Clinical Discussion: Karla May G. Jamosmos, MAN, RN Clinical Instructor

CLINICAL DISCUSSION
Karla May G. Jamosmos, MAN, RN

Clinical Instructor
STANDARD (UNIVERSAL)
PRECAUTIONS
 Recommended for the care of all patients, regardless of
their diagnosis or presumed infection status
 Designed to provide a barrier precaution for all health-
care providers to prevent the spread of infectious
diseases
 Applies to blood, other bodily fluids, secretions,
excretions, non-intact skin, and mucous membranes
TYPES OF STANDARD PRECAUTION
 Hand washing – perform before and after every patient
contact, after contact with blood, bodily fluids and
contaminated equipment
 Gloves
 Mask and eye protection
 Gown
 Disposal of sharps
 Containment
 Decontamination
TRANSMISSION-BASED PRECAUTIONS
o Airborne – in addition to Standard Precaution, use
Airborne Precaution
 Transmitted by airborne nuclei
 Measles, chickenpox, TB
 Specific Prec: private room, negative airflow, and
mask for HC provider. The pt may be required to
wear a mask if coughing is excessive.
o Droplet – in addition to Standard Precaution, use
Droplet Precaution
 Transmitted by large droplet nuclei
 Meningitis, Pneumonia, mumps
 Specific Prec: private room and mask for HC
provider. The pt may be required to wear a mask if
coughing is excessive.
o Contact – In addition to Standard Precaution, use
Contact Precaution
 Transmitted by direct pt contact or by items in the
patient’s environment
 GI, respiratory, skin or wound colonization or
infection with drug-resistant bacteria, C-diff, E-coli,
hepatitis, impetigo, chicken pox, Ebola
 Specific Prec: private room, gloves and gown for HC
provider. Mask if coughing is excessive
NOSOCOMIAL INFECTION
 A hospital-acquired infection that can be fatal to an
immunosuppressed pt.
 Transmitted by either accidental or deliberate disregard
for standard prec
 C-diff, MRSA, VRSA, VRE
 Likely access: indwelling catheters, vascular access

devices, ET tubes, NG and gastric tubes and surgical
wound sites
 Prevention: Use Standard Precautions during pt contact
VITAL SIGNS
Temperature – A stable temp pattern promotes proper
function of cells, tissues and body organs; a change in
this pattern usually signals the onset of illness.
Rectal, Axillary, Tympanic
Factors that affect temp: age, sex, emotional

conditions, and environment
Use the same thermometer for repeat temp taking to
ensure more consistent results
Pulse – can be palpated at locations on the body where an
artery crosses over bone or firm tissue
 Brachial
 Radial- most common for adults and children older than 3
years old
 Femoral
 Carotid
 Pedal
 Popliteal
 Posterior tibial
 Apical – PMI is at 5th ICS, Left, MCL
* When the pt’s peripheral pulse is irregular, take an apical pulse to
measure the heartbeat more directly.
Respiration – exchange of oxygen and carbon dioxide
between the atmosphere and the body
 The best time to assess your pt’s respiration is
immediately after taking his pulse rate.
 Observe for signs of dyspnea, such as anxious facial
expression, flaring nostrils, heaving chest wall and
cyanosis.
Blood Pressure – lateral force that blood exerts on arterial
walls
 systolic (contract) vs. diastolic (relax
 Pulse pressure – difference between systolic and

diastolic pressures
 Normal Pulse pressure = 40 mmHg
 Narrow = difference of less than 30
 Widened = more than 50 mmHg

 Choose appropriate cuff size.
 Arm extended at heart level. If the artery is below
heart level, you may get a false high result.
 Don’t take a blood pressure measurement on the same
arm with AV Fistula, affected side of a mastectomy, or
peripherally inserted central catheter.
TROUBLE SHOOTING VENTILATOR
ALARMS
 Low-Pressure – Usually caused by system
disconnections or leaks
 Reconnect pt to ventilator
 Evaluate cuff and re-inflate if needed (if ruptured, tube

will need to be replaced).
 Evaluate connections and tighten or replace as needed.
 Check ET tube placement.

 High-Pressure – usually caused by resistance within the
system; can be due to kink or water in the tubing, pt
biting the tube, copious secretions or plugged ET tube.
 Suction
 Reposition head and neck or tube
 Sedation after careful assessment and as ordered

High RR – can be caused by anxiety or pain, secretions in
ETT/airway or hypoxia
 Suction
 Look for source of anxiety
 Evaluate oxygenation
Low Exhaled Volume – usually caused by tubing
disconnection or inadequate seal
 Evaluate /re-inflate cuff. If ruptured, ETT must be
replaced.
 Evaluate connections; tighten or replace as needed,
check ETT placement, reconnect to ventilator.
NGT CARE
 Reassess placement of tube prior to administering
feedings, fluids, or meds.
 Flush tube with 30 mL of water before and after feeding

and administration of meds
 Assess for skin irritation or breakdown. Re-tape daily

and alternate sites to avoid constant pressure on one area
of the nose. Gently wash around nose with soap and
water and dry before placing tape.
 Provide nasal care daily and PRN.
 Provide oral hygiene every 2 hours and PRN. If pt is

performing oral hygiene, remind not to swallow water.
NGT FEEDINGS
 Confirm placement.
 Flush before and after feedings, meds or checking for

residuals.
 Obtain all meds in liquid form. If not available, ask

pharma if meds can be crushed. Administer each meds
separately and flush between each meds. Do not mix
meds with feeding formula.
 Check residuals before feeding and giving of meds.
Hold feeding if greater than 100 ml or accdg to hosp
policy. Recheck in 1 hour, if residuals are still, notify
physician.
IFC CARE
 Use standard prec.
 Keep bag below level of pt’s bladder at all times.
 Check for kinks and loops in the tubing and that pt is not
lying on the tubing.
 Wash around the catheter entry site with soap and water
twice each day and after BM.
 Check skin around the catheter entry site for signs of
irritation, redness, tenderness, swelling or drainage.
 Empty collection bag each shift, note quantity, color,
clarity, odor and presence of sediment.
 Refer if with blood, cloudiness or foul odor, fever or
abdominal or flank pain.
INTAKE AND OUTPUT
Normal I and O
Intake: 1500-2500 ml over a 24-hr period
A kg gained is a liter retained.
Output: 1500-2500 ml over a 24-hr period (40-80ml/hr)
Minimum urine output is 30 ml/hr.
Insensible loss(respiration, sweating, BM) is 500-1000
ml/day
Intake (ml)
 IVF infused
 Fastdrip given
 Oral Fluid Intake
 NGT feeding including free water
 IV medications thru IV push
 IV medications thru infusion
 Irrigants (catheter- calculate the amt of irrigate delivered

and subtract it from the total urine output)
Output (ml)
 Urine output
 Liquid stool (ostomy or diarrhea)
 Emesis
 Wound drainage or tube drains
 Suction (Gastric or respiratory)
 No BM – ask when was the last BM

Insensible loss is not included but needs to be considered.
It can’t be measured. According to Mosby’s Med
Dictionary, it is estimated to be 600 ml/day.
This varies depending on the patient’s activity level,
temperature. Take this in account when assessing if the
patient is at risk for fluid volume deficit or fluid volume
overload.
When you do your I and O rounds,
1. Check the present level of the IVF. Deduct the present level of the
IVF to the initial level you received in the morning. (Level
received in the morning – present level = total amt infused)
2. Identify if the patient received IV meds thru IV push, IV med thru
infusion or fast drip. Include it in the intake.
3. Ask how much water/fluid intake does the patient took from 6am
up to the time you are doing the I and O (ml).
4. NGT – total feeding and flushing in ml
5. Ask how many times the patient has voided
(frequency) and the volume. (Ex: Was a total of 300 ml
from 2 voids of 150 ml or from 10 voids of 30 ml
each?)
6. FC – add all the urine outputs drained (ml).
7. Ask if there was BM. If none, ask when was the last
time.
8. Include all drain outputs including wound drainage,
CTT, suctioned secretions.
MEDICATION ADMINISTRATION
Medication Rights
1. Right Patient
2. Right Medication
3. Right Dose
4. Right Time
5. Right Route
6. Right patient Education
7. Right Documentation
8. Right to Refuse.
9. Right Assessment
10. Right Evaluation

Triple Check
 When obtaining medication from where it is stored
 Side-by-side comparison of medication and the written

order and the MAR
 One last time after preparation, just prior to
administration
Approximate Onset
IV 3-5 MINUTES
IM 3-20 MINUTES
SC 3-20 MINUTES
PO 30-45 MINUTES
These onset times are only approximate, but will help you
in your assessment.
Assessment and Documentation
 Assessment needs vary and depend on route and
medication.
 Always assess patient after giving drugs that may
adversely affect RR, HR< BP, LOC, and blood glucose.
 Assess meds for their efficacy and adverse drug reaction
 Document drug, dose, route, time given, and time

discontinued if applicable. Include patient response and
any ADR.
Aspirate (IM and SC injections)
 To ensure that the needle is not in a blood vessel
 If blood appears in the syringe, withdraw the needle,

discard the syringe and prepare a new medication.
When Not to Aspirate
 When administering SC anticoagulants (eg. Heparin) or
insulin
 Aspiration while administering anticoagulants increases
the risk of bleeding and bruising.
IV Fluids (Reference: IV Therapy Notes)
Types of Solution (page 27-31)
Anatomy, Selection of IV Site and IV Catheter (page 36-
38)
Complications of IV Therapy (page 60)
Blood Transfusion (Reference: IV Therapy Notes, page

106-117)

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CLINICAL DISCUSSION

Karla May G. Jamosmos, MAN, RN

 Mask and eye protection

 Likely access: indwelling catheters, vascular access

Factors that affect temp: age, sex, emotional

 Pulse pressure – difference between systolic and

 Narrow = difference of less than 30

 Widened = more than 50 mmHg

 Evaluate cuff and re-inflate if needed (if ruptured, tube

 Check ET tube placement.

 Reposition head and neck or tube

 Sedation after careful assessment and as ordered

 Look for source of anxiety

 Flush tube with 30 mL of water before and after feeding

 Assess for skin irritation or breakdown. Re-tape daily

 Provide oral hygiene every 2 hours and PRN. If pt is

 Flush before and after feedings, meds or checking for

 Obtain all meds in liquid form. If not available, ask

 Oral Fluid Intake

 NGT feeding including free water

 IV medications thru IV push

 IV medications thru infusion

 Irrigants (catheter- calculate the amt of irrigate delivered

 Liquid stool (ostomy or diarrhea)

 Wound drainage or tube drains

 Suction (Gastric or respiratory)

 No BM – ask when was the last BM

6. Right patient Education

10. Right Evaluation

 Side-by-side comparison of medication and the written

 Document drug, dose, route, time given, and time

 If blood appears in the syringe, withdraw the needle,

Blood Transfusion (Reference: IV Therapy Notes, page

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