Essential Nursing Procedures and Clinical Documentation

Documentation and Physician Orders

Recall and Documentation: When giving a report, include the patient's condition, changes within the last 24 hours, abnormal laboratory results, recent vital signs, medications, new orders, and tasks for the next shift.

Transcribing Physician Orders: Ensure the inclusion of the date, time, signature, and accuracy. Verbal Orders: These are permitted only in emergencies. You must read back the order to the physician. It must be signed later, typically within 24 hours.

Heparin Administration and Monitoring

Action: Heparin blocks the conversion of fibrins and acts as an anticoagulant to prevent blood clot formation; it prolongs clotting time. It can be administered as a bolus or via IV. The minimum bolus rate is 25 mL/hr.

• Indications: Pulmonary embolism, venous thrombosis (VT), deep vein thrombosis (DVT), mechanical heart valves, atrial fibrillation (AFIB), and acute coronary syndrome (ACS).
• Monitoring: Monitor PT, PTT, INR, and CBC. Obtain baseline INR, PTT, and CBC. Repeat CBC 24 hours after the baseline, then every 2 days until Heparin is discontinued.
• Risks and Complications: Bleeding, Heparin-induced thrombocytopenia (HIT), and hematoma.
• Nursing Responsibilities: Double-check the dosage, monitor for bleeding, and follow the facility protocol. Use caution with medications that decrease platelets.

Patient-Controlled Analgesia (PCA)

PCA uses lockout intervals to prevent overdose. The patient can receive a specific number of doses every hour. Only the patient should push the button.

Monitoring: Assess pain levels, respiratory rate, sedation levels, and pump function.

IV Insertion and Gauge Selection

Consider the patient's condition, age, diagnosis, and vein quality. Palpate up to 10 cm (4 inches) above the insertion site.

• 18 Gauge: Blood administration and surgery.
• 20 Gauge: Routine therapy.
• 22 Gauge: Elderly patients and children.
• 24 Gauge: Infants and small children.

Nursing Responsibilities: Use aseptic technique, change the dressing every 7 days, monitor the site hourly, and monitor for complications.

Hypodermoclysis and Central Venous Access

Hypodermoclysis: A subcutaneous route for patients with difficulty swallowing, nausea/vomiting, impaired venous access, or palliative patients. Change tubing every 72 hours if continuous and every 24 hours if intermittent.

Central Venous Access (CVA): The catheter tip is inserted into the distal third of the superior vena cava.

• Non-tunneled: Temporary access via the arm, neck, chest, or groin.
• Types: PICC, jugular, femoral, and hemodialysis lines.

PICC Line Management

Indications: Long-term therapy, poor peripheral access, vesicant medications, and Total Parenteral Nutrition (TPN).

Nursing Assessment: Check the insertion site, dressing, patency, and external length measurement. Complications: Infections, occlusions, thrombosis, and migration.

Tracheostomy Care and Emergency Equipment

Management: Maintain the airway, provide humidification, and assess respiratory status.

• Outer Cannula: The main component; can be fenestrated or non-fenestrated.
• Inner Cannula: Aids in cleaning and prevents obstruction.
• Cuffed: Used when the patient is on a ventilator to protect from aspiration.
• Cuffless: Used as part of the weaning process to increase airway clearance.

Suctioning: Perform when there are visible secretions, abnormal lung sounds, or respiratory distress. Assess oxygen levels, secretions, and patient tolerance.

Emergency Care: Keep an obturator at the bedside, a spare tracheostomy tube (same size or smaller), suction equipment, and a bag-valve mask.

Dosage and IV Rate Calculations

Primary Infusion IV Rate (mL/hr): mL/hr = Total Volume (mL) / Time (hrs). Example: 1000 mL over 8 hours (1000 / 8 = 125 mL/hr).

Secondary (IVPB) Rate: mL/hr = Medication Volume (mL) / Time (hr). Example: 50 mL of antibiotics over 30 minutes (0.5 hr) = 50 / 0.5 = 100 mL/hr.

Reconstitution Formula: Volume to give = (Dose ordered / Dose on hand) * Volume on hand.

• Example 1: Order 500 mg, vial after reconstitution is 1 g (1000 mg) in 4 mL. (500 / 1000) * 4 = 2 mL.
• Example 2: Order 250 mg, available 500 mg in 2 mL. (250 / 500) * 2 = 1 mL.