEMORAL ARTERIAL LINES

STANDARDS: * Registered Nurses accredited to work with pressure lines in an Intensive Care Setting and Registered Nurses training to work in an Intensive Care Setting under the supervision of an accredited Registered Nurse may manage Radial/Femoral Arterial Lines* Arterial Catheter dressings must be changed at least every 48hrs or when dressing becomes soiled.* Area around catheter insertion site will remain free from any signs or symptoms of possible infections.* Area around catheter insertion site will remain aseptic to decrease changces of possible infection.* Any sign of infection or possible infection will be reported to the Physician for assessment at the earliest possible moment.

OUTCOMES: * The area around the catheter insertion site is to remain infection free during the hsopital stay of the patient.* If signs of infection do occur, arrangements must be made with the Physician for earliest possible site changed to be carried out.

EQUIPMENT:

Dressing pack x 1 Hansaport wound dressing 15cm x 8cm x 1cmHibitane solution Rubbish binMicropore tape Overbed table PROCEDURE: * Explain the procedure to patient prior to commencement.* Aseptic preparation prior to commencing procedure.* Prepare dressing pack at bedsie on overbed table prior to positioning patient.* Remove armband and place arm on bed with dressing facing up. If patient restless have second nurse to secure limb to avoid accidental removal of arterial line.* Remove old dressing and check site for erythema, drainage, tenderness, suture integrity and catheter position.* Clean area around insertion site with Hibitane solution, allow area to dry before applying Hansapor dressing. Ensure pressure line loops over top of Hansapor dressing.* Use micropore tape to secure pressure line and transducer so it will not interfer when armboard placement.


* Replace armboard and secure with velcro straps.* Check monitor to ensure adequate wave form, depressed wave form may indicate a bend in the arterial line.* Label dressing with time and date of change.* Record date and time of next dressing change on flow chart.* Note in patient's chart condition of insertion site and inform Physician of signs of infection.

Ref: Maki G (1994), Infection Associated with Indwelling Medical Devices, 2nd Ed., Ch 8, pg 188-189


6. REMOVAL OF ARTERIAL LINE

STANDARDS: * Arterial Lines are to be removed prior to transferring patients to the ward

Arterial Lines sites should be rotated at least every seven (7) days or sooner if infection occurs* Post removal Arterial Line site must be observed for bleeding, bruising and swelling frequently over the next 24 hours* Upon removal of the arterial Line, Universal precautions must be maintained to avoid contamination of the health care worker through exposure to blood borne pathogens.* Aseptic technique is used at the insertion site to decrease chances of infection to the patient.

OUTCOMES: * The area around the catheter insertion site is to remain infection free during the hospital stay of the patient.* If signs of infection do occur, arrangements must be made with the Physician for earliest possible site changed to be carried out.* There will be no excessive blood lose, swelling or bruising post removal of Arterial Line

EQUIPMENT:

Dressing pack x 1

Elastoplast dressing

Hibitane solution

10cm x 10cm gauze Suture cutter

PROCEDURE: * Explain the procedure to patient prior to commencement.* Aseptic preparation prior to commencing procedure.* Prepare dressing pack at bedside on over bed table prior to positioning patient.* Remove armband and place arm on bed with dressing facing up. If patient restless have second nurse to secure limb to avoid accidental removal of arterial line.* Ensure pressure bag is clamped off to Arterial Line* Remove old dressing and check site for erythema, drainage, tenderness, suture integrity and catheter position.* Clean area around insertion site with Hibitane solution.


* Remove sutures holding in Arterial Line. Protect against accidental removal of the Arterial Line at this point to avoid unnecessary blood lose from artery

Place sterile gauze over insertion site and apply pressure too site while withdrawing Arterial Line* Pressure should be maintained at least 5 minutes over site to prevent blood lose and excess bruising and swelling.

* Longer periods of applied pressure will be necessary if the patient has been anti-coagulated

* Observer site and when bleeding and swelling have stopped remove old gauze. Applied new sterile gauze over insertion site and secure with Elastoplast dressing.

* Continue to observe site for bleeding* Chart that Arterial line has been removed time, date and condition of catheter. Chart condition of patients skin i.e. swelling, redness or discharge


7. CENTRAL VENOUS CATHETER SITE DRESSING

STANDARDS: * Management and care of Central Venous Catheters (CVC) may only be undertaken by Registered Nurses accredited to give intravenous medication and Registered Nurses accredited to give intravenous medication may undertake training to care for CVC.* Central Venous Catheter dressings must be changed at least every 72 hours or when dressing becomes soiled.* Area around catheter insertion site will remain free from any signs or symptoms of possible infections.* Area around catheter insertion site will remain aseptic to decrease chances of possible infection.* Any sign of infection or possible infection will be reported to the Physician for assessment at the earliest possible moment.

OUTCOMES: * The area around the catheter insertion site is to remain infection free during the hospital stay of the patient.* If infection does occur, arrangement must be made with the Physician for earliest possible site change to be carried out. EQUIPMENT: Dressing pack x 1 Hansapor (wound dressing) 15 cm x 8 cm x 1 Hibitane solution Rubbish bin.

PROCEDURE: * Explain procedure to patient prior to commencement.* Aseptic preparation prior to commencing procedure.* Prepare dressing pack at bedside prior to positioning patient.* Place patient in supine position.* Remove old dressing and check site for discomfort, redness, inflammation and/ or leakage of fluids from around insertion site.* Clean area around insertion site with Hibitane solution, allow area to dry before applying Hansapor dressing.* Label dressing with time and date of change.* Record date and time of dressing change on flow chart.* Note in patient's chart condition of insertion site and inform Physician of signs of infection.


8. CENTRAL VENOUS CATHETER LINE CHANGE

STANDARDS:* Management and care of CVC may be undertaken by Registered Nurses accredited to give intravenous medication.* A volumetric flow devise must be used when fluids are being administered through any CVC line ( ie. Gemini infusion pump).* Central Venous Catheter external tubing changes must be preformed every seventy-two (72) hours, or- if there is damage to the line- if line contamination occurs.* Procedure must be carried out under strict asepsis.* All infusion tubes to be labelled with the time and date of last change.* Catheters must not be compressed with clamps containing serrated teeth.

OUTCOMES: The patient will experience no infection through contamination of the CVC line during his or her stay in the hospital

EQUIPMENT:

Sterile dressing pack two 10 cm x 10 cm sterile gauze packsNew IV administration set ( Gemini) IV solution, as ordered,Hibitane solution one pair sterile glovesInfusion Pump

PROCEDURE:* Explain the procedure to the patient prior to procedure.* Aseptic preparation prior to commencing procedure.* Prepare dressing pack at bedside prior to positioning patient.* Hang new IV solution as ordered by Physician, spike new solution bag with new administration set (protecting distal end from contamination by placing distal end on open dressing pack).* Prime IV line with appropriate solution (remove all air from IV- line) and clamp administration set with roller clamp.* On CVC lumen extension (pigtail) being changed, stop infusion pump and clamp IV line, with roller clamp.* Clamp off line of CVC pigtail being changed with blue slide clamp.* Place new IV administration set and IV solution into Infusion Pump.* Position patient in bed on back.* Thoroughly swab CVC pigtail and IV line being changed 5 cm on both sides of port connection with Hibitane solution from dressing pack.


* Place cleaned CVC pigtail and IV line on sterile towel from dressing pack and allow solution to dry before proceeding to next step.* Start Infusion Pump and allow fluid to run into sterile field of dressing pack.* Disconnect cleaned IV line from CVC pigtail which has been cleaned and place on sterile towel.* Connect new IV line too CVC pigtail and remove blue slide clamp from CVC pigtail.* Observe for leakage or blood back up from CVC pigtail connection site.* Label IV administration set with time and date of change.* Record date and time of next line change on flow chart.* Note in patients' chart that the lines have been changed and any problems noted during procedure.


9. CENTRAL VENOUS CATHETER PORT DESIGNATION

STANDARDS: * To ensure uniformed use of catheter lumens by the Health Care Personnel providing care of Central Venous Catheters and accessing ports for treatment.* Each Port of the CVC should be properly label in accordance to its use. Each label should be placed on the distal end of the infusion line after attachment to the appropriate CVC port.* The usage of each CVC port should be stated in the patients notes and on the ICU flow sheet at each patients bedside.

OUTCOMES: * Uniform usage by hospital staff of CVC ports in accordance with the manufacture's regulations.

LUMEN USAGE

Proximal

Blood SamplingMedicationBlood Administration

Medial

Total Parenteral Nutrition (TPN)Medication ( Only if TPN is not anticipated)

Distal

CVP MonitoringBlood AdministrationHigh Volume or Viscous FluidsColloidsMedication

4 th Lumen

InfusionMedication


10. DRAWING BLOOD FROM A CENTRAL LINE

POLICY : Management and care of CVC may only be under taken by the following:

a) Registered Nurses accredited to give intravenous medicationb) and only Registered Nurses accredited to give intravenous medication may undetake training to care for CVC sites and lines.

STANDARDS :

Procedure should be cared out under strict asepis.

To have a uniformed approach to drawing blood from a centraal line by trained staff.

The CVC is not an ideal site for drawing blood samples but may be used in conditions where other access is not available.

Caution is to be taken when aspirating blood samples from the CVC not to hemolysis sample or collapse/ damage catheter or blood vessel

Caution is to be taken not to contaminate blood sample with solutions infusing through other ports.

OUTCOMES :

The Patient will experience no infection through contamination of the CVC line during his or her stay in the hospital.

Blood samples drawn from the CVC will not be contaminated by other solutions infusing through CVC

No damage will occur to the vessles or CVC during the taking of blood samples from the CVC.

EQUIPMENT :

Sterile dressing pack, two 10cm x 10cm, Hibitane solution, One pair sterile gloves

,Rubbish bin

Yellow leur lock cap, Heparinized Saline

( 50 u/ 50 mls), #19 needle to draw up solutions,


Sodium Heparin 5000 u/ ml, Yellow ' Vacutaainer' shield, Eye protection

,'Vactutainer' luer adaptor, 5 ml syringe x 2, 1 ml syringe x 1, approiate 'Vacutaainers' for collecting blood samples.

PROCEDURE :

Explain procedure to patient prior to commencement

Aseptic preparation prior to commencing procedure.

Prepare drsg pack at bedside prior to postioning patient.

Clamp off port on CVC being changed with blue slide clamp. With multiple lumen catheters blood sampling is done through the Proximal port


11. DRAWING BLOOD FROM A CENTRAL VENOUS CATHETER

STANDARDS: * Management and care of Central Venous Catheters (CVC) may only be undertaken by registered nurses accredited to give intravenous medication* Procedure should be cared out under strict asepsis.* To have a uniformed approach to drawing blood from a Central Venous Catheters by trained nursing staff.* The Central Venous Catheters is not an ideal site for drawing blood samples but may be used in conditions where other access is not available.* Caution is to be taken when aspirating blood samples from the Central Venous Catheters not to haemolysis sample.* Rapid withdrawal can create a vacuum which may damage/ collapse catheter or blood vessel.* Caution is to be taken not to contaminate blood sample with solution infusing through other ports.* Proximal port on the Central Venous Catheter should be designated for drawing blood and kept Heparinized for this reason.

OUTCOMES: * The patient will experience no infection through contamination of the Central Venous Catheters during his/ her stay at LBH.* Blood samples drawn from the Central Venous Catheters will not be contaminated by other solutions being infused through other ports of the same Central Venous Catheter.* No damage will occur too either the blood vessels or the Central Venous Catheters through excessive force while drawing blood.

EQUIPMENT: Equipment as for Heparinizing Central Venous CathetersEye protection ApronYellow Vacutainer Shield Vacutainer luer lockAppropriate blood collection tubes.

PROCEDURES : * Explain procedure to patient prior to commencement.* Aseptic preparation prior to commencing procedure.* Maintain proper barrier protection to protect nurse against possible blood contamination;


prepare dressing pack at patients bed side* Place patient in supine position. Have patient turn head away from Central Venous Catheters site during procedure.* Turn off infusion at least one minute prior to sampling.* See Policy and Procedure for 'Heparin Lock for Central Venous Catheter Lines' * After removing 5 mls of blood from CVC pigtail attached syringe and remove required amount of blood for blood test. Draw off blood for electrolytes and full blood counts prior to coagulation studies. If coagulation studies are the only tests required it may be necessary to draw up to 10 mls of blood for discard prior to drawing sample bloods. * Re-heparinize CVC port following Policy and Procedure for 'Heparin Lock for Central Venous Catheter Lines'.* Record date and time of procedure on flow chart.* Note in patients chart procedure carried out and any problems noted during procedure.


12. HEPARIN LOCK FOR CENTRAL VENOUS CATHETER LINES

STANDARDS: * Management of care of central venous catheters (CVC) may only be undertaken by Registered Nurses accredited to give intravenous medication and Registered Nurses accredited to give intravenous medication may undertake training to care for CVC sites and lines.* Central Venous Catheters lumen extension (pigtail) must be heparin locked when not in use, or after each intermittent medication, to ensure patency.* Procedure should be carried out every forty-eight hours unless line is already assessed.* Procedure must be carried out under strict asepsis.

OUTCOMES: The patient will experience no infection through contamination of the CVC line during his/her stay in Lismore Base Hospital.

EQUIPMENT:

* Sterile dressing pack 2 10-x10cm sterile gauze packs* IV solution, as ordered Hibitane solution* 1 pair sterile gloves Rubbish bin* Yellow luer lock cap one per pigtail Heparin flush (sodium heparin 50u/50mls) per pigtail* 2 x 5ml syringes per pigtail 1 x 1ml syringe per pigtail* Sodium Heparin 5000u/ml needles to draw up solutions

PROCEDURES: * Explain the procedure to the patient prior to procedure.* Aseptic preparation prior to commencing procedure.* Prepare dressing pack at bedside prior to positioning patient.* Clamp off line of CVC pigtail being heparin locked with blue slide clamp.* Position patient in bed on back.* Clamp off line of CVC pigtail being changed, with blue slide clamp.* Remove Heparin label from luer lock cap on pigtail if present.* Thoroughly swab CVC pigtail and IV line being heparin locked, 5 cm down from luer lock cap on pigtail and including yellow cap connection with Hibitane solution from dressing pack.* Place cleaned CVC pigtail on sterile towel from dressing pack and allow solution to dry before proceeding to next step.* Place on sterile gloves.* Disconnect luer lock cap from CVC pigtail which has been cleaned and place on sterile towel.


* Draw out 5 mLs of blood from CVC pigtail with 5 mL syringe from dressing pack set up and discard.* Flush CVC pigtail with 5 mls of Heparin flush, drawn up with the use of sterile gauze to maintain sterility.* Next flush CVC pigtail with appropriate amount of Sodium Heparin 5000 u/ mL with 1 mL syringe also drawn up with the use of sterile gauze to maintain sterility.* Do not allow entry of air into CVC pigtail through injection by syringes.* Place new luer lock cap on CVC pigtail.* Mark luer lock cap on CVC pigtail with green Heparin label.* Observe for leakage or blood back up from CVC pigtail connection site.* Label IV administration set with time and date of change.* Record date and time of next line change on flow chart.* Note in patients' chart that the lines have been changed and any problems noted during procedure.

ADMINISTRATION ISSUES: Standing Orders :* Inject pigtail with the following amounts of IV Sodium Heparin

DOUBLE LUMENDistal ( Brown ) 0.50 mL Sodium Heparin 5000u/ s/ mLProximal ( White ) 0.45 mL Sodium Heparin 5000u/ s/ mL

TRIPLE LUMENProximal ( White ) 0.45 mL Sodium Heparin 5000u/ s/ mLMiddle ( Blue ) 0.40 mL Sodium Heparin 5000u/ s/ mLDistal ( Brown ) 0.50 mL Sodium Heparin 5000u/ s/ mL

QUAD LUMENProximal ( White ) 0.45 mL Sodium Heparin 5000u/ s/ mLMiddle 2 ( Blue ) 0.40 mL Sodium Heparin 5000u/ s/ mLMiddle 1 ( Grey ) 0.50 mL Sodium Heparin 5000u/ s/ mL

Recording of Drug :* The administration is to be entered on the medication chart in the same manner as a telephone order and confirmed by a Medical Officer's signature within 24 hr.* Adopted by the Drug Committee of the Board of Directors.


13. REMOVAL OF CENTRAL VENOUS LINE

STANDARDS: * Management and care of CVC may be undertaken by a registered nurse accredited to give intravenous medication.

* Upon removal of the CVC, Universal precautions must be maintained to avoid contamination of the health care worker through exposure to blood borne pathogens.* Aseptic technique is used at the insertion site to decrease chances of infection to the patient.* Dressing is to remain in place 24-72 hours according to lenght of time that catheter was in place.* Observe patient post removal for the following i.e S&S of bleeding, air embolism or infection of at the site.

OUTCOMES: * The patient will experience no infection through contamination of the CVC site during his or her stay in the hospital.

EQUIPMENT:

Sterile dressing pack Air occlusive dressing i.e. tela gauze with antimicrobial ointment

Hibitane solution

One pair sterile gloves

Rubbish bin Sterile jar to collect catheter tip if infection is suspected

Stitch cutter for removing sutures, Sterile scissors

PROCEDURE: * Explain the procedure to the patient prior to procedure.* Aseptic preparation prior to commencing procedure.* Prepare dressing pack at bedside prior to positioning patient.* Turn off all infusions * Place patient in Trendelburg or supine position.* Instruct patient to preform Valsalva maneuver or to hold breath on command.* If tip of catheter to be sent for cultures have sterile equipement ready.* If tip to be cultured prep skin around site with aseptic solution and remove catheter at 90 degree angle* Remove suture holding in CVC while insuring CVC does not accidently migrate out. Ensure all


suture material has been removed.* As catheter is removed ask patient to preform Valsalva maneuver or to hold breath.* Immediately cover area with sterile guaze to apply pressure to area.* Cover the site with occulsive dressing while patient is still reforming Valsalva maneuver.* Reposition patient. * Chart that central line has been removed time, date and condition of catheter. Chart type of catheter removed. Chart condition of patients skin i.e. swelling, redness or discharge.


14. CHEST PAIN

POLICY: Management of chest pain may be undertaken by registered nurses.

STANDARDS:

- Patients admitted to Coronary Care Unit.

- All patients to be monitored and rhythm strips to be recorded fourth hourly.- Patients to have intravenous access unless otherwise ordered by medical officer.- All events must be recorded chronologically in progress notes.- Medications charted; date and time.- Serial ECG's attended.- Serial cardiac enzymes attended.

PROCEDURES:

- Oxygen 6-8 litres administered via hudson mask.- A physical assessment to be carried out. (Physical assessment should include time of onset, intensity i.e. pain score out of 10).- Observations including BP and pulse.- If pain persists and systolic BP 100, administer SL arginine and repeat dose up to 3 times in 10 minutes.- If pain still persists, contact physician for review and possible IV nitrate therapy.- Attend ECG.

OUTCOMES: Pain free status in patient.


-

15. EMERGENCY DEFIBRILLATION

STANDARDS: * Defibrillation may be performed by any Registered Nurse accredited to Emergency Care Protocol (ECP).* ECP protocol guidelines are to be followed at all times.* Establish and document that patient is definitely in life threatening rhythm i.e. VF/VT, compromising satisfactory circulation and consciousness.* Deliver appropriate defibrillation effectively and restore normal cardiac rhythm and output.

OUTCOMES: * To revert heart rhythm to sinus pathway.* To promote rapid recovery after delivering effective defibrillation.* To prevent injury or danger to the client and staff by incorrect or negligent defibrillation.

SPECIALCONSIDERATIONS:* All stages of nursing actions should be documented with rhythm strips i.e. VF/VT, sinus/idioventricular.* Settings for defibrillation (in Joules) should follow ECP protocol i.e. 200 joules, 360 joules.


16. CARDIOVERSION

INTRODUCTION: Synchronised Cardioversion:

INDICATIONS:- Atrial fibrillation- Atrial flutter- Atrial tachycardia- Supraventricular tachycardias

Unsynchronised Cardioversion/Defibrillation: INDICATIONS:- Ventricular tachycardia - compromising- Ventricular fibrillation

Both compromising causing loss of consciousness.

STANDARDS: * Management and care of cardioversion procedure is to be undertaken by:- Medical officers of either ICU or CCU.- Registered nurses who have been accredited for the emergency care protocol or FLEC (First Line Emergency Care) accredited by the Health Service.* In emergency situations registered nurses only who are FLEC accredited may defibrillate in a cardiac arrest.* Procedure should be carried out by authorised medical personnel.* Should be done under close monitoring continuous ECG and recording facilities. * Cardioversion requires an anaesthetist and anaesthetic agents, laerdel bag and oxygen equipment to maintain airway with induced unconsciousness.* The defibrillator should be checked prior to use and the emergency trolley should also be checked and placed in patients room.* Ensure patient has been on NBM for 4-6 hours prior to elective cardioversion.* Ensure patient has an IV cannula.* Ensure a recent 12 lead ECG is available and recording of a baseline observation.* Patient should have procedure explained to them by medical officer and a consent form signed.* All cardioversion being elective are to be attended in ICU or CCU.

OUTCOMES: The procedure will be terminated either by a successful reversion to sinus rhythm or when the medical officer determines that cardioversion will not revert the rhythm.


SPECIAL CONSIDERATIONS:

In elective cardioversion the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrhythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle (the peak of the R wave) so as to avoid discharging during the relative refractory stage of the cycle (the end of the T wave), as this may result in the development of ventricular fibrillation.

EQUIPMENT:

* Defibrillator with a synchronising button* Emergency trolley with emergency drugs; atropine and adrenaline* Intubation equipment* Oxygen mask, laerdel bag - Guedels airway* Hudson mask* Monitor and continuous recording facilities

PRE PROCEDURE: PATIENT PREPARATION:* Baseline observations - BP pulse and ECG for post procedure comparison.* Be aware of the patients serum K+ level or whether the patient has been digitalised. Notify medical officer.NB: Digitalis is usually discontinued 24-36 hours prior cardioversion; its presence may result in an increased risk of cardioversion induced arrhythmias.* Ensure patient IV access.* The patient is connected to the monitoring function of the defibrillator baseline rhythm recorded, Lead selected for recording, Lead II.

PROCEDURE: * The anaesthetic agents are chosen by the Anaesthetist; short acting general anaesthetics. The patient will require recovery nursing care.* Once the patient is anaesthetised get gel pad interface or defibrillator pads are applied to the chest. The correct positions are to the right of the upper sternum for the sternal pad and paddle and between the left midclavicular line and the left mid axillary line for the apical pad and paddle.* Place defibrillator paddles over the gel or defibrillator pads apply 10-12kg of weight; charge machine to the joule level selected by the medical officer. Commencement at 50-150j increasing to 300-360j.* Ensure bed is clear; no one is in contact.* Press the discharge buttons and maintain pressure on the paddles for one second following electrical discharge.

POST PROCEDURE: * The procedure will be terminated either by a successful reversion to sinus rhythm or when the medical officer determines that cardioversion will not revert the rhythm.* Ensure the patients airway is patent.


* Patient nursed in the left lateral position until fully conscious. Oxygen administration c/- hudson mask.* BP record immediately post procedure at 5 minute intervals for 15 minutes then 15 minute intervals for 2 hours.* A 12 lead ECG is recorded within _ an hour of the procedure. * Documentation should include:- Pre and post procedure ECG- Pre and post procedure rhythm strip- Pre and post procedure observations- The number of shocks and joules used- The condition of the skin following cardioversion


17. EMERGENCY INTUBATION (E. I.)

EMERGENCY INTUBATION (E. I.)

STANDARDS: * Emergency intubation to be undertaken by the medical officer skilled in this procedure.* Persons warranting E.I. must have a registered nurse in constant attendance.* IV access made available.* Cricoid pressure to be applied prior to intubation and removed only after cuff inflation.* Cuff inflated to 20mmHg and no more than 30mmHg.* Positioning of the ETT is verified by observing chest movement.* Auscultation of the chest and stomach.* Chest x-ray (reviewed by medical officer).* ETT sizes ranging from 2.5mm to 9.5mm. Selection appropriate to patient size.* Necessary drugs are prescribed and administered at medical officers request.

OUTCOMES: Patient airway available with means to maximise respiratory function.

EQUIPMENT:

* Oxygen* Suction* 10ml syringe attached to buffered artery forcep* Laryngoscope* Magills forceps* Lubricant (H20 solution or L.A.)* 1m white tape* Scissors* Geudel airway * Laerdal resuscitation and mask* Yankeur sucker* Drugs as ordered* Stethoscope* Leucoplast tape

PROCEDURE: * Excess secretions/foreign bodies removed from oropharynx prior to procedure.* Patient pre-oxygenated with 100% oxygen.


* Patient placed in supine position with adequate access to the head.* Drugs prepared and available close to IV access.* Manual of mechanical ventialtion comenced when ETT in situ.* Record size of ETT and placement at the lips.* Observe and record respiratory observations.


18. SECURING AND CARE OF ENDOTRACHEAL TUBES (ETT's)

STANDARDS: * All registered nurses and medical officers may secure and care for endotracheal tubes. Two people are required for this procedure.* The endotracheal tube will be secured in such a way as to maintain its desired position.* The cuff pressure of an endotracheal tube will be checked once a shift and prn.* The endotracheal tube will be secured in such a way as to prevent pressure sores from developing.* The endotracheal tube will be secured so as not to occlude the pilot tube.

OUTCOMES: * The patient will not develop problems with pressure sores from securing an ETT.* The ETT will not become malpositioned.

EQUIPMENT:

* 1.5 m length of _ inch cotton tape* Acetone* Friars balsam* Large cotton applicators* Leucoplast tape - 1 inch

PROCEDURE: * Once the ETT is placed in the patient and position is checked by auscultation the ETT is tied in using white cotton tape. * The tape is doubled and the loop end placed near the ETT. The two ends of the tape are then passed around tube and through the loop forming an initial knot that is tied firmly. A reef knot is then tied over this.* The ends of the tape are then passed around the patients neck and tied at the side of the neck using a reef knot.* The tape should be tight enough to prevent migration of the tube but must allow one finger to be placed under it at any point.* A chest x-ray should be attended to check on position of ETT and the distance of the tube at the patients lips.* Leucoplast tape is then prepared for more permanent tube security by cutting two pieces approx. 20cm long and cutting each to form trouser leg shape with legs approx. 12cm long.* One operator secures tube by hand whilst the other removes white cotton tape.* The cheeks are cleaned with acetone, shaved if necessary and then painted with friars balsam


except if allergy noted.* The leucoplast is applied so as main body of tape sits on cheeks and the bifurcation sits at the corner of the mouth. One leg of each tape is secured around tube and one leg is taped to either the top or bottom of each lip.* The tube is to be anchored to both top and bottom lips to ensure good security.* An additional piece of tape can be placed over the tape and under the lower lip to give added security.

POST PROCEDURE: Note tube distance at patients lips on the patients flow chart.


19. SUCTIONING A PATIENT WITH AN ENDOCTRACHEAL TUBE (ETT)

STANDARDS: * Aseptic technique will be used when suctioning.* Suction catheters should be less than half the size of the endotracheal tube insitu.* During suctioning procedure the catheter should only occluded for 5 second intervals.* The catheter should be inserted into the trachea tube with gentle pressure and withdrawn from the trachea tube using a rotating technique.* The patient should be monitored by oximetry for O2 saturation during the procedure.* The need for suctioning should be assessed at least every two hours or more frequently as need arises.* Suctioning should be performed PRN or at frequent intervals as ordered by Physician.* Over suctioning should be avoided to decrease potential damage to patients airway.

OUTCOMES: * Explain the procedure to the patient prior to procedure.* Aseptic preparation prior to commencing procedure.* Open sterile gloves and suction catheter packages.* Place clean Latex glove on non-dominate hand. Place on eye protection at this time.* Clean end of blue bodai connector on trachea tube with alcohol swab.* Place patient on Oxygen monitor if available or patient in unstable respiratory condition for monitoring of oxygen saturation's during procedure.* Pre-oxygenate patient with Lardel bag on a 100% O2 for 2 minutes prior to suctioning. - Turn on suctioning equipment with suction tubing and place near head of patient.* Place sterile glove on dominate hand and connect suction catheter to suction tubing.* From this stage the suction catheter should only be handled using the sterile glove. * Using aseptic technique, pass the suction catheter through blue bodai connector down into trachea tube entering the patients upper airway. The suction catheter is advanced in this way until the patient coughs. Do not apply suction up to this point.* Apply suctioning withdraw suction catheter with a rotating motion and apply suctioning only at 5 second intervals.* If repeated suctioning is to be performed allow the patient rest for several minutes to regain adequate oxygen levels. Patient may be ventilated with Lardel bag on a 100% O2 to being O2 back up to an acceptable range or if patient becomes distressed during procedure.* Clean out patient oral pharyngeal airway with either suction catheter or yankeur sucker. Suction catheter must never be placed back in trachea tube after being placed in either patients mouth or nasal passage ways.* At end of procedure discard suction catheter in trash bin. Rinse suction tubing with water.


POST PROCEDURE:* Monitor patients respiratory effort and oxygen saturation.* Note amount, colour and consistency of tracheal aspiration in nurses notes and ICU flow sheet. Also chart how patient tolerated procedure and any problems encountered.


20. ENDOTRACHEAL TUBE SUCTIONING PROCEDURE (Infant)

POLICY:* Suctioning should be performed as often as necessary to maintain airway and endotrachealtube patency.* The infant should be allowed to rest between any suction attempts and suctioning should beinterrupted if bradycardia develops, or if the infant demonstrates deterioration in colour orsaturation levels.* Assess the infant’s colour, heart rate, chest expansion, breath sounds, lung compliance, SpO2and TcCO2 prior to suction and until the infant is stable post suction.* Infants who are intubated DO NOT require routine oropharyngeal suctioning.* The infant will be adequately ventilated and oxygenated throughout the procedure and returnedto the pre-suctioning ventilator parameters and oxygen requirements. Hypoxia must be avoided,but prolonged periods of hyperoxia should also be avoided.

* Indications for suctioning are:a) in response to clinical assessment of the infantb) minimum q12hc) as part of physiotherapy.

* Routine use of instillation is not encouraged. Indications for instillation are:a) lubricate suction catheterb) known thick secretions.

* Utilize developmental supportive care strategies during suctioning procedure: ensure arms andlegs are flexed and as midline as possible; provide containment, and provide opportunities toself-regulate.

EQUIPMENT:1. Suction unit with collection bottle2. 1 to 2 – 10 ml Polyamps of sterile 0.9% NaCl3. Sterile/clean gloves4. Manual resuscitation equipment (flow inflating bag connected to a pressuremanometer, appropriate size mask and oxygen tubing).5. Appropriate sized sterile suction catheter (French size 5, 6.5 or 8)


PROCEDURE:NOTE: Suctioning is a sterile technique1. COLLECT supplies for suction procedure.2. OBTAIN assistance from a second person (Nurse, Respiratory Therapist, Physiotherapist)3. DETERMINE FiO2 needed to maintain infant’s SpO2 during suctioning procedure.4. DETERMINE insertion depth of suction catheter (refer to notes for measurement).4. WASH hands.5. ASSEMBLE equipment:a) Open end of suction catheter package and connect to suction tubingb) CHECK and set suction pressure between 80-100 mm hgc) CHECK and set blender as per infant’s identified needs: minimum 10% greaterthan ventilator FiO2 setting.6. AUSCULTATE breath sounds.7. GLOVE both hands. Suctioner should apply a clean glove to hand controlling suction and asterile glove to the hand controlling the suction catheter. Have assistant put on a pair ofclean gloves.8. ASSISTANT disconnects the infant from the ventilator.9. ASSISTANT connects ETT to the flow inflating bag and manually ventilates infant as perventilator settings.10. IF INSTILLATION REQUIRED:ASSISTANT disconnects flow inflating bag.INSTILL 3 to 6 drops 0.9% NaCl into the ETT.RESUME manual ventilation.11. MOISTEN distal portion of the catheter with 0.9% NaCl.12. ASSISTANT disconnects flow inflating bag.13. INSERT suction catheter to the predetermined length.14. APPLY continuous suction while rolling the suction catheter during removal. Do not suctionfor longer than (5) seconds.15. ASSISTANT resumes manual ventilation.16. RINSE catheter with 0.9% NaCl to remove any secretions which may adhere to thecatheter.17. REPEAT step 10 only if clinically indicated.18. REPEAT steps 11-18 until ETT clear or no palpable or audible secretions, allowing infantsufficient time for recovery between catheter insertions.19. RECONNECT infant to ventilator and check ventilator and FiO2 parameters.20. SUCTION nares and oropharynx as necessary.21. DISCARD used equipment.22. AUSCULTATE infant’s chest.23. WASH hands.24. DOCUMENT indications for suction, procedure, and the infant’s response.

REFERENCES:Blackwood, B. (1999). Normal saline instillation with endotracheal suctioning: primum nonnocere (first do no harm). Journal of Advanced Nursing, 29(4), 928-934.


Colliton, K.K, Bissenger, R., Speaks, C., Weiss, C., Harvery, D., DeWitt, D., Broderick, T., &Southgate, M. (2001). Suctioning practice in the NICU: Evidence based practice initiative.NANN 17th Annual Conference, Salt Lake City: NANN Proceedings.

Shorten, D., Byrne, P. & Jones, R. (1991). Infant responses to saline instillations andendotracheal suctioning. JOGNN, 20(6), 464-469.

Wrightson, D. (1999). Suctioning smarter: Answers to eight common questions aboutendotracheal suctioning in neonates. Neonatal Network, 18(1), 51-55.


21. SUCTIONING A PATIENT WITH A TRACHEOSTOMY TUBE

STANDARDS: * Management and care of tracheostomy tube through suctioning may be undertaken by Registered Nurses, Physiotherapists and Medical Officers. In emergency situations all Registered Nurses may perform suctioning procedures on tracheostomies.* Aseptic technique will be used when suctioning trachea.* Suction catheters should be less than half the size of the trachea tube insitu.* During suctioning procedure the catheter should only occluded for 5 second intervals.* The catheter should be inserted into the trachea tube with gentle pressure and withdrawn from the trachea tube using a rotating technique.* The patient should be monitored by oximetry for O2 saturation during the procedure.* The need for suctioning should be assessed at least every two hours or more frequently as need arises.* Suctioning should be performed PRN or at frequent intervals as ordered by Physician.* Over suctioning should be avoided to decrease potential damage to patients airway.

OUTCOMES: * Explain the procedure to the patient prior to procedure.* Aseptic preparation prior to commencing procedure.* Open sterile gloves and suction catheter packages.* Place clean Latex glove on non-dominate hand. Place on eye protection at this time.* Clean end of blue bodai connector on trachea tube with alcohol swab.* Place patient on Oxygen monitor if available or patient in unstable respiratory condition for monitoring of oxygen saturation's during procedure.* Pre-oxygenate patient with Lardel bag on a 100% O2 for 2 minutes prior to suctioning. * Turn on suctioning equipment with suction tubing and place near head of patient. * Place sterile glove on dominate hand and connect suction catheter to suction tubing.* From this stage the suction catheter should only be handled using the sterile glove.* Using aseptic technique, pass the suction catheter through blue bodai connector down into trachea tube entering the patients upper airway. The suction catheter is advanced in this way until the patient coughs. Do not apply suction up to this point.* Apply suctioning withdraw suction catheter with a rotating motion and apply suctioning only at 5 second intervals.* If repeated suctioning is to be performed allow the patient rest for several minutes to regain adequate oxygen levels. Patient may be ventilated with Lardel bag on a 100% O2 to being O2 back up to an acceptable range or if patient becomes distressed during procedure.* Clean out patient oral pharyngeal airway with either suction catheter or yankeur sucker. Suction catheter must never be placed back in trachea tube after being placed in either patients mouth or nasal passage ways.


* At end of procedure discard suction catheter in trash bin. Rinse suction tubing with water.

POSTPROCEDURE: * Monitor patients respiratory effort and oxygen saturation.* Note amount, colour and consistency of tracheal aspiration in nurses notes and ICU flow sheet. Also chart how patient tolerated procedure and any problems encountered.


22. TRACHEOSTOMY DRESSING

STANDARDS: * The tracheal tube will be secured in the midline position.* Aseptic technique to be used when changing tracheostomy dressing.* Dressing to be changed for the first time 24hrs post procedure.* Dressing to be changed thereafter once a shift or PRN when soiled.* Tie tapes holding tracheostomy tube will not be secured so tight around neck as to occluded patients circulation.

OUTCOMES: * Complication of tracheal stenosis and erosion are minimised by securing the tracheal tube in midline position.* The patient tracheostomy site will remain infection free during his or her stay in hospital.

EQUIPMENT:

Basic dressing pack Normal saline2 pack sterile gauze 10x10cm 2 x _ in white cotton tape x 1m lengths

PROCEDURE: * Explain the procedure to the patient prior to procedure.* Aseptic preparation prior to commencing procedure.* Prepare dressing pack at bedside prior to positioning patient.* Suction patient (refer to Suctioning of patient with tracheostomy tube).* Arrange for second nurse to hold the tracheostomy tube. * Remove old dressing and ties.* Swab around tracheal stoma with normal saline until the area is cleaned.* Fold sterile gauze squares in half and place on under each flange of the tracheostomy tube.* Attach cotton tape to tracheostomy tube flange by passing doubled cotton tape up through opening in flange then threading loose ends up through loop. The end result should have two tails extending out from flange, one tail being 15cm of the one metre length. Repeat procedure for the side of the flange.* Threat the two long portions of the cotton tape behind the patients head.* The long cotton tape are then to be tied to the shorter tied leaving at least a two finger space between patient and tie tapes.* Ensure patients comfort with new dressing.* Test cuff press with cuffed tracheostomy tubes. Pressure should be <25cm H2O.


23. CLEANING OF ELECTRICAL EQUIPMENT CONTAMINATED WITH BODY PRODUCTS

STANDARDS:

* Occupational Health & Safety practices should ensure that staff and patients are NOT placed at risk.* All nurses working in the ICU/CCU should ensure that all equipment is cleaned appropriately or sent to correct area for effective appropriate cleaning process prior to use on a patient.

OUTCOMES:

* Prevent nosocomial infection.* Prevent danger of electrical hazards from inappropriately cleaned electrical monitoring cables.* Increase life duration of equipment.* Decrease cost of equipment replacement from inappropriate cleaning/damage.

EQUIPMENT:

* Oxygen saturation probes* Temperature sensors from ventilators (grey cables)* Rectal temperature probes

PROCEDURE:

* Temperature (grey ventilator sensors) sent to Endoscopy in brown paper bag. Clean item placed in Respiratory Room.* Rectal temp probes to Endoscopy in brown paper bag for soaking. Clean item stored in equipment storage area.* Electrical equipment wiped over with alcohol wipes ONLY.


24. COOLING OF PATIENTS

STANDARD: * All registered nurses are approved to conduct cooling measures.* Observe temperature minimum of Q1L.* Temperature measured via a rectal probe or IDC temperature sensor.* Create heat loss through convection and evaporation.* Minimise heat production by limiting anxiety and/or movement.* Institute measures singularly from least to most stimulating until effect produced.* Observe for vasoconstriction, increasing temperature, deteriorating LOC, vital signs.

OUTCOME: * Maintain core temperature <39.5%C and >36%C in general ICU patients.* Maintain core temperature <38%C and >36%C in all patients with cerebral disorders.* Maintain core temp just below upper limit avid rapid rise and fall.

PROCEDURES: * Institute following singularly and in order 1-4:(1) Expose patients trunk thighs and arms to room air.(2) Tepid sponge vasodilated body surface areas.

Obtain doctors prescription for use of:-(3) * a fan(4) * ice to arterial points (axilla, carotids, femoral)(5) * sedatives/paralytics. NB: these may be used in conjunction with all of the above. * Turn patient on side to side regularly if possible.* Notify Physician of increasing temperature or ineffectual intervention.* Cease measures if vasocontriction and/or shivering occurs.

NURSES ROLE: * Observe and record temperature.* Observe and record patients progress and effect of nursing/medical intervention.* Notify Physician of complications.


25. CPAP FACE MASKS

STANDARDS:

* All trained registered nurses working in the ICU/CCU will ensure that a clean, correct sized mask is used for CPAP on each patient.* Correct care and use of mask during the duration of patients stay in ICU/CCU will minimise risk of nosocomial infection.* Correct use will maximise masks usability for individual patient during ICU/CCU stay.

OUTCOMES:

* The patient will experience no infection through contaminated mask.* Progressive recovery from effective and correct use of CPAP mask.

EQUIPMENT:

* Sizes available - large and medium.* Each mask will stay with the patient for duration of stay in ICU/CCU or duration of CPAP therapy. On discharge/transfer mask is disposable.* Mask cushion is made of soft silicon for comfortable fit.

PROCEDURE:

* During fitting of mask, explain to the patient aim of treatment and that the mask can easily be removed.* Place mask for optimal comfort and effective CPAP.* Single Patient Use Only - Kept at bedside until patient is discharged or transferred from unit. - Replace if mask cushion hardens or tears, air leakage increases around mask, the valve dysfunctions or O2 ports block with patient secretions.


26. NURSING MANAGEMENT: CONTINUOUS POSITIVE AIRWAY PRESSURE OXYGEN THERAPY (CPAP )

STANDARDS: * A registered nurse who has been orientated to the ICU/CCU and who has been assessed as competent in the management of the patient receiving ventilatory assistance may manage a patient receiving CPAP.

Patient Safety: * At the beginning of the shift, the nurse should check the CPAP circuit for proper functioning: that is: absence of circuit leaks; maintenance of positive pressure; adequate inspiratory air flow and prescribed FIO2.* At no time, should the patient receiving CPAP be left without the direct supervision of a "responsible" nurse.* The principles of "Universal Precautions" are to be adhered to at all times. In particular, no piece of equipment is to be shared between patients, without having been first been cleaned according to the policy / procedure "Ventilatory Circuit Changes and Setups".

Patient Comfort: * At all times, the nurse should attempt to:- involve the patient and their family in the planning and implementation of nursing care;- orientate the patient to their environment and events;- carefully explain all procedures to the patient, prior to their commencement;- facilitate a proper day / night rhythm for the patient;- provide a suitable means of communication for the patient.

OUTCOMES: While receiving CPAP, the patient will experience an adequate supply of oxygen and concurrently, adequate elimination of carbon dioxide at the cellular level. The patient will express verbally that their work of breathing has been reduced following instigation of CPAP.

EQUIPMENT: CPAP machine with circuit; appropriately sized mask and rubber securing band;Alternate oxygen mask

Sterile water for irrigation (1000 ml bottle)

PROCEDURE: * Confirm with Medical Officer the desired FIO2; level of positive airway pressure and time period for CPAP therapy.* Attach CPAP machine medical air and oxygen gas lines to wall sources.* Prepare humidification source (refer to policy / procedure: Humidification).


* Select prescribed FIO2 on oxygen blender.* Turn flow on to level above 25 litres / min.* Position rubber securing band behind the patient's head, centred on occiput.* Position face mask over the patient's face ensuring that a firm seal around their chin is established.* Attach lower rubber straps to mask creating a secure fit around the chin.* Run upper straps over the ears and along cheek line and secure on mask while maintaining a tight seal.* Listen to and feel gas flow to verify that minimal air leak around the mask rim is present.* Adjust level of positive expiratory pressure to prescribed level.* Adjust inspiratory gas flow so that minimal fluctuations are present on pressure gauge.* Observe and document respiratory rate; work of breathing and SpO2.* If respiratory work is excessive or the patient complains of continuing dyspnoea - increase inspiratory flow.* Maintain continuous SpO2 monitoring with alarm function in place.* Humidification temperature is usually maintained at 36 o C, or at temperature as tolerated by the patient.* Remain with patient until apprehension is allayed.

Required Observations: * Every 30 minutes: visual check. Note respiratory rate and effort; SpO2; nausea and vomiting.* Hourly: pulse rate and rhythm; blood pressure; peripheral circulation and proper functioning of humidification system.* Every two hours: condition of skin around and under mask and rubber securing band. Document condition and interventions; condition of conjunctivae.* Every four hours: palpate abdomen for distension and assess need for stomach decompression. Auscultate lungs for equal air entry.* Every four hours: palpate abdomen for distension and assess need for stomach decompression. Auscultate lungs for equal air entry.


27. COMPLETING THE NEUROLOGIC EXAMINATION

Take the patient’s temperature, pulse rate, respiratory rate,and blood pressure. His pulse pressure—the difference between systolic pressure and diastolic pressure—is especiallyimportant because widening pulse pressure can indicate increasing ICP.

Special considerations

NURSING ALERT If a previously stable patient suddenlydevelops a change in neurologic or routine vital signs, furtherassess his condition, and notify the physician immediately.

A change in the LOC is one of the earliest changes that may occur with increased ICP. Changes in pulse and blood pressure also occur, but are generally seen late in the course of increasing ICP. Other vital sign changes include widening pulse pressure, increase in systolic blood pressure, and bradycardia. Cushing’s triad, also called Cushing’s sign, is a late sign indicating brain stem dysfunction. Vital signs associated with Cushing’s triad include hypertension (usually withwidened pulse pressure), bradycardia, and abnormal or irregular respiratory patterns.


28. DRAWING BLOOD SAMPLES FROM A RADIAL/FEMORAL ARTERIAL LINES ON ADULT PATIENTS

STANDARDS: * Registered Nurses accredited to work with pressure lines in an Intensive Care setting and Registered Nurses training to work in an Intensive Care setting under the supervision of an accredited Registered Nurse may care for radial/femoral arterial lines.* Procedure must be carried out under strict asepsis.* Strict attention should be given to position of stop cock at end of procedure to prevent accidental uncontrolled bleeding of patient from radial/femoral artery.* Proper use of available equipment to prevent accidental injury to staff or patients.

OUTCOMES: * The patient will experience no infection through contamination of the Arterial Line during his or her stay in the hospital.* Proper position of stop cock will be ensured to prevent any accidental blood loss leading to injury of the patient during hospital stay.* Potential injury to the nurse will be minimised through proper use of equipment.

EQUIPMENT:

* Yellow vacutainer shield Vacutainer for collecting blood samples* 3ml syringe (arterial) 5ml syringe (femoral)* Alcohol swabs

*Vacutainer luer adaptor for pressure lines* 10cm x 10cm sterile gauze

*Arterial blood gas syringe (if appropriate)* Eye protection

Blue protective sheet* Gloves

If drawing cultures from an Arterial Line the following equipment will also be needed:* Blood culture bottles x 2; red and green topped* Chlorhexidine


* Large clear vacutainer shield to accommodate blood culture bottle.

PROCEDURE: Procedure "A", removal of blood from a radial/femoral arterial line for routine screening* Explain the procedure to the patient prior to procedure.* Aseptic preparation prior to commencing procedure.* Lay out necessary equipment on over bed table next to patient bed and within easy reach.* Lay blue protective sheeting under limb with arterial line to protect patient and bed clothing from accidental back flow of blood from pressure line.* Open sterile gauze package on bedside table.* Open 3ml or 5ml syringe as required.* Attach luer adaptor to yellow shied by removing top protector from adaptor and screwing adaptor into shield. The yellow shield severs several purposes:- it helps to guide the vacutainer for collecting blood over the needle end of the luer adaptor,- it protects the user from coming into contact with the needle end of the adaptor and- prevents the plastic protector over the needle end of the adaptor from being sheered exposing the needle and allowing flow back of arterial blood.* Hit three minutes silence alarm on overhead monitor.* Place on gloves and eye protection.* Ensure three way stop cock is turned off to sample port.* Remove cap from pressure line transducer and place on sterile gauze to protect from contamination.* Wipe down sample port with alcohol swab before starting procedure.* Place appropriate syringe securely onto sample port.* Turn stop cock off to pressure bag and with draw blood into syringe from arterial line. Withdraw 3mls from radial line and 5mls from femoral line.* Turn stop cock 45 degrees back towards sample port and remove blood filled syringe and discard appropriately.* Remove protection cover from bottom part of luer adaptor, place adaptor into sample port securely.* Turn stop cock off to pressure bag. Observe for inappropriate leakage of blood from around or up through adaptor, turn stop cock off to sampler if this develops.* Place vacutainer into shield and press down firmly over needle. Blood should be drawn into vacutainer automatically, self filling will stop when vacutainer filled.* Remove vacutainer from shield without dislodging adaptor and repeat process until all bloods have been taken. It is not necessary to move stop cock during this procedure

* Turn stop cock off to patient when blood is drawn and remove adaptor. Flush pressure line with stop cock in this position to clear blood from sample port. During procedure hold sterile gauze over open port to control fluid loss. Next turn stop cock off to sample port and flush pressure line for two to three seconds to clear all blood in line. Replace cap back on sample port.


Procedure "B", removal of blood from a radial/femoral arterial line for Arterial Blood Gases:* Arterial Blood Gases (ABG's) may be drawn from arterial line using an ABG syringe after routine bloods have been drawn. In this case turn the stop cock only 45 degrees back towards sample before removing adaptor.* Replace adaptor with ABG syringe then turn stop cock off to pressure bag.* Draw 1ml to 1.5mls into syringe (arterial pressure should fill syringe). When blood is drawn remove and flush line as above.* ABG's may be drawn on own after removal of appropriate amount of blood from line using the above procedure for removing routine bloods.

Procedure "C", removal of blood from radial/femoral arterial line for culture samples:* Cultures may be drawn from arterial lines where other veins are inaccessible.* Follow procedure above for removal of routine bloods except for the following:- the sample port is wiped down with Proviadine instead of alcohol and allowed to dry prior to attaching adaptor to sample port.- instead of the yellow shield a large clear plastic shield (removal butterfly line fro shield when used with arterial line) apply to accommodate the culture bottle is used.* Sterility is important when drawing blood culture, therefore the clear plastic caps are left in place on the culture bottles until they are ready to be placed in the adaptor from drawing bloods. Bottles fill on own to desired amount needed.* After the bottles have been removed, the tops of each bottle is wiped immediately with Proviadine.* Procedure is terminated; has explained for routine bloods


29. DRAWING ABG's/ANALYSIS

STANDARDS: * All Registered Nurses working in the ICU/CCU area may collect arterial samples from arterial lines if familiar with the management of arterial lines. * Radial puncture should only be attempted by Registered Nurses familiar with or experienced in technique, or under supervision of same persons.* Goals to be achieved are to obtain accurate and satisfactory sample without undue stress or discomfort for patient.* Prevention of contamination into arterial infusion/monitoring set.* Minimise possible risk of haematoma formation.

OUTCOMES: * Maintenance of patient safety.* Prevention of introduced infection in the critically ill patient.

PROCEDURE: * Wash hands prior to collection sample.* Assemble equipment; blood gas syringe, swabs, 5ml syringe, gauze to evacuate blood line onto.* Swab area on and around port.* Remove cap.* Attach syringe and openline to air.* Draw off line fluid and initial blood - approximately 5mls.* Discard 5ml syringe after closing 3 way stop cock _ way to both air and patient.* Draw off sample.* Close stop cock to air.* Remove sample syringe.* Flush line. * Close stop cock to patient and flush blood line into gauze.* Discard.* Close stop cock to air.* Replace port cap.

SPECIAL CONSIDERATIONS: * Sample should be taken to gas analysis machine at earliest possible moment, as results may be altered. * Agitate sample between palms of hands to mix blood and syringe content well prior to putting sample into machine.* Samples that are being sent to the lab need to be transported on ice to prevent deterioration.


* Ensure correct labelling information is on blood sampling and form.

30. DRAWING BLOOD CULTURES

STANDARDS: * Management and care of CVC may only be undertaken by a registered nurse.

Procedure should be carried out under strict aseptic technique.* To have a uniformed approach to drawing blood cultures by trained staff.

* Two sets of blood cultures consisting of two bottles per set i.e. green (aerobic) and red (anaerobes).* Samples should be taken at least one hour apart preferably from different sites.* Samples ideally should be drawn prior to commencement of antibiotic treatment.* Samples should be drawn from the patients limbs when ever possible. Central Lines and Arterial Lines are used only when patients limbs are unaccessible.* If antibiotic administration has been commenced collection at three separate sites on one occasion.* Blood culture should be performed in every case of serious sepsis regardless of whether a primary site has been identified and sampled microbiologically.

OUTCOMES: * Potential injury to the nurse will be minimised through proper use of equipment.* There will be no contamination of blood samples during procedure ensure accurate results from blood sampling.

EQUIPMENT:

* Sterile dressing pack Rubbish bin * Povidone-iodine Blood bottles x 2; red and green topped * Eye protection, 20 ml syringe/ 19G needle* Large clear vacutainer shield to accommodate blood culture bottle culture PROCEDURE: * Explain procedure to patient prior to commencement.* Setup dressing tray with Povidone-iodine on over bed table at patients bedside.* Identify target vein.* Prepare area over vein with Povidone-iodine by applying solution in a circular motion until a area of 5cms is covered.* Allow solution to dry for at least one minute after skin contact.* Venepuncture and blood withdrawal using a' no touch' technique, this maybe done with the appropriate Vacutainer shield and butterfly needle or appropriate needle and syringe.* If needle and syringe are used a new needle must be used when inoculating blood into media bottles i.e. one clean needle per bottle. Do not use needle that blood was drawn from


patient with.* Tops of media bottles must be sterilized with Povidone-iodine prior to inoculation with clean needles. Sterilization of the bottle top is repeated after needle has been withdrawn from bottle.* Only 5-10 ml of blood should be placed into each culture bottle. For adult patients overfilling inadequate dilution leading to inadequate neutralisation. Smaller volumes decrease sensitivity. For children it is only necessary to have 1-5 ml per bottle.Note: Caps of bottles must never be removed from top of bottles to inoculate blood.* If Vacutainer shield and butterfly needle are used the tops of the media bottles are prepared in the same way as per needle and syringe. After the butterfly needle has been inserted into the vein the culture bottles are then inserted into the protective shield and allowed to fill on own to desired level. Again after withdrawal of culture bottle from Vacutainer shield sterilize top of bottle with Povidone-iodine.* Remove Povidone-iodine from patients puncture site and ensure bleeding has stopped by applying pressure to the site.* Send both culture bottles to the lab with the appropriate requisition forms.* Bar codes from the two culture bottles should be placed on the requisition form.* When placing the patients identity labels on the culture bottles ensure that the labels do not cover the open window left where the bar codes where removed. * Chart procedure in the patients chart and record any difficulties or complications during procedure.* Place time, date and type of specimen sent to lab on Pathology sheet.

Ref: Kempler, Dr ( Mar 1990), Richmond Pathology Service Handbook, 20 Jan, 1994, Collection pg 10.


31. HEAD INJURY PRINCIPLES

STANDARDS: * Management and care of Acute Head Injury may be undertaken by all Registered Nurses unless in a critical area or patient ventilated or has haemodynamic monitoring, critical care certificate nurses and registered nurses under supervision * Vital signs, Glasgow Coma Scale and pupil observations Q1h (maximum) but may be as frequent as every 15 to 30 minutes.* SBP maintained within 90-200mmHg.* Core body temperature maintained 38C.* Intervention individualised depending on nature and/or severity of injury.* Unconscious patients or those with impaired cough and/or gag reflex must have airway protection.* Maximise O2 uptake and minimise CO2 retention.* Disorientated, confused patients or those with impaired judgement must be protected from physical injury.* Prevent increases in Intracranial pressure.* Prevent increases in intrathoracic pressure.* Unconscious and/or severe head injured patients to have IDC and naso/oropharyngeal tube.* Cervical spine injury to be assumed until proven otherwise.

OUTCOMES: * Limit primary injury.* Prevent secondary injury.* Maximise potential neurological recovery.* Maintain homeostasis.

PROCEDURES: * Notify Physician immediately of significant change in vital signs, neurological observations, urine output or biochemistry.* Place unconscious patients in "recovery" position with guedels in situ.* Place ventilated patients in semi-recumbent position with head elevated 30%.* Place head in midline position and avoid compression/kinking neck veins (may require support with sandbags/rolled towel).* Secure ETT as per policy.* Suction ETT only when necessary.* Remove excess oral secretions.* Assess temperature with rectal tube or IDC sensor.


* Cool patients with temperature >38%C as per policy.* Measure urine output Q1h.* Minimise straining and/or movement.* Maintain adequate sedation and give analgesia/sedatives/paralysing agents as prescribed.* Notify Physician immediately if shivering/seizures/pain observed.* Use spenco mattress and give Q2-4h pressure care for immobile patients.* Use a hard cervical collar and log roll patients with suspected neck injury. Head must be supported by one staff member during procedure.* Give supplemental O2 as prescribed.

NURSES ROLE: * Observe/record response to treatment.* Carry out prescribed treatment.* Act as a liaison and/or keep family/significant others informed of patients progress.


32. HUMIDIFICATION - AEROSOL AND NEBULISER

STANDARDS: * Nebulisers to be ordered by medical officer and to be administered by a Registered Nurse.* Nebulisation of saline will be given same priority as any other prescrubed medication.* Nebuliser will be rinsed and left to dry following each use.* Nebuliser mask will be fitted and medication must be administered in such a way as to ensure a comfortable, efficient exercise.* Nebulisation will be given with air or oxygen according to medical officer's orders.

OUTCOMES:* Patient will obtain medication in a form that requires less coordination and effort.* Patient will receive medication; saline to assist with bronchial dilatation and expectoration of sputum.

EQUIPMENT:

Nebuliser, mask and O2 tubingO2 or air supplyMedication or saline

PROCEDURE: * Add prescribed medication to nebuliser.* Attach nebuliser to mask and then attach mask to patient.* Turn on O2/air to give fine mist.* Remove when misting ceases.


33. LATEX POLICY

Introduction Latex allergy is a serious occupational hazard for people working in health care settings, and patients. This policy sets the framework for: • The identification of people who are at risk; • The prevention of allergic responses to latex; • Action to be taken if latex allergy occurs.

Key Points Staff • Pre-employment inquiry into latex allergy shall take place; • Powder-free, non-latex gloves will be available in all units and departments for use by staff who are contraindicated for allergy from latex; • An audit and review of glove use and glove purchasing will be undertaken within each unit.

Service Users • Pre-admission inquiry into latex allergy shall take place; • Where latex allergy is present, this shall be documented and health staff notified; • A latex safe environment shall be provided for latex allergic service users.

Responsibility It is the responsibility of managers to ensure that: • All those at risk in their area of responsibility receive appropriate instruction, information and training upon commencement of employment with the Trust; • Suitable and sufficient risk assessments are undertaken and appropriate controls introduced;


• Those who have, or consider they have a problem related to latex exposure seek the advice of the Occupational Health Department; • Alternative latex-free equipment is available for staff who suffer adverse health effects from latex.

1. INTRODUCTION

1.1 Repeated exposure to rubber latex products can produce serious allergic responses to either the naturally occurring proteins in latex, or chemicals used in the manufacturing process. Many health care products contain latex, therefore the risk of latex allergy can be a serious occupational hazard for health care employees and for patients.(1)

1.2 This policy sets the framework for:

• The identification of people who are at risk;

• The prevention of allergic responses to latex;

• Action to be taken if latex allergy occurs.

2. VALUES

2.1 The values which underpin this policy include:

• The provision of services which are safe, optimal and appropriate;

• The provision of environment that is healthy and safe for staff and service users.


3. DEFINITIONS

3.1 Latex is a natural substance derived from the sap of the rubber tree, which contains naturally

occurring proteins. Chemicals, known as ‘accelerators’, are used in the refining process.

3.2 Allergy is defined as ‘any immunologic reaction to a foreign substance that produces

detrimental consequences to the body’ (Thompson et al, 1993).

3.3 Hypersensitivity is ‘a type of inappropriate or excessive response of the immune system’

(Thibodeau and Patton, 1993).

3.4 Sensitisation is the process of the body producing specific antibodies in response to repeated

exposure to a specific antigen. Allergic Responses 3.5 A description of allergic responses is provided in Appendix 1.

3.6 A list of items containing latex is provided in Appendix 2.

4. STRATEGIC OBJECTIVES

4.1 The strategic objectives of this policy are:

• To establish standardised practice for the prevention of allergy or hypersensitivity for

staff and people who use the services.

• To avoid the use of products containing latex where alternatives are available.

• To establish standards against which the use of latex and products alternative to latex

can be audited, for the purpose of monitoring and review.

5. PRODEDURES

Occupational Health


5.1 Pre-employment health screening will be provided for people who have been offered

appointments with the Trust. This will be by questionnaire assessment. Where indicated, referral

will be made to the Occupational Health Physician, and/or advice will be given to the individual

and his/her line manager for the provision of safe systems of work.

5.2 The Occupational Health Department will provide information, advice and surveillance for

staff who are concerned that they may already have developed, or in the future may develop

symptoms related to latex exposure.

5.3 Latex-free equipment and surgical supplies shall be made available routinely for staff and

patients who have latex allergy.

5.4 Powder-free non-latex gloves will be available in all units and departments, for use by staff

who have contraindicated for allergy from latex. (2)

5.5 Where latex allergy, or suspected latex allergy occurs in a member of staff:

• S/he must notify the line manager and Occupational Health Nurse immediately;

• Action shall be taken to remove all sources of latex from the proximity of the member of

staff, immediately;

• The member of staff shall be advised to seek medical treatment and advice;

• An Adverse Incident Report shall be filed;

• S/he shall be offered counselling and support from the Trust Occupational Health

Physician regarding the management of latex allergy at work.

5.6 Service users will be screened for latex allergy before clinical procedures commence.

5.7 The nurse in charge is responsible for assessing the service user’s known allergies including

documenting this in the service user’s records, and notifying all other health


workers involved in the person’s treatment/care (Appendix 3, Inquiry into Latex Allergy). This will include:

• Inclusion of a record in the service user’s notes indicating the type of allergic reaction to

latex (refer to Appendix 1, Table 1);

•Placing a sticker indicating ‘Latex Allergy’ on the inside front leaf of the service user’s

notes;

• Notifying all other departments involved in the service user’s care, e.g. Theatre, Support

Services, etc.

5.8 Latex safe environments will be provided for latex allergic service users throughout their

treatment.

5.9 Where latex allergy occurs in a service user, this shall be notified to the nurse in charge and

the attending physician (consultant or GP) immediately. Action shall be taken to remove all

sources of latex, and medical treatment, advice and information shall be given to the patient (and

carers, where appropriate).

6. RESPONSIBILITIES

6.1 It is the responsibility of line managers to ensure that:

• All those at risk in their area of responsibility receive appropriate instruction

, information and training upon commencement of employment with the Trust;

• Suitable and sufficient risk assessments are undertaken and appropriate controls

introduced;

• Alternative latex-free equipment is available for staff who suffer adverse health effects

from latex;

• Only powder-free, non-latex gloves are purchased and made available to staff.


6.2 It is the responsibility of all staff to ensure that:

• Those who have, or who consider they have a problem related to latex exposure seek the

advice of the Occupational Health Department.

7. IMPLEMENTATION, MONITORING, STRATEGIC REVIEW

7.1 Training on screening for and management of latex allergy will be provided through the Trust

core training programme.

7.2 A review of glove use shall be undertaken, across the Trust. The implementation of this shall

be the responsibility of the Chairperson, Health Safety and Occupational Health Risk Group,

with Hospital Managers.

7.3 An audit of glove use shall be undertaken in clinical areas across the Trust, in order to

provide information about how to minimise risk from latex allergy, while at the same time

ensuring that the gloves available to staff provide optimal protection for the patient against

infection, and protection for staff from patient’s pathogens.

7.4 The Trust glove purchasing practice shall be reviewed in order to develop a Trust glove

purchasing policy which is cost effective, and minimises risk. This shall consider:

• Range/types of gloves used, and volume;

• Properties of gloves used, and their source;

• Unit costs of glove types;

• Unit costs of powder-free gloves.


7.5 Where latex allergy occurs in staff and service users, this shall be reported to the Trust Risk

Manager via the Adverse Incident Report procedure.

7.6 Under the Reporting of Injuries, Disease and Dangerous Occurrence Regulations 1995 any

allergic response to latex shall be reported by the Trust Risk Manager.(3)

7.7 When a surgeon or other health care worker suffers dermatitis associated with wearing latex

gloves during surgery, the Health and Safety Executive or local authority will be notified by the

Trust Risk Manager.(3)

7.8 The Trust Risk Manager shall report all cases of latex sensitivity to the Health and Safety

Executive.

References

• Royal College of Nursing, 1999, Latex Allergy in Health Care Settings, Employment Brief 25/99.

• A number of studies (OR Manager, 1995; Yunginger et al, 1994; Tarlo et al, 1994) demonstrate that glove powder represents a threat to individuals allergic to natural rubber latex. It may represent an important agent for sensitising non-allergic individuals because the latex proteins combine with the powder and are spread in the air. Glove powder also acts as an abrasive, cracking and drying the skin, causing irritation, and contact dermatitis (Jeanes, 1997). The broken skin barrier allows easier penetration of infections, and of chemical accelerators and latex protein increasing the likelihood of the development of both Type 1 and Type IV latex allergy (Royal College of Nursing, 1999, Latex Allergy in Health Care Settings, Employment Brief 25/99, p.5).

• HS 1999/186 NHSE Latex Medical and Powdered Latex Medical Gloves.


APPENDIX 1

ALLERGIC RESPONSE TO LATEX

1. Type 1 allergy is a response to the naturally occurring proteins in latex. There is immediate hypersensitivity triggered by antigens which penetrate the skin, respiratory tract or gastrointestinal tract. Symptoms appear between five and thirty minutes after exposure, and may include localised reactions such as skin reddening or wheezing. Potentially fatal anaphylactic shock is possible. Apart from circumstances where anaphylactic shock has occurred, immediate hypersensitivity reactions usually subside within two hours of removal of the allergen.

2. Type IV allergy is a response to the chemical accelerators used in latex manufacturing

processes. There is delayed hypersensitivity (cell mediated) reaction. Following repeated

contact with the allergen, an acute rash can occur 6-48 hours after exposure. Once someone is

sensitised to an allergen, the slightest contact may provoke recurrence.

3. Generally a Type IV latex allergy involves a less serious clinical response than a Type 1

allergy, but both may prevent a health worker from continuing to work.

4. Table 1 below outlines type of contact and symptoms.

Table 1 Reactions to Latex

Reactions Type of Contact Symptoms

Irritant Contact Dermatitis is not an allergic reaction and is reversible. It is treated by avoiding irritants and by use of emollient creams.

occur immediately after glove use, or with repeated exposure, or from repeated hand washing

cutaneous dry skin, local irritation


Type 1 Allergy allergy to natural latex proteins causes immediate hypersensitivity. There is currently no cure.

occur 5-30 minutes after exposure

cutaneous facial swelling airborne mucosal/indirect

local or generalised urticaria, rhinitis, conjunctivitis, asthma, anaphylaxis

Type 1V Allergy is delayed hypersensitivity (cell-mediated). There is currently no cure.

occurs 6-48 hours after exposure

cutaneous urticaria, erythema, blistering

Progression: in rare cases, severe allergic reactions, including anaphylaxis, have occurred in individuals with no previous history of latex sensitivity.


APPENDIX 2 ITEMS CONTAINING LATEX

(List not exhaustive) Items Containing Latex

sphygmomanometer cuffs balloons stethoscope tubing rubber bands disposable gloves condoms airways diaphragms endotracheal tubes kitchen gloves tourniquets dummies intravenous tubing cosmetics electrode pads shoe soles goggles sports equipment catheters underwear elastic wound drains toys injection ports hotwater bottles chair cushions bicycle/motorbike handle grips reflex hammer carpeting ostomy pouches telephone leads suction tubing extension cords ventilators electrical equipment anaesthetic masks adhesive agents oxygen masks Royal College of Nursing, 1999, Latex Allergy in Health Care Settings, Employment Brief 25/99.


APPENDIX 3 INQUIRY INTO LATEX ALLERGY

Atopic individuals, i.e. those with existing predisposition to allergy, e.g. with dermatitis and/or food allergies, are more likely to develop sensitisation to latex. Screening for allergy should address:

• Previous anaphylaxis; nature of products/circumstances; • Previous history of reactions to latex products (list common household and medical products) • Whether experienced symptoms after handling any products containing latex (list symptoms); • Previous history of relevant allergies/autoimmune diseases; • Previous history of congenital abnormalities (spina bifida, myeloma, urological etc); • Food allergies; • Previous surgery and number of operations before age of 7 years; • Previous and current occupational history.


34. PULMONARY CAPILLARY WEDGE PRESSURE MEASURE

POLICY:* May be attended by MD or ICU nurse.* No more than 1.5mls of air to be used.

PROCEDURE:* Ensure pulmonary artery lumen patent.* Position patient.* Level transducer to phlebostatic axis and zero.* Have waveform on scales.* Inflate balloon carefully. Observe monitor for PCWP trace.* Freeze trace, deflate syringe passively. (Do not draw back on syringe). Disconnect syringe. Re-connect. Turn stop-cock Off to avoid inadvertent wedging.* Position cursor at end expiration. Record PCWP and patient position.* Reposition patient and terminate procedure appropriately.* Notify MD of changes of 5mmHg or more.


35. PULSE OXIMETRY

STANDARDS: * All registered nurses working in the ICU/CCU and general wards may record pulse oximetry to assess respiratory function and oxygen therapeutical needs.* Registered nurses using this equipment should have a basic understanding of pulse oximeters and the need to obtain an adequate waveform.* Pulse oximetry is a vital tool for providing continuous observation in a safe and non invasive way.* Goals to be achieved are to obtain accurate and satisfactory information from pulse oximetry to asses in effective management of oxygen therapy needs.

OUTCOMES: * Maintenance of adequate oxygen therapy and prevention of respiratory difficulty.* Maintenance of patient safety.

PROCEDURE: * Fingernail bed should be clean and free of nail polish.* Probe light source should be place on finger or ear.* Monitor visual and audible displays should be observed to assess if a strong pulse is achieved.

SPECIAL CONSIDERATIONS: * Use of oximetry increases patient safety both intra and post operatively.* Falling percentiles in oximetry readings should be brought to the medical officers attention as soon as possible to enable adequate oxygen therapy be maintained


36. ENTERAL FEEDING

STANDARDS: * Enteral feeding is ordered by medical officers.* Trained registered nurses and medical officers may insert salem sump/fine bore gastric tubes in the Richmond Health Service.* A salem sump tube is essential to allow monitoring of absorption of feeds when first commenced.* Radiological verification of tube position is essential before enteral feeding.* Only eight hours enteral feed in the bottle at any one time.* Patients must be on a fluid balance chart whilst receiving enteral feeding.* The tube must be securely anchored to the patients nose.* The tube should be flushed with 10-20ml of sterile H20 before and after administration of medication.* Enteral feed giving set to be changed at 2000hrs daily.

OUTCOMES: * Store enteral feed in refrigerator and do not use feed more than 24 hours old.* The tube will not become malpositioned.* The patient will attain optimum nutrition from enteral feeding by correct choice of feed type and volume.

EQUIPMENT:

* Enteral feeding bottle* Enteral feeding set* Enteral food solution and opener* Alcohol swabs* Label for feeding bottle* Pump

PROCEDURE: * Check and verify type and rate of enteral feeds to be used. Check expiry date.* Collect all equipment at bedside.* Assemble feeding bag and lines.* Verify feeding tube placement.* Fill feeding bottle with 8 hours of feeding solution.* Prime line and connect to patients enteral feeding tube; ensure tight connection.* Attach label to bag detailing feed type, amount, patients identification and your signature.


POST PROCEDURE:

* Document procedure in nursing notes.* Ensure adequate supply of appropriate feed.* Follow regimen below then commence feeding.


37. TOTAL PARENTERAL NUTRITION

STANDARDS: * Total Parenteral Nutrition (TPN) is ordered by the Duty Intensivist. TPN may be administered by Registered Nurses who are accredited to give intravenous medication and have undertaken training to care for CVC sites and lines. * The position of the CVC must be confirmed by chest XR prior to commencement of TPN. * TPN must be infused via a dedicated lumen of the CVC. Line integrity is not to be compromised except for bag/line change or CVC removal. No bolus injections may be given into a TPN line.* TPN must be infused via a volumetric pump at a constant rate over 24 hours as specified by the Intensivist.* Care of CVC as per CVC dressing protocol.* Change of TPN line as per CVC line change protocol.* Bag must be checked by two registered nurses against orders, patient identification, date of expiry and for any sign of contamination.* TPN bag change as per CVC line change protocol, except TPN line is retained and is used for 72 hours.* TPN bag is protected against light.* Nursing observations required:- Q4H TPR. If temperature over 38 degrees Celcius, notify M.O.- Daily ward urinalysis as per urinalysis protocol.- Strict fluid balance charting of input and output.- Daily weigh.- Baseline and routine laboratory investigations as per table.


38. TRANSFER OF PATIENTS TO OTHER WARD AREAS

POLICY: Transfer of patients from ICU and CCU may be undertaken by all registered nurses.

STANDARDS:

- Patients may be transferred from ICU with the agreement of the Duty Intensivist.- Patients may be transferred from CCU with the agreement of the Duty Cardiologist or the Medical Registrar who will liaise with the Duty Cardiologist or Specialist Medical Officer.- A bed in the ward must be available and ward nursing staff notified of impending transfer.- The patient must be informed of their transfer to the ward. The patients next of kin may be notified if required.

OUTCOMES: The patient will be safely transferred from ICU/CCU to other ward areas. Continuity of medical and nursing care to the patient is maintained.

EQUIPMENT:

* 02 cylinder (full)* Oxygen tubing* Hudson mask* Suction tubing* Yankauer sucker* Y suction catheters* Gloves

PROCEDURE:

- The patient must be transferred upon the bed occupied, with bed rails up.- A portable oxygen supply must accompany all transfers.- Assistance is required from a Wardsman or another member of nursing staff.- Patient documentation including current medical/nursing notes, X-Rays, old notes and any patient specific equipment must be transferred to the ward.- Clerical staff at front desk or emergency department (after hours) must be notified of patients transfer.- Handover of relevant patient information is given to nursing staff on arrival to ward.


39. UNDERWATER SEAL DRAINAGE

STANDARDS : * Registered Nurses and Enrolled Nurses are approved to care for patients with Underwater Seal Drainage (UWSD).* Changes in management of UWSD are by written instruction of attending medical officer and may include the addition of suction; the clamping and/or removal of UWSD.* Removal of UWSD may be attended by RNs in ICU, otherwise may only be attended by a medical officer. Indications for removal being a re-expanded lung or a blocked intercostal drain.* Dressings to intercostal drain sites to be changed when integrity impaired, every 2 days or when otherwise ordered.

OUTCOMES: * Insertion of an intercostal catheter and commencement of UWSD allows for:- expansion of the lung- escape of air from the pleural cavity and maintenance of lung expansion- drainage of pus, blood and fluid- the prevention of air being sucked back into the chest which would cause a pneumothorax.

SPECIAL CONSIDERATIONS: * Ensure patient is aware of the procedure for insertion of intercostal catheter as appropriate.* Position and prepare patient as required with the application of oxygen as required, assessment of base line observations, administration of analgesia as required.* DO NOT CLAMP INTERCOSTAL DRAIN when patients are on Positive Pressure Ventilation or Continuous Positive Airway Pressure when changing bottles and/or tubing, nursing procedures, chest physiotherapy or during transportation.* Two rubber-tipped Harrison-Cripps forceps for each UWSD should be positioned at the head of the spontaneously breathing patient's bed for cases of accidental disconnection from underwater seal.* When changing UWSD bottles and/or tubing on a spontaneously breathing patient, CLAMP INTERCOSTAL DRAIN at two points close to the patient's chest.

* Ensure drainage bottles are kept at a lower level than the chest to prevent fluid syphoning into pleural cavity.* UWSD bottles should be securely taped to tubing and positioned so as to prevent dislodgement of intercostal drain and entry of air into pleural space

* UWSD site should be dressed appropriately and securely to prevent entry of air into pleural space.* Ensure two bottle system is used to prevent UWSD bottle being placed inappropriately on high suction.


EQUIPMENT:

For Insertion of UWSD:* Drapes, including fenestrated drape Hibitane solution* Sterile gown Tinc benz solution* Mask Local anaesthetic agent* Sterile gloves Basic dressing pack* Universal instrument pack Elastoplast - 8cm wide and 2.5cm wide* Harrison-Cripps forceps Disposable underpad* Intercostal catheter - appropriate size Kendall curity thorax 1 - single use UWSD system* Scalpel blade (tubing and underwater drainage bottle)* Gauze squares 1 x 5ml syringe* 2/0 black silk suture on straight needle 1 x 25g, 1 x 19g needles

For Dressing Intercostal Catheter Exit Site/Securing Intercostal Drain: * Basic dressing pack Hibitane solution * Sterile gauze squares Sterile scissors* Elastoplast: Sterile cotton wool swabs* 2 x 20cm pieces with trouser legs, Tinc benz solution* 1 x 15cm pieces, Disposable underpad* 3 x 8cm pieces for each connection

For Removal of Intercostal Drain: * Basic dressing pack Gauze squares* Fenestrated drape Combine (small)* Universal instrument pack Elastoplast* Stitch cutter 1 x 5ml syringe* Hibitane solution 1 x 19g needle, 1 x 25g needle* Sterile gloves * Suture material, local anaesthetic, 1 x 5ml syringe, 1 x 19g and 25g needle, OR Jelonet for sealing over exit site.

PROCEDURE: For insertion of intercostal drain and commencement of underwater seal drainage, dressing of intercostal catheter exit site and securing of intercostal catheter and UWSD: * Assemble equipment* Position patient in appropriate lateral position to ensure easy access with affected side uppermost* Maintain continuous observation of patient during procedure, report any change in vital signs.* Set up two bottle suction system as per attached diagram so as to deliver appropriate level of suction.* Assist medical officer with connection of tubing and ensure connections secure. Secure


connections with 8cm pieces of brown elastoplast, one lengthwise each side of tubing and one around centre of connection. * Place drainage bottle at a position below patient's chest. * Assist medical officer with application of sterile dressing to insertion side of intercostal catheter and with the securing of tubing to patient's chest wall.* Cleanse area appropriately to insertion site with Hibitane solution, apply gauze squares from opposite sides of drain, Tinc benz solution to areas where elastoplast will be applied. Apply two 20cm pieces of elastoplast with trouser legs on apposite sides of drain and one 15cm piece.* Monitor vital signs and record post procedure.* Monitor and record observations on UWSD including observations on presence and quantity of air leak and amount/presence of oscillation hourly.* Maintain an aseptic technique when working with intercostal catheter, dressing, tubing and drainage bottle. Change UWSD bottle and tubing each 24hr period and 12 midnight and monitor amount of drainage, re-secure tapes as discussed previously. Review dressing and change as appropriate.

For Removal of Intercostal Drain: * Assemble equipment.* Position patient in appropriate lateral position with affected side uppermost.* Ensure explanation and reassurance of procedure adequately given.* Instruct patient to perform the VALSALVA MANOEUVRE (forced exhalation against a closed glottis, holding breath) during procedure.* Apply occlusive dressing of Jelonet, small combine and elastoplast over exit site.* Record procedure and amount of drainage.* Continue observation of patient for signs of respiratory distress. Record and report any changes to medical officer.* Assist with post removal chest x-ray.* Review exit site two days post removal, replacing dressing with Hansapor dressing.


40. VENTILATOR CIRCUIT SETUPS AND ASSEMBLY

POLICY: - Ventilation type and mode will be ordered by the medical officer. - All Registered Nurses working in ICU/CCU orientated to changing ventilator circuits, or assembling circuits at ICU can assemble and change ventilatory circuits.- All circuits are to be checked by two Registered Nurses after assembly.

STANDARDS: Goals to be achieved are:- Prevention of contamination of ventilatory circuits during assembly.- Correct and consistent assembly of ventilatory circuits.

OUTCOMES: - Prevention of introduced infection to the critically ill patient, requiring ventilatory support.- Maintenance of patient safety by using correct setup of circuits consistently.

PROCEDURES: - Hands are washed prior to assembly of circuits.- Workbench surface is to be cleaned with alcohol environmental wipes in Respiratory Room.- Circuit to be laid out on surface and assembled - guidelines for assembly

NB : Duplicate ventilator/respiratory book to identify missing parts from circuits.- Dirty circuits are to be collected at bedside in bucket, taken to pan room, rinsed in soapy water, then placed in secured plastic bag for dispatch to bins.

ERICA VENTILATOR CIRCUIT ASSEMBLY:Setup: - Connect corrugated tube to Y piece.- Inspiratory Line : Temperature probe adaptor on long tubing with humidification red cable in line. Humidifier Fisher Paykel base.- Expiratory Line : Short tubing. Water trap. Short tubing. Metal box with valve, spring, black bag and metal rod. Grey temperture probe to be added to setup when circuit changed on ventilator (between patients only).

BIRD 8400 CIRCUIT ASSEMBLY :

Setup: - Connect corrugated tube to Y piece. - Inspiratory line - NB: Temperature probe hole on inspiratory line side of Y piece. Long tubing with humidification Red cable in line. Humidifier (Fischer Paykel) base. - Expiratory line - short tubing. Water trap (2 pieces), base and top. Short tubing. Expiratory plastic connector. Grey silicone valve. Flow transducer. Plastic elbow angled connector. Short tubing. Straight plastic connector.


BIRD 6400 CIRCUIT ASSEMBLY:

Setup: - Connect to corrugated tube. Y connector with high pressure hose and small connector on expiratory side, temperature adaptor hole on inspiratory side. - Inspiratory side - long tubing with inspiratory humidification red cable in line. Humidifier (Fischer Paykel) box.- Expiratory Line - short tubing. Water trap (2 pieces), base and top. Expiratory (6400 plastic) valve. Red expiratory silicone valve. Plastic elbow angled connector. Short tubing. Straight plastic connector.

CPAP/AUSPAP CIRCUIT :

Setup: - Connect facemask/bodai to Y piece. - Inspiratory line - silicone connector. Plastic connector. Temperature adaptor. Long tubing with red humidification cable line. Straight plastic connector. Short tubing. - Expiratory line - short tubing. Water trap (2 pieces) base and top - filter/bacteria barrier (Fischer Paykel) humidification base.

Blowover Circuit AssemblyBodai - corrugated tube - plastic connector - t-piece. Inspiratory line - temperature adaptor - long tubing with humidification cable (red) in line - plastic connector - medium tubing - bacterial filter - humidifier base (Fischer Paykel). Expiratory line - medium length tubing on other side of t-piece.

SPECIAL CONSIDERATIONS :

- All circuits are to be changed routinely every Sunday and Thursday. Nebulisers and spacers changed weekly on Sunday. (Discard spacers and used nebulisers - not to be sent for cleaning).- All assembly and ventilator setups are to be done only by Registered Nurses familiar with the procedure, or have been instructed in setups.- All circuit setups to be checked as correct and signed as such by 2 x Registered Nurses.- Grey temperature probes are to be wiped with an environmental wipe and then set to Endoscopy department for cleaning. NB: Send in plain brown paper bag.- Dirty dismantled circuits are to be rinsed in soapy water then placed in secure plastic bag for dispatch to bins. - Clean ventilators and circuits to be stored with plastic bag dust covers.


41. VENTILATOR EMERGENCY

STANDARDS:* Nursing management of each patient receiving ventilatory assistance, should be provided by a "responsible" registered nurse. The "responsible" nurse is one who has been orientated to the Intensive Care Unit; and who has been assessed as competent in the management of the patient receiving ventilatory assistance

by the Nursing Unit Manager (ICU/CCU) or their delegate.* At no time, should the ventilated patient be left without the direct supervision of a "responsible" nurse.* This policy/protocol is to be implemented when any of the following conditions occur in the ventilated patient:- ventilator failure;- ineffective ventilation;- sudden drop in SpO2.* At all times, the nurse should attempt to:- carefully explain all procedures to the patient, prior to their commencement- provide a suitable means of communication for the patient.

OUTCOMES: While receiving ventilatory assistance, the patient will experience an adequate supply of oxygen and concurrently, adequate elimination of carbon dioxide at the cellular level. Any mechanical; physical or psychological barrier to effective respiration will be identified and corrected promptly.

EQUIPMENT:

* Laerdal resuscitator (with mask and oxygen flow tubing)* High volume, low pressure cuff manometer

* Suction equipment (refer to policy/procedure: Suctioning A Patient With A Endotracheal / Tracheostomy Tube)Stethoscope 12 g. Dwellcath cannula.

PROCEDURE:* Problems Associated With Mechanical Ventilator: - Detach patient from ventilator and manually ventilate patient using Laerdal Silicone Resuscitator (attached to endotracheal tube) and high flow oxygen.- If the patient is "easy" to manually ventilate and settles once removed from the ventilator - the


ventilator has been identified as the primary source of the ventilator emergency.- While one nurse manually ventilates the patient, a second skilled nurse inspects the ventilator and attends performance check (as per manufacturer's guidelines).- If the problem cannot be identified and rectified, the ventilator is replaced with another.- The malfunctioning ventilator is sent to biomedical engineering for review.

* Problems Associated With The Endotracheal Tube: - If the patient is "easy" to manually ventilate but an audible air leak is present, check cuff pressure with manometer.- If the leak persists or is unsealable, check tube position / length and air entry.- Reinsert tube to correct length.- Check for absence of cuff leak and equal air entry.- Document event.* If the patient is "difficult" to ventilate, attempt to pass suction catheter.* If the suction catheter cannot be passed further than 5 cm - verify that the patient is not biting on the tube. Insert oropharyngeal airway and attempt to suction patient again. If difficulty persists: proceed.* If the suction catheter cannot be passed further than 10-15 cm:- Position patient's head / neck in a position of neutral alignment and attempt to suction patient again.- If difficulty persists: proceed.* If the suction catheter cannot be passed further than the tip of the endotracheal tube:- Deflate cuff.- Pass suction catheter. - Reinflate cuff to pressure of 15 to 25 cm H2O.- Attempt to pass suction catheter again.- If passage of catheter is impossible and ventilation is absent: remove tube. - Call for assistance of Director of ICU immediately.- Manually ventilate patient using Laerdal Silicone Resuscitator and appropriately sized mask.- Prepare for reintubation.

Problems Isolated Within The Chest Cavity: - If ineffective ventilation continues, inspect and auscultate the patient's chest for equal and adequate air entry.- If there is unequal chest wall movement and / or decreased air entry on one side, exclude the following causes:

Malpositioned Tube: Signs: chest movement and air entry on one side.Actions: - Summon the assistance of the Director of ICU- Reposition and resecure tube (refer to the policy / procedure: Securing and Care of an Endotracheal/Tracheostomy Tube.)- Recheck chest movement and air entry.Atelectasis :Signs: no chest movement over the affected side;


no air entry over the affected side;dull sound on percussion over the affected side;tracheal shift towards the affected side.Actions: - Aggressive endotracheal suctioning including the use of saline lavage.- Aggressive chest physiotherapy.- Notify the Director of ICU

Tension Pneumothorax: Signs:

* No chest movement over the affected side;* No air entry over the affected side;* Hyper resonant sound upon percussion;* Tracheal shift away from the affected side Actions: - Summon medical assistance.- Insert 12g. dwellcath needle into the second intercostal space, mid-clavicular line.- Observe patient for a large "hiss" of air.- Prepare for the introduction of an intercostal catheter attached to underwater sealed drainage.

Problems Associated With The Central Nervous System: - If ineffective ventilation continues and no physical or mechanical cause can be found, sedate patient as per medication chart.


42. PATIENT RECEIVING VENTILATORY ASSISTANCE

POLICY : Nursing management of each patient receiving ventilatory assistance, should be provided by a "responsible" registered nurse. The "responsible" nurse is one:- who has been orientated to the Intensive Care Unit;

- who has been assessed as competent in the management of the patient receiving ventilatory assistance by the Nursing Unit Manager (ICU/CCU) or their delegate.

STANDARDS : Patient Safety: * At the beginning of the shift, the nurse should perform the six-point safety check, as detailed in the "Nursing Alert".* At no time, should the ventilated patient be left without the direct supervision of a "responsible" nurse.* The principles of "Universal Precautions" are to be adhered to at all times. In particular, no piece of equipment is to be shared between patients, without having been first been cleaned according to the policy / procedure: Ventilatory Circuit Changes and Setups .

Patient Comfort: At all times, the nurse should attempt to:- involve the patient and their family in the planning and implementation of nursing care;- orientate the patient to their environment and events;- carefully explain all procedures to the patient, prior to their commencement;- facilitate a proper day / night rhythm for the patient;and - provide a suitable means of communication for the patient.

OUTCOMES : While receiving ventilatory assistance, the patient will experience an adequate supply of oxygen and concurrently, adequate elimination of carbon dioxide at the cellular level.

EQUIPMENT :

- Laerdal resuscitator (with mask and oxygen flow tubing)- Suction equipment (refer to policy / procedure: Suctioning A Patient With A Endotracheal / Tracheostomy Tube ) including a Yankeur suction catheter - Mechanical ventilator - having passed Performance Check ( as detailed by manufacturer)- Stethoscope- High volume and low pressure cuff manometer - 12 g Dwellcath cannula.


PROCEDURE :

Endotracheal Tube: Position: - The correct position / length of the endotracheal tube, as verified by Chest X-Ray, should be documented in the patient's progress notes and upon the daily flow chart.- The "responsible" nurse should verify, at the beginning and end of their shift, that the endotracheal tube position is at the documented level.

Endotracheal Tube: Securing: - At all times, the endotracheal tube should be securely taped, according to the policy / procedure: Care and Securing of an Endotracheal / Tracheostomy Tube. Endotracheal Tube: Cuff: -At all times, the "responsible" nurse should listen for an air leak in the tube cuff, as evidenced by a gurgling sound.- Hourly, the "responsible" nurse should document on the daily flow chart the actual cuff pressure measurement or the presence or absence of an audible air leak during the previous hour. - The cuff pressure should be maintained from 15 to 25 cm H2O. The cuff pressure should be verified, by use of a cuff pressure manometer: at least every four hours; upon hearing an air leak or after repositioning the endotracheal tube.- The cuff pressure of low volume / high pressure cuffed endotracheal tubes are not routinely measured. If an audible air leak presents, using a syringe instill sufficient air into the cuff to seal the leak - then, withdraw 0.5 ml of air.

Tracheal / Oropharyngeal Aspiration: - Refer to the policy / procedure: Suctioning of an Endotracheal / Tracheostomy Tube. - At least second-hourly, unless stipulated by the Director of ICU or his delegate, attend tracheal aspiration maintaining strict asepsis. Note the amount and nature of secretions on the daily flowchart.- At least second-hourly, using a Yankeur sucker and a clean technique, aspirate oropharyngeal secretions.

Humidification: Refer to the policy / procedure: Humidification. - At the beginning of the shift: verify that the temperature of the inspiratory tubing is warm to touch.- Hourly: check and document the temperature of humidified air ( as registered on the Fisher - Paykel humidifier base). Unless otherwise ordered by the Director of the ICU, or his delegate, it should be functioning at 37o C. (that is: 39o C. at humidifier base and -2o C. at distal end of temperature probe).- Hourly: check and verify that the level of sterile water in the humidifier is around indicated level. Replenish volume as required, ensuring minimal interruption to ventilation.

Ventilatory Assistance: - Continuously: observe patient for signs of respiratory distress. ( These include: increased respiratory effort; increased difficulty in ventilation; agitation; a sudden decrease in SpO2; poor


or unequal chest expansion and cyanosis.) If these signs occur, the "responsible" nurse should be prepared to manually ventilate the patient, using a Laerdal silicone resuscitator, while investigating the cause of the ventilator emergency. Refer to the policy / procedure: Nursing Management: Ventilator Emergency. - Continuously observe the patient's SpO2. Inform Director of ICU, or his delegate, if SpO2 deviates from the accepted parameters. The SpO2 alarm limits should be functioning at all times. - Hourly: observe and document respiratory and ventilatory functioning. In particular:- Ventilatory inspiratory modes and measurements;- Ventilatory expiratory mode and measurement;- Intermittent mandatory ventilation rate;- Spontaneous breath rate;- I.M.V. tidal volume;- Spontaneous breath tidal volume;- Peak inspiratory airway pressure;- Peak inspiratory flow and flow pattern;- Sensitivity;- Fraction of inspired oxygen;- Low airway pressure limit;- High airway pressure limit;- SpO2.- At the beginning of the shift and every four hours: auscultate patient's lung fields. Document and report, whether air entry is equal to both lungs and the presence of adventitious breath sounds.

Observation of Vital Signs: - At the beginning of the shift: ascertain desired parameters of heart rate; blood pressure and central venous pressure. Record parameters on daily flow chart.- Continuously: observe patient's heart rate and rhythm. Verify that heart rate alarm are set at all times.- Hourly: document heart rate and rhythm on the daily flow chart. Document and report any cardiac arrhythmias.- Frequency of blood and central venous pressure measurements are determined by the haemodynamic stability of the patient.- Continuously: observe the patient's level of consciousness; sedation and co-operation.

Document and report behaviour trends.- At all times: maintain an accurate fluid balance record.- Hourly: document urine output on the daily flow chart (if applicable). Notify the Director of ICU, or his delegate, if output falls outside desired urine output parameters, or when output is less than 0.5 ml/ kg/ hour for longer than 3 hours.

Physiotherapy: - At the beginning of the shift, in liaison with the Director of ICU and attending physiotherapist, the "responsible" nurse


Should ascertain the physiotherapy requirements of the patient.- Unless contraindicated: the physiotherapy regime for the ventilated patient will include:- Hourly to second-hourly tracheal aspiration. Refer to the policy / procedure: Suctioning of an Endotracheal Tracheal Tube. - Second-hourly: hyperinflation and hyperoxygenation of lungs using Laerdal Silicone Resuscitator.- Second to fourth-hourly: postural drainage; gentle percussion and vibrations (alternating lung fields).- Each shift, if the patient is unable to move their limbs fully and independently, attend full range of motion exercises.

Elimination: - Daily: attend and document urinalysis. Report abnormalities to the Director of ICU, or his delegate,- Each shift: document bowel motions. If bowels have not been opened in the previous 24 hours, attend a rectal examination.- Each shift, if flatus has not been passed, auscultate and document the nature of bowel sounds.- If enteral feeding is not in progress, connect nasogastric tube to drainage bag. Manually aspirate nasogastric tube every four hours. Note amount and nature of drainage.

Maintenance of Mucous Membrane Integrity (Hygiene Needs): - Every two hours, unless contraindicated, reposition patient. Maintain correct body alignment at all times. Unless the patient conscious and co-operative, three staff are required for each position change. One for either side of the patient and the third person to control the patient's head and neck and maintain the security of the endotracheal tube.- Each shift all pressure-prone areas are to be inspected and sufficient action taken to prevent further deterioration in skin integrity.- Every two hours, following oropharyngeal suctioning, attend oral cavity care. Apply emollient cream to the patient's lips. - Every two hours, attend patient's eye toilet. If the patient is unconscious or has inflamed conjunctiva, apply liberal amountsof lubricant ung to the lower conjunctival sacs. In the unconscious patient, if the eyelids will not stay closed independently, they should be taped shut with 1 cm wide hypoallergenic tape. If the patient is conscious, lubricant drops should be used rather than ung, to prevent corneal ulceration.- Every four hours, attend nasal toilet. - Every four hours, attend perineal / meatal hygiene.- Daily and as required: attend full sponge.- Weekly and as required, attend hair wash.- Document changes in condition of skin and mucous membranes and subsequent nursing actions in progress notes.

ALERTAt beginning of the shift: the "responsible" nurse is to verify that:


* The endotracheal, or tracheostomy, tube is adequately secured and is patent.* There is a functioning suction source and equipment in close proximity to the patient.* There is a functioning oxygen cylinder under the patient's bed.* All alarms on the ventilator are correctly functioning.* The ventilator is attached to an uninterrupted power source. (Refer to the policy / procedure: Electricity in ICU ).

No change should be made in ventilatory management without prior consultation with the Director of ICU, or his delegate.


43. SENGSTAKEN-BLAKEMORE TUBE

STANDARDS: * Inserted by a Gastroenterologist or a medical officer who is skilled at this procedure.* The patient will have an endotracheal tube in-situ (with rare exceptions), prior to insertion of a Sengstaken-Blakemore tube.* The patient will be nursed in ICU by an ICU Registered Nurse or a Registered Nurse who is under the supervision of an ICU RN while balloons are inflated.* Patients safety will be maintained during insertion, whilst this tube is in-situ and during extubation.* Universal precautions will be adhered to during insertion whilst this tube is in-situ and during extubation.

OUTCOMES: * Bleeding from oesophageal varices will be arrested while tube is in-situ and following the deflation of balloons.* The tube will be placed and maintained in the correct position as evidenced by:- Aspiration and pH testing OR- Injecting air and auscultating over stomach AND- X-ray confirming that the part of the tube where the oesophageal and gastric balloons meet is at the level of the xiphoid process.* Accurate records will be kept of amount and nature of drainage from tube or from mouth.* Intensivist will be notified in the event of:-- Evidence of markedly increased haemorrhage- Evidence of shock- Evidence of respiratory embarrassment should the tube migrate superiorly* Correct traction weight and balloon pressures will be maintained as prescribed by Gastroenterologist or appropriately skilled medical officer.* The patients nose and mouth will be kept clean and free of pressure areas.

EQUIPMENT:

* Sterile Sengstaken-Blakemore tube with instructions* Pair of scissors* 50ml syringe* 2 x rubber tipped artery forceps* Water soluble lubricant* 3 metres of white linen tape* Adhesive tape* Pressure gauge


* Weight for traction* Pulley* Drainage bag* Gloves* Goggles* Plastic aprons

PROCEDURE: "Instructions for use of Sengstaken-Blakemore Tube" for details re insertion.

ALERTS: * Balloon pressures should never exceed 45mmHg.* Fully deflate both balloons prior to extubation.* Clamp the tube before extubation to prevent liquid escaping from distal end and being aspirated into lungs.* Traction (if ordered) must be maintained as constant at all times.* Scissors are kept near patient at all times in case balloons migrate superiorly and cause respiratory obstruction in non intubated patients. The whole tube can be cut and removed, remembering to grasp the tube between the patient and scissors.* The used tube should be washed and dried, once removed, and placed in a paper bag, along with "instructions for use" and remain with the patient until discharge. The tube may need to be reinserted if bleeding reoccurs.


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Critical Care Nursing Manuall I