What is Nursing Care Of Patient On Intra Aortic Balloon Pump?

What is lntra-Aortic Balloon Pump Therapy – It is a short-term cardiac assist device placed in the descending aorta to improve myocardial oxygen supply and reduce cardiac workload by decreasing afterload.

What are the steps required for such cases?

  1. A credentialed physician will oversee the IABP management and manipulation.
  2. Only competent nurses who have demonstrated competency may nurse and adjust IABP augmentation as per physician order.
  3. All IABP patients will be continuously hemodynamically monitored via an arterial pressure line.
  4. The following assessments will be done every hour and PRN:
    1. Level of Consciousness (LOC)
    2. Heart rate and rhythm
    3. Record systolic/diastolic/mean arterial pressures and diastolic augmentation.
    4. Peripheral perfusion – pedal pulses distal to the catheter site (Doppler may be necessary to assess pulse)
    5. Color, temperature and capillary refill
    6. Sensation and movement of both lower extremities
    7. Urine output
  5. Assess insertion site each shift for redness, ooze, signs of bleeding, infection, hematoma, pain, or compartment syndrome of the affected limb and skin integrity.

What are the PROCEDURES & RESPONSIBILITY for each healthcare provider dealing with this case?

  1. Nurse:
    1. Complete and maintain IABP competency.
    2. Inform the physician of any problems encountered during IABP therapy especially in terms of complications (i.e. difficult augmentation, changes in LOC, hemodynamic instability, decreased urine output, peripheral vascular compromise) and optimizing augmentation.
    3. Be guided by AACN Procedure Manual for Critical Care, Chapter 51, p.362-80, for IABP nursing management, assessment, and augmentation adjustment.
    4. Maintain documentation as per IABP Monitoring Record.
    5. Write an order for any authorized nurse interventions when arriving ICU.
  2. Physician:
    1. Obtain informed, written consent from the patient before insertion of IAPB catheter.
    2. Notify CCU / ICU nurse that IABP catheter is correctly positioned based on an assessment of CXR.
    3. Assess hemodynamic information to direct therapeutic interventions and determine the continued requirement for IABP to remain in-situ.
    4. Perform removal of IABP catheter and achieve hemostasis at discontinuation of therapy.

What is Electronic occurrence variance report (e-ovr)?

Electronic Occurrence Variance Report (E-OVR) – an electronic report generated from the Hospital Portal System manifesting the documented account of an incident including the details of the investigation and corrective actions taken.

Incident — is an occurrence or any reportable event not consistent with the routine norms and operation of the hospital/ healthcare unit or routine care of that has a potential for or results in injury to an individual and/ or damage/ loss of property.

Classification of Incidents:

  1. Near Miss — any process variation that did not affect the outcome but for which a recurrence carries a significant chance of a serious adverse outcome. Also referred to as “Close call”- it is an event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention.
  2. Adverse Event — unanticipated, undesirable or potentially dangerous occurrence in a healthcare organization. Examples of such are falls, injuries, pressure ulcers and adverse drug reactions.
  3. Sentinel Event — is an unanticipated occurrence involving death or serious physical or psychological injury. Serious physical injury specifically includes loss of limb or functions, such events are called Sentinel because they signal the need for immediate investigations and response.
  4. Other Incidents — are incidents that can happen within the day to day operation of the hospital and do not meet the definition of the above-mentioned classifications and conclude not to have resulted in unwanted consequences or does not result to patient harm

 

 

Why would you need E-OVR?

  • To ensure that there is immediate management of an incident when required and that every incident is appropriately prioritized, investigated and managed.
  • To provide a simple, accessible, and confidential system for reporting issues relevant to a culture of safety in the hospital that may involve patients, visitors, employees, and hospital properties
  • To minimize risk and prevent future incidents through the development of appropriate action plans, recommendations, and review to identify opportunities to improve the quality of care.
  • To meet statutory and/or regulatory requirements through informing staff of their responsibilities in relation to essential notification reporting and ensuring the correct authority is notified in an accurate and timely manner by the organization.
  • To facilitate identification of issues/ incidents that may lead healthcare providers to engage in unsafe behaviors.
  • To provide education and feedback to clinicians and staff to prevent and reduce future incidents.

 

 

What should be done?

 

  • The hospital values the importance of safety of patient, employees, visitors and all those who have access to our services and facilities. In order to do this staff must report all incidents, both actual and ‘near misses’ so that real opportunities for improvement and risk reduction are taken. To enable this to occur, staff must make themselves fully aware of this policy and the arrangements in place for the management, reporting, and investigation of incidents.
  • All hospital staff must ensure that incident reports are made promptly and accurately.
  • The incident reporting will not result in a disciplinary proceeding, except in the most exceptional circumstances, for example where there has been a breach of law, gross negligence or professional misconduct.
  • Patient/ Family complaints are not to be entered in the E-OVR.

 

  • All completed investigation and planned actions are deemed CONFIDENTIAL.
  • Printing of the E-OVR is not allowed unless the risk management or quality management and the CEO approve the hard copy reproduction for amicable reasons.
  • The Risk Management under Quality Management Department is responsible for the control of E-OVR module, likewise for data aggregation and trending of all incident reports. Result of the aggregated monitoring and information is used for improvement.
  • As part of the general mandatory orientation program, all new hire/transfer staff are educated by the RM Department about the incident reporting process of the hospital.
  • As part of the department orientation program, all new hires/transfer receives in-service of E-OVR from the HOD / Designee Unit Supervisor or Departmental Q.l. Officers.

Who is the Most Responsible Physician (MRP)?

Most Responsible Physician (MRP): Most Responsible Physician is the Admitting Physician who is responsible for the overall care rendered to the patient and accountable for the outcome of care provided to the patient except in closed ICU system where the MRP will be the lntensivist/ ICU physician with admission privilege.

When a patient moves from one phase of care to another (for example medical to surgical) the individual responsible for the patient care (MRP) may change and this should be documented clearly in the patient medical record along with summery of patient care information which includes reason for admission, significant findings, diagnosis, procedures performed, medications administered and other treatments provided and patient’s condition at the time of transfer.

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Informed Consent

Informed Consent — agreement or permission accompanied by full information on the nature, risks, and alternatives of a medical procedure or treatment.

Comgetent Individual – A person who is mentally capable of understanding the nature of the procedure and associated risks who has reached the age of consent.

Sterilization – permanent method of contraception.

M.T.P. – Medical Termination of Pregnancy

  1. Informed consent is obtained before surgery, anesthesia, procedural sedation, use of blood and blood products and other high risk treatments and procedures.
  2. Consent must be taken by explaining to the patient/ family the following:
    1. Nature of the treatment or procedure
    2. Expected benefits, complications and risks
    3. Alternative courses of action
    4. Consequences of not undergoing the treatment or procedure
  3. Any procedure or treatment that, in the judgment represents a potential medico-legal risk should complete an informed consent.
  4. Exclusion: The following circumstances, only in the ER, do not require informed consent for procedural moderate sedation/ analgesia or procedure (but not limited to):
    1. Majorjoint dislocations or fracture dislocations.
    2. Displaced extremity fractures with severe angulations.
    3. Any fracture with evidence of distal vascular compromise.
    4. Major burns requiring immediate management and debridement 2″°’ degree and above
    5. Cardioversion for unstable dysrhthmias resulting in end-organ compromise.
    6. Emergency insertion of:
      1. Central venous catheters
      2. Chest decompression needles or drainage devices
  • Pericardiocentesis needle drainage
  1. Diagnostic peritoneal lavage catheters in the setting of trauma
  2. Any necessary invasive procedure that is urgently required in a patient whose judgment seriously impaired by substances and where treatment delay could potentially result in significant patient harm.
  1. All consent forms must be written in English and Arabic if patient’s first language is Arabic.
  2. Any competent individuals may sign his/ her own consent form.
  3. An adult female (i.e., has reached the legal age of 18 years) is legally responsible for herself and may consent to treatment (subject to local custom).
  4. Minors (patient who are under the age of 18 years) or a person not physically or mentally fit to give consent will be exercised through their parents or other representative.
  5. Minors who are not accompanied by their parent(s), spouse, closest adult male relative or other appropriate legal guardian:
    1. Shall not be treated if they presented with non-emergent conditions to the clinic or ER and inform Social Worker and the patient’s closest male relative or sponsor.
    2. Shall receive treatment without delay in ER for life or limb-threatening through emergent conditions while efforts are made to contact the patient’s closest male relative or sponsor.
  6. Nursing Service Dept. personnel sign as a witness on consent forms, acknowledging they have witnessed the signing, not the explanation of the procedure (informed consent).
  7. A second witness of consent can either be relative, friend, and attending doctor or sponsor if attending with the patient.
  8. Duration of (all) informed consent forms:
    1. From the date a consent form is signed by the patient/ patient’s representative, it is “valid”:
      1. For single procedures — maximum of 15 days
      2. For repeating a single procedure — either for the number of procedures of the time period specified on the consent form (as part of the physician’s specific treatment regimen).
    2. Consent must be reobtained and redocumented:
      1. If more than 15 days lapse between the date the patient/ patient’s representative signs the consent form and when the procedure is performed (for a single procedure).
      2. If the condition of a patient admitted for a specific treatment or procedure subsequently changes significantly.
  • If a different procedure is required.
  1. For medical termination of pregnancy, patient and husband will sign two (2) forms: informed for medical termination of pregnancy, patient and husband will sign two (2) forms: informed consent and “Justification for MTP Counseling & Consent” form in English or Arabic.
  2. in case of emergency where surgery, anaesthesia, use of blood and blood products, and other high-risk treatments is needed and the patient is unable to give consent and no relative or guardian or sponsor is available, the following will be followed:
    1. The attending physician must secure the agreement of another qualified physician after consultation that it is imperative to perform the procedure without delay.
    2. The attending physician and consulted physician will record in the patient’s file after agreement that the surgery is absolutely necessary without delay and signed by both physicians.
  3. Any patient who refuses treatment or surgery, anaesthesia, use of blood and blood products, and other high-risk treatments deemed necessary by the treating clinician or who discharges him/herself from hospital will sign ”RELEASE FROM LIABILITY” form. As stated in “Refusal of admission, leaving against medical advice (LAMA) and/ or refusal to accept medical/ dental care” This form may be signed by inpatients, outpatients and Emergency Room patients.

Combined management and MRP

Combined management: Combined management is a comprehensive care, with the involvement of more than one specialty for the patients requiring complex care. Patient will be admitted under the Most Responsible Physician who will be able to provide the maximum care to the most significant presenting symptoms of the patient.

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Intravenous Thrombolytic Therapy

Ischemic chest pain of at least 15 minutes duration, and unrelieved with sublingual nitroglycerine (2 times).
ECG evidence of Acute Myocardial Infarction (1- 2 mm ST segment elevation in two contiguous leads or new onset of complete left bundle branch block.
Thrombolytic therapy should be given within 12 hours (preferably < 4 hours) of onset of chest pain that is consistent with myocardial infarction .In case of recurrence or persistence  of chest pain the period can be extended to 24 hours.

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Prevention Of Venous Thromboembolism (VTE)

Venous thromboembolism (VTE) is a disease includes deep venous thrombosis (DVT) and pulmonary embolism (PE) and is a significant potential health complication for hospitalised patients. Serious adverse outcomes may occur, including an increased risk of recurrent thrombosis, morbidity from post thrombotic syndrome or death.

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Hospital Care of Patients Valuables

To provide guidelines for staff to follow when patients are unable to be responsible for caring for
their own possessions temporarily or permanently. And to protect patients possessions from theft or loss.

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Immunoglobulins

 

 

Normal immunoglobulin

 

HUMAN NORMAL IMMUNOGLOBULIN:

Indications: Replacement therapy in: Primary immunodeficiency syndromes such as: congenital agammaglobulinaemia and hypogammaglobulinaemia. common variable immunodeficiency. severe combined immunodeficiency. Wiskott Aldrich syndrome. Myeloma or chronic lymphatic leukaemia with severe secondary hypogammaglobulinaemia and recurrent infections. Children with congenital AIDS and recurrent infections. Immunomodulation. Idiopathic thrombocytopenic purpura (ITP) in children or adults at high risk of bleeding or prior to surgery to correct the platelet count. Guillain Barré syndrome. Kawasaki disease Allogeneic bone marrow transplantation.

Contraindications: Hypersensitivity to the active substance or to any of the excipients. Hypersensitivity to homologous immunoglobulins, especially in the very rare cases of IgA deficiency when the patient has antibodies against IgA.

Dose and Administration: The dose and dosage regimen is dependent on the indication. In replacement therapy the dosage may need to be individualised for each patient dependent on the pharmacokinetic and clinical response. The dosage regimen should achieve a trough level of IgG (measured before the next infusion) of at least 4 – 6 g/l. Three to six months are required after the initiation of therapy for equilibration to occur. The recommended starting dose is 0.4 – 0.8 g/kg, followed by at least 0.2 g/kg every three weeks. The dose required to achieve a trough level of 6 g/l is of the order of 0.2 – 0.8 g/kg/month. The dosage interval when steady state has been reached, varies from 2 to 4 weeks. Trough levels should be measured in order to adjust the dose and dosage interval. Guillain Barré syndrome: 0.4 g/kg/day for 3 to 7 days.

 

Specific Immunoglobulin

 

HEPATITIS B IMMUNOGLOBULIN:

Indications: indicated for post-exposure prophylaxis following either parenteral exposure (e.g. accidental “needle-stick”), direct mucous membrane contact, or oral ingestion of HBsAg-positive materials, such as blood, plasma or serum. Also indicated for the temporary protection of infants born to HBsAg-positive mothers (especially those who are HBeAg-positive), since these infants are at risk of acquiring hepatitis B infection. Infants born to HBsAg-positive mothers should receive hepatitis B immunoglobulin and the first dose of hepatitis B vaccine at the same time.

Contraindications: Intramuscular injections are not advocated for patients with bleeding disorders. The risk-benefit ratio in patients with a history of immunoglobulin A (IgA) deficiency or severe anaphylactic reactions to plasma

products should be considered. Is not appropriate for the treatment of any type of hepatitis B infection.

Dose and Administration: By intramuscular injection (as soon as possible after exposure; ideally within 12 hours, but no later than 7 days after exposure), adult and child over 10 years 500 units; child under 5 years 200 units, 5–9 years 300 units; neonate 200 units as soon as possible after birth

 

ANTI-D (RH0) IMMUNOGLOBULIN:

Indications: Rh (D) incompatibility.

Contraindications: Thrombocytopenia, coagulation disorders preventing intramuscular injection.

Dose and Administration: By intramuscular injection, to rhesus-negative woman for prevention of Rh0 (D) sensitisation: Following birth of rhesus-positive infant, 1000–1650 units immediately or within 72 hours; for large transplacental blood loss, 50–125 units per mL of fetal red cells. Antenatal prophylaxis, 1000– 1650 units given at weeks 28 and 34 of pregnancy; if infant rhesus-positive, further dose is needed immediately or within 72 hours of delivery.

 

 

 

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