Table Of Content5133 FM.qxd 8/23/08 15:35 Page i
N U R S E’S
5-MINUTE
CLI N ICAL
CONSU LT
Procedures
5133 FM.qxd 8/23/08 15:35 Page ii
STAFF The clinical treatments described and recom-
mended in this publication are based on research
Executive Publisher
and consultation with nursing, medical, and legal
Judith A. Schilling McCann, RN, MSN authorities. To the best of our knowledge, these
procedures reflect currently accepted practice.
Editorial Director
Nevertheless, they can’t be considered absolute
H. Nancy Holmes
and universal recommendations. For individual
Clinical Director applications, all recommendations must be con-
sidered in light of the patient’s clinical condition
Joan M. Robinson, RN, MSN and, before administration of new or infrequently
Art Director used drugs, in light of the latest package-insert in-
Elaine Kasmer formation. The authors and publisher disclaim any
responsibility for any adverse effects resulting from
Editorial Project Manager the suggested procedures, from any undetected
Jennifer Kowalak errors, or from the reader’s misunderstanding of
the text.
Clinical Project Manager
© 2008 by Lippincott Williams & Wilkins. All rights
Beverly Ann Tscheschlog, RN, BS reserved. This book is protected by copyright. No
Editors part of it may be reproduced, stored in a retrieval
Naina D. Chohan, Julie Munden system, or transmitted, in any form or by any
means—electronic, mechanical, photocopy,
Clinical Editor recording, or otherwise—without prior written
Kathryn Henry, RN, MSN permission of the publisher, except for brief quota-
tions embodied in critical articles and reviews and
Copy Editors testing and evaluation materials provided by pub-
Kimberly Bilotta (supervisor), Jane Bradford, lisher to instructors whose schools have adopted
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cott Williams & Wilkins, 323 Norristown Road, Suite
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Designer
NCCPROC010107
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Digital Composition Services Library of Congress
Diane Paluba (manager), Joyce Rossi Biletz Cataloging-in-Publication Data
Nurse's 5-minute clinical consult. Procedures.
Manufacturing
p. ; cm.
Beth J. Welsh
Includes bibliographical references and index.
Editorial Assistants 1. Nurse practitioners—Handbooks, manuals, etc.
Megan L. Aldinger, Karen J. Kirk, 2. Nursing —Handbooks, manuals, etc. I.
Lippincott Williams & Wilkins. II. Title: Nurse's five-
Linda K. Ruhf
minute clinical consult. Procedures. III. Title:
Design Assistant Procedures.
Georg W. Purvis IV [DNLM: 1. Nursing Care—methods—Handbooks.
2. Clinical Medicine—Handbooks. WY 49 N97428
Indexer 2007]
Barbara Hodgson RT82.8.N874 2007
610.7306'92—dc22
ISBN13: 978-1-58255-513-3
ISBN10: 1-58255-513-3 (alk. paper) 2006032412
5133 FM.qxd 8/23/08 15:35 Page iii
Contents
Contributors and consultants iv
PROCEDURES
A toZ 2
Index 590
iii
5133 FM.qxd 8/23/08 15:35 Page iv
Contributors and consultants
Marsha Conroy,RN,MSN,APN Grace G.Lewis,RN,MS,BC
Nurse Educator Assistant Professor of Nursing
Cuyahoga Community College Georgia Baptist College of Nursing of
Cleveland MercerUniversity
Atlanta
Kim Cooper,RN,MSN
Nursing Department Program Chair Sherry Rogman,RN
Ivy Tech Community College Registered Nurse
Terre Haute, Ind. BryanLGH Memorial Hospital
Lincoln, Neb.
Arlene M.Coughlin,RN,MSN
Nursing Faculty Kelley Straub,RN,BSN,CCRN,RCIS
Holy Name Hospital School of Nursing Interventional Radiology Nurse Manager
Teaneck, N.J. Mercy Suburban Hospital
Norristown, Pa.
Donna Headrick,RN,MSN,FNP
Professor Kimberly Such-Smith,RN,BSN,LNC
Bakersfield (Calif.) Community College Legal Nurse Consultant/Healthcare
Advocate/Nurse Case Manager
Christine Kennedy,RN,MSN
Nursing Analysis and Review, LLC
Nursing Instructor
Byron, Minn.
Eli Whitney Technical School
Hamden, Conn. Colleen R.Walsh,RN,MSN,ACNP-BC,CS,ONC
Faculty, Graduate Nursing
Theresa M.Leonard,RN,BSN,CCRN
University of Southern Indiana
Unit Educator
Evansville
Stony Brook (N.Y.) University Hospital
iv
5133A.qxd 8/23/08 15:36 Page 1
NURSE’S
5-MINUTE
CLINICAL
CONSULT
Procedures
1
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Admixture of drugs in a syringe
◆Invert the vial and keep the needle’s
OVERVIEW KEY STEPS
bevel tip below the level of the solu-
tion as you withdraw the prescribed
DESCRIPTION WARNINGDrugs that come in dose.
◆Combining two drugs in one syringe prefilled cartridges require a ◆Put the sterile needle cover over the
alleviates the discomfort of two in- cartridge-injection system.(See needle.
jections. Cartridge-injection system.) ◆Wrap a sterile gauze pad or alcohol
◆Drugs usually can be mixed in a sy- ◆Verify that the drugs match the pa- pad around the ampule’s neck to
ringe: tient’s drug record and the pre- protect you from injury (in case the
– from two multidose vials (for exam- scriber’s orders. glass splinters).
ple, regular and long-acting insulin) ◆Calculate the dose. ◆Break open the ampule, directing the
– from one multidose vial and one am- ◆Wash your hands. force away from you.
pule ◆If desired, switch to the filter needle
– from two ampules MIXING DRUGS FROM TWO to filter glass splinters.
– from a cartridge-injection system MULTIDOSE VIALS ◆Insert the needle into the ampule.
combined with either a multidose ◆Before you insert the first needle, WARNINGBe careful not to touch
vial or ampule. wipe the vial’s rubber stopper with the outside of the ampule with
the needle.
an alcohol pad.
CONTRAINDICATIONS ◆Pull back the syringe plunger until ◆Draw the correct dose into the sy-
◆Combining drugs if their compatibil- the volume of air drawn into the sy- ringe.
◆If you switched to a filter needle,
ity isn’t known ringe equals the volume to be with-
◆Combining more than two compati- drawn from the drug vial. change back to a safety needle to give
ble drugs in the same injection sys- ◆Without inverting the vial, insert the the injection.
tem needle into the top of the vial, mak-
ing sure that the needle’s bevel tip MIXING DRUGS FROM TWO
doesn’t touch the solution. AMPULES IN A SYRINGE
EQUIPMENT ◆Inject the air into the vial and then ◆Know that an opened ampule doesn’t
withdraw the needle. The air replaces contain a vacuum.
Prescribed drugs ◆patient’s drug the liquid in the vial and prevents the ◆Calculate the prescribed doses.
record and chart ◆alcohol pads ◆sy- creation of a partial vacuum when ◆Open both ampules using aseptic
ringe and needle ◆safety needle (op- the drug is withdrawn. technique.
tional) ◆cartridge-injection system ◆ ◆Repeat the above steps for the sec- ◆If desired, use a filter needle to draw
filter needle ◆gauze pad ond vial. up drugs.
◆After injecting air into the second ◆If a filter needle is used, change to a
PREPARATION vial, invert the vial, withdraw the pre- safety needle to give the injection.
scribed dose, and withdraw the nee-
◆The type and size of syringe and nee-
dle.
dle depend on:
◆Wipe the rubber stopper of the first
– drugs prescribed Cartridge-injection
vial again and insert the needle, tak-
– patient’s build ing care not to depress the plunger. system
– route and site of administration.
◆Invert the vial, withdraw the pre-
scribed dose, and withdraw the nee- A cartridge-injection system,such as Tubex
dle. or Carpuject,is a convenient,easy-to-use
injection method that facilitates accuracy
MIXING DRUGS FROM A and sterility.The device consists of a plastic
MULTIDOSE VIAL AND AN cartridge-holder syringe and a prefilled
drug cartridge with needle attached.The
AMPULE
drug in the cartridge is premixed and pre-
◆Clean the vial’s rubber stopper with measured,which saves time and helps en-
an alcohol pad. sure an exact dose.The drug remains
◆Pull back on the syringe plunger until sealed in the cartridge and sterile until the
the volume of air drawn into the sy- injection is given to the patient.
ringe equals the volume to be with- The disadvantage of this system is that
drawn from the drug vial. not all drugs are available in cartridge form.
◆Insert the needle into the top of the However,compatible drugs can be added
to partially filled cartridges.
vial and inject the air.
2 ADMIXTURE OF DRUGS IN A SYRINGE
5133A.qxd 8/23/08 15:36 Page 3
SPECIAL CONSIDERATIONS PATIENT TEACHING DOCUMENTATION
◆Insert the needle through the vial’s ◆Tell the patient what drugs are in the ◆Record the drugs given.
rubber stopper at a slight angle, bevel injection system. ◆Note the injection site.
up, and exert slight lateral pressure to ◆Explain the drugs’ purpose. ◆Document the time of administra-
avoid cutting a piece of rubber out of ◆Describe the expected outcomes. tion.
the stopper, which could be pushed ◆Instruct the patient to inform you of ◆Record adverse drug effects.
into the vial. adverse reactions. ◆Note how the patient tolerated the
◆Be careful not to contaminate one injection.
drug with the other when mixing
drugs from multidose vials. SELECTED REFERENCES
◆The needle should be changed after Paparella, S. “Death by Syringe,” Journal
drawing the first drug into the sy- of Emergency Nursing30(6):552-55,
ringe. This isn’t always possible be- December 2004.
cause many disposable syringes Preston, S.T., and Hegadoren, K. “Glass
don’t have removable needles. Contamination in Parenterally Admin-
◆Some drugs are compatible only istered Medication,” Journal of Ad-
briefly after combining and should vanced Nursing48(3):266-70, Novem-
ber 2004.
be given within 10 minutes after mix-
Prot, S., et al. “Drug Administration Errors
ing.
and Their Determinants in Pediatric
◆After 10 minutes, temperature and
In-patients,” International Journal for
exposure to light and humidity may
Quality in Health Care17(5):381-89,
alter compatibility. October 2005.
◆Parenteral drugs are usually dis- Thomas, M., et al. “I.V. Admixture Conta-
pensed in single-dose vials to avoid mination Rates: Traditional Practice
contamination. Site Versus a Class 1000 Cleanroom,”
◆When combining a cartridge-injec- American Journal of Health-System
tion system and multidose vial, use a Pharmacy 62(22):2386-392, November
separate needle and syringe to inject 2005.
air into the multidose vial to prevent
contamination by the cartridge-
injection system.
MIXING INSULINS
◆Insulin is one of few drugs still pack-
aged in multidose vials.
◆Check facility policy before mixing
insulins.
◆Be careful when mixing regular and
long-acting insulins.
◆Draw up regular insulin first to avoid
contamination by long-acting sus-
pension.
◆Know that if a small amount of regu-
lar insulin is accidentally mixed with
long-acting insulin, it won’t change
the effect of the long-acting insulin.
COMPLICATIONS
None known
ADMIXTURE OF DRUGS IN A SYRINGE 3
5133A.qxd 8/23/08 15:36 Page 4
Airborne precautions
OVERVIEW EQUIPMENT KEY STEPS
DESCRIPTION Respirators (either disposable N95 or ◆Situate the patient in the negative-
◆Used with standard precautions, air- HEPA respirators, or reusable HEPA pressure room with the door closed
borne precautions prevent the respirators or powered air purifying (there should be an anteroom if pos-
spread of infectious diseases trans- respirators ◆surgical masks ◆isola- sible).
mitted by airborne pathogens that tion door card ◆thermometer ◆ ◆Put an airborne precautions sign on
are breathed, sneezed, or coughed. stethoscope ◆blood pressure cuff ◆ the door to notify anyone entering
(See Diseases requiring airborne pre- personal protective equipment as the room.
cautions.) needed ◆Keep the patient’s door (and ante-
◆Airborne precautions include the for- room door) closed to maintain nega-
mer categories of acid-fast bacillus PREPARATION tive pressure and contain airborne
isolation and respiratory isolation. ◆Keep airborne precaution supplies pathogens.
◆They require a negative-pressure on the cart outside of the isolation ◆Monitor negative pressure.
room with the door closed to main- room. ◆Put on the respirator according to the
tain air pressure balance between the manufacturer’s directions.
isolation room and adjoining ante- ◆Adjust the straps for a firm, comfort-
room, hallway, or corridor. able fit.
◆Everyone entering the room must ◆Check the fit and respiratory seal.
wear respiratory protection. (See Respirator seal check.)
◆Negative air pressure must be moni- ◆Tape an impervious bag to the pa-
tored, and air must be either vented tient’s bedside for disposal of facial
to the outside of the building or fil- tissues.
tered through a high-efficiency par- ◆Make sure that visitors wear respira-
ticulate air (HEPA) filtration system tory protection while in the room.
before recirculation. ◆Limit the patient’s movement from
◆Protection is provided by using a dis- his room.
posable or reusable respirator. ◆Make sure that the patient wears the
WARNINGThe respirator must be surgical mask over his nose and
fit to the face properly each time mouth when leaving the room.
it’s worn,regardless of what type is ◆Notify the receiving department of
used. isolation precautions so they can be
◆The patient needs to wear a surgical maintained and the patient can be
mask over his nose and mouth when returned to his room promptly.
leaving the room.
CONTRAINDICATIONS
None known Diseases requiring airborne precautions
DISEASE PRECAUTIONARY PERIOD
Chickenpox (varicella) Until lesions are crusted and no new lesions appear
Herpes zoster (disseminated) Duration of illness
Herpes zoster (localized in an Duration of illness
immunocompromised patient)
Measles (rubeola) Duration of illness
Smallpox Duration of illness
Tuberculosis (TB) (pulmonary Depends on clinical response; patient must be on effective therapy,
or laryngeal,confirmed or be improving clinically (decreased cough and fever and improved
suspected) findings on chest X-ray),and have three consecutive negative spu-
tum smears collected on different days,or TB must be ruled out.
4 AIRBORNE PRECAUTIONS
5133A.qxd 8/23/08 15:36 Page 5
SPECIAL CONSIDERATIONS PATIENT TEACHING DOCUMENTATION
◆Before leaving the room, remove ◆Explain isolation precautions to the ◆Record the need for precautions on
your gloves (if worn) and wash your patient and his family. the care plan, as indicated by your fa-
hands. ◆Instruct the patient to cover his nose cility.
WARNINGStrict hand washing is and mouth with a tissue when ◆Document the precaution period.
required after contact with the coughing or sneezing, to properly ◆Describe the patient’s tolerance of
patient or items contaminated with dispose of soiled tissues, and to wash the procedure.
respiratory secretions. his hands frequently. ◆Document patient or family teach-
◆Remove the respirator outside of the ing.
room after closing the door. ◆Record the date precautions were
◆Discard the respirator or clean and discontinued.
store it until next use; follow facility ◆Document microbiology and virolo-
policy and the manufacturer’s rec- gy specimens obtained and the re-
ommendations. sults of laboratory tests if available.
◆To prevent microbial growth, store
nondisposable respirators in a dry, SELECTED REFERENCES
well-ventilated place (not a plastic Coffey, C.C., et al. “Errors Associated with
bag). Three Methods of Assessing Respirator
◆Two patients with the same infection Fit,” Journal of Occupational and Envi-
may share a room if necessary. ronmental Hygiene3(1):44-52, January
2006.
COMPLICATIONS Gamage, B., et al. “Protecting Health Care
Workers from SARS and Other Respira-
None known
tory Pathogens: A Review of the Infec-
tion Control Literature,” American
Journal of Infection Control33(2):114-
21, March 2005.
Leonard, M.K., et al. “Increased Efficiency
in Evaluating Patients with Suspected
Respirator seal check Tuberculosis by Use of a Dedicated Air-
borne Infection Isolation Unit,” Ameri-
can Journal of Infection Control
Before using a respirator,always check the 34(2):69-72, March 2006.
respirator seal.To do this,place your hands Muller, M.P., and McGeer, A. “Febrile Res-
over the respirator and exhale.If air leaks piratory Illness in the Intensive Care
around your nose,adjust the nosepiece.If Unit Setting: An Infection Control Per-
air leaks at the respirator’s edges,adjust spective,” Current Opinion in Critical
the straps along the side of your head. Care 12(1):37-42, February 2006.
Recheck the respirator’s fit after this ad- Stirling, B., et al. “Nurses and the Control
justment. of Infectious Disease. Understanding
Epidemiology and Disease Transmis-
sion Is Vital to Nursing Care,” The
Canadian Nurse 100(9):16-29, Novem-
ber 2004.
Thrupp, L. “Tuberculosis Prevention and
Control in Long–Term-Care Facilities
for Older Adults,” Infection Control and
Hospital Epidemiology 25(12):1097-
108, December 2004.
Mask
AIRBORNE PRECAUTIONS 5
5133A.qxd 8/23/08 15:36 Page 6
Alignment and pressure-reducing devices
OVERVIEW EQUIPMENT KEY STEPS
DESCRIPTION Protective boots ◆abduction pillow ◆ ◆Confirm the patient’s identity using
◆These devices are used to maintain trochanter rolls ◆hand rolls (see two patient identifiers according to
correct body positioning and prevent Common preventive devices) facility policy.
complications that result from pro- ◆Explain the purpose and steps of the
longed bed rest. procedure to the patient.
◆Equipment includes alignment and
pressure-reducing devices, such as: APPLYING A PROTECTIVE BOOT
– boots that help protect heels and ◆Open the slit on the superior surface
help prevent skin breakdown and of the boot.
footdrop ◆Place the patient’s foot in the boot
– abduction pillows that help prevent and fasten the ankle and foot straps.
internal hip rotation after femoral ◆If he’s positioned laterally, apply the
fracture, hip fracture, or surgery boot only to the bottom foot and
– trochanter rolls that help prevent ex- support the flexed top foot with a pil-
ternal hip rotation low.
– hand rolls that help prevent hand ◆Insert the other foot in the second
contractures. boot, if needed.
◆Protective boots, trochanter rolls,
and hand rolls are useful when car-
ing for patients who have a loss of
sensation, mobility, or conscious- Common preventive devices
ness.
Equipment is available to reduce pressure or help maintain positioning,depending on the patient’s
CONTRAINDICATIONS
needs.
None known
Boot—Prevents footdrop and skin breakdown Abduction pillow—Prevents internal hip
rotation
Trochanter roll—Prevents external hip Hand roll—Prevents hand contractures
rotation
6 ALIGNMENT AND PRESSURE-REDUCING DEVICES
