lOMoARcPSD|64639315
Nurs 311 Lecture Notes
Sept 11th, 2023
A few notes for SIM Labs
- Takes notes on the vitals and know when to reassess them
- Go through your 10 rights and 3 checks every time you give a medication
- Use the IV med manual provided
- Communicate your vitals to your partner
- Blood glucose monitoring
- Palpate the pulse (is it regular, bounding)
- RR
Check all 5 points of the environment in every scenario
- Suction setup and function
- Oxygen
- Bed safety
- IV
- Tubes
Complete everything identified on the focused assessment that is relevant to your patient
Communicate your assessment findings to your partner
- Communicate throughout the scenario,
- Review doctor’s orders, MAR and pertinent labs together at the beginning of the
scenario
- Identify priorities of the scenario (together
- Make sure you SBAR at the end of every scenario
What is Clinical Judgement?
- Clinical judgement is the observed outcome of critical thinking and decision making
- Involves critical thinking and decision making plus knowledge
- Is a behavior “think like a nurse”
What’s your recognizing cues?
- Identifying relevant and important information forma variety of sources
- What information is most important?
- What is of immediate concern
- Subjective or objective assessment data such as vital signs or lab values
What’S Analyzing cues?
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- Always refer to the parenteral manual prior to administration to ensure health authority
policy
- Examine insertion and patency
- Perform the 10 rights and 3 checks
Peripheral Intravenous Tubing Port (Y site)
- Select the injection port of the IV tubing closest to the patient (neddless syringe, filter if
required) wipe the port with alcohol for 15 seconds and allow to dry
*If medication is compatible with IV solution
- Attach medication syringe to y site port by pushing and turning
- Occlude the IV line by pinching the tubing just above the injection port
- Inject the medication at the correct rate
-Flush the injection port with 0.9% sodium chloride
-Ensure correct infusion rate
If medication is not compatible with IV solution
- Stop the IV infusion and scrub the y site port with alcohol
- Flush with 10 mls 0.9% sodium chloride
- Inject the medication at the correct rate
- Scrub the y site port with alcohol and flush again with 10 mls 0.9% sodium chloride
- Re-establish infusion and ensure correct rate
Peripheral saline lock
- Scrub needleless adapter with alcohol for 15 seconds and allow to dry; attach syringe
with 0.9% sodium chloride to needleless adapter by pushing and twisting until tight and
then flush (3mls)
- Scrub needleless adapter with alcohol for 15 seconds and allow to dry attach medication
syringe; inject at the correct rate
- Scrub needleless adapter with alcohol for 15 seconds and allo to dry; flush with 0.9%
sodium chloride and remove syringe from needleless adapter
How to Time an IV Push medication?
- Normal time for flush is 2-5 minutes
- If for ex you have 2 ml of medication, consider diluting in 10 ml for erase of med math
and administration
- Consider: 10 ml to push over 2 minutes
- How many Ml/min: 5 ml
- How many ml in/30sec? 2.5 ml
- How mny ml/15 sec? 1.25 ml
What are the potential complications for IV push medications?
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, lOMoARcPSD|64639315
How to insert Chest tube?
Air- Placed anteriorly through the 2nd intercostal space
Fluid and blood – Placed posteriorly through the 8th or 9th intercostal space
What do Nurses do for the insertion of the chest tube?
- We will assist in the sterile procedure
- X-ray following to make sure the tube is in the right place and routinely afterward
(whether or not if the pt still need the tube)
What are the chest drainage equipment?
- Large bore
- Pig tail
- Jackson pratt
- Pleur X
- Heimlich valve
- Attached to suction
- Drain passively
What are the type of drainage systems
- Wet or dry
- Disposable, self-contained system
- Glass bottle system (1,2 or 3 bottles)
What’s the dry suction water seal system?
A= suction regulation
B=water seal chamber
C= Air leak monitor
D= Collection chamber
E= Suction monitor bellows
What are the nursing care of chest tubes?
- Nurses don’t put them in or remove them. We will assist practioners with the inserion
and removal chest tubes, as well as maintain and care for chest tubes.
- Chest tibes attached to a drainage unit with adjustable suction levesl require an order
for amount of suction
- Drainage units must be maintained below the chest level in an upright position and
tubing be in nondependent loops on the bed
Downloaded by Skyler Sammuel's ()
Nurs 311 Lecture Notes
Sept 11th, 2023
A few notes for SIM Labs
- Takes notes on the vitals and know when to reassess them
- Go through your 10 rights and 3 checks every time you give a medication
- Use the IV med manual provided
- Communicate your vitals to your partner
- Blood glucose monitoring
- Palpate the pulse (is it regular, bounding)
- RR
Check all 5 points of the environment in every scenario
- Suction setup and function
- Oxygen
- Bed safety
- IV
- Tubes
Complete everything identified on the focused assessment that is relevant to your patient
Communicate your assessment findings to your partner
- Communicate throughout the scenario,
- Review doctor’s orders, MAR and pertinent labs together at the beginning of the
scenario
- Identify priorities of the scenario (together
- Make sure you SBAR at the end of every scenario
What is Clinical Judgement?
- Clinical judgement is the observed outcome of critical thinking and decision making
- Involves critical thinking and decision making plus knowledge
- Is a behavior “think like a nurse”
What’s your recognizing cues?
- Identifying relevant and important information forma variety of sources
- What information is most important?
- What is of immediate concern
- Subjective or objective assessment data such as vital signs or lab values
What’S Analyzing cues?
Downloaded by Skyler Sammuel's ()
, lOMoARcPSD|64639315
- Always refer to the parenteral manual prior to administration to ensure health authority
policy
- Examine insertion and patency
- Perform the 10 rights and 3 checks
Peripheral Intravenous Tubing Port (Y site)
- Select the injection port of the IV tubing closest to the patient (neddless syringe, filter if
required) wipe the port with alcohol for 15 seconds and allow to dry
*If medication is compatible with IV solution
- Attach medication syringe to y site port by pushing and turning
- Occlude the IV line by pinching the tubing just above the injection port
- Inject the medication at the correct rate
-Flush the injection port with 0.9% sodium chloride
-Ensure correct infusion rate
If medication is not compatible with IV solution
- Stop the IV infusion and scrub the y site port with alcohol
- Flush with 10 mls 0.9% sodium chloride
- Inject the medication at the correct rate
- Scrub the y site port with alcohol and flush again with 10 mls 0.9% sodium chloride
- Re-establish infusion and ensure correct rate
Peripheral saline lock
- Scrub needleless adapter with alcohol for 15 seconds and allow to dry; attach syringe
with 0.9% sodium chloride to needleless adapter by pushing and twisting until tight and
then flush (3mls)
- Scrub needleless adapter with alcohol for 15 seconds and allow to dry attach medication
syringe; inject at the correct rate
- Scrub needleless adapter with alcohol for 15 seconds and allo to dry; flush with 0.9%
sodium chloride and remove syringe from needleless adapter
How to Time an IV Push medication?
- Normal time for flush is 2-5 minutes
- If for ex you have 2 ml of medication, consider diluting in 10 ml for erase of med math
and administration
- Consider: 10 ml to push over 2 minutes
- How many Ml/min: 5 ml
- How many ml in/30sec? 2.5 ml
- How mny ml/15 sec? 1.25 ml
What are the potential complications for IV push medications?
Downloaded by Skyler Sammuel's ()
, lOMoARcPSD|64639315
How to insert Chest tube?
Air- Placed anteriorly through the 2nd intercostal space
Fluid and blood – Placed posteriorly through the 8th or 9th intercostal space
What do Nurses do for the insertion of the chest tube?
- We will assist in the sterile procedure
- X-ray following to make sure the tube is in the right place and routinely afterward
(whether or not if the pt still need the tube)
What are the chest drainage equipment?
- Large bore
- Pig tail
- Jackson pratt
- Pleur X
- Heimlich valve
- Attached to suction
- Drain passively
What are the type of drainage systems
- Wet or dry
- Disposable, self-contained system
- Glass bottle system (1,2 or 3 bottles)
What’s the dry suction water seal system?
A= suction regulation
B=water seal chamber
C= Air leak monitor
D= Collection chamber
E= Suction monitor bellows
What are the nursing care of chest tubes?
- Nurses don’t put them in or remove them. We will assist practioners with the inserion
and removal chest tubes, as well as maintain and care for chest tubes.
- Chest tibes attached to a drainage unit with adjustable suction levesl require an order
for amount of suction
- Drainage units must be maintained below the chest level in an upright position and
tubing be in nondependent loops on the bed
Downloaded by Skyler Sammuel's ()
