Monthly Archives: January 2018

Quality Point of View on Nursing Care of Patients on Thrombolytic Therapy

This is focusing on how Nursing Quality can deal with Thrombolytic  Patients …

Thrombolytic Therapy Definition – also known as Thrombolysis, is a treatment to dissolve dangerous clots in blood vessels, improve blood flow, and prevent damage to tissues and organs. Thrombolysis may involve the injection of clot-busting drugs through an intravenous (IV) line or through a long catheter that delivers drugs directly to the site of the blockage. Thrombolysis is often used as an emergency treatment to dissolve blood clots that form in arteries feeding the heart and brain.

From Quality Department point of view a registered nurse should (Nursing Quality):

  • Assess and record baseline data i.e. vital signs, skin color, and temperature; CNS: orientation, reflexes; CVS: peripheral perfusion.
  • Review medical history for existing or previous conditions that:
    • Require cautious use of thrombolytic agents
    • Contraindicate use of thrombolytic agents
  • Ensure that one-nurse remains at patient’s bedside observing the patient during the administration of a thrombolytic agent.
  • Establish minimum two peripheral venous lines, with gauge #18 or gauge #20 cannula prior to the administration of a thrombolytic agent.
  • Arrange for ECG and lab work before starting thrombolytic therapy.
  • Ensure emergency trolley is at bedside and ready for use.
  • Follow thrombolytic therapy standing order once it is filled, signed, stamped and timed by the Medical resident on duty.
  • Monitor patient for vital signs every 15 minutes during the therapy and then hourly.
  • Monitor patient for any potential internal or external bleeding.
  • Monitor patient for any signs of allergic reactions and inform doctor promptly.
  • Avoid arterial invasive procedures and IM injections before and during the therapy.
  • Maintain patient on bed rest during the entire course of therapy and avoid handling patient unnecessarily because bruising occurs readily.
  • Document appropriately in the Nurses’ Progress Notes and other adjunct/relevant forms.

What is nursing care of patient with transcutaneous pacing?

Transcutaneous Pacing – is a non-invasive method of stimulating myocardial depolarization through the chest wall via two large pacing pads. The multifunctional pads are placed on the anterior and/or posterior chest wall or just below Rt. Clavicle and Lt. Midaxillary line, below the nipple and are attached by a cable to an external pulse generator that houses the pacemaker control.

Transcutaneous pacing is initiated as a temporary short-term measure when there has been a failure of the normal conduction of the heart to produce an electrical impulse resulting in a hemodynamic compromise in the patient.

  1. CCU/ICU Nurse shall adhere to standards of nursing care, documentation and safety relating to the use of external transcutaneous (external) pacing.
  2. A detailed operation, troubleshooting and safety checks will be carried out as per the manufacturer’s operating manuals.
  3. The initiation and indications for this treatment will be in accordance with the recommendations and guidelines described in the current ACLS algorithms.

CCU/ICU Registered Nurse should follow procedure guidelines in the AACN Procedure Manual for Critical Care, Procedure 48, Temporary Transcutaneous (external) Pacing, p. 333-339.

CCU/ICU Registered Nurse should maintain current certification in advanced life support or demonstrate competent clinical and technical skill in initiating transcutaneous pacing.

The physician should explain the procedure to the patient and/or the patient’s family and evaluate the patient to identify the need and writes the order.

 

 

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.

Flu vaccines are grown in eggs and they…

Flu vaccines are grown in eggs, and they partially consisting of proteins and components that might trigger an allergic reaction to population allergic to eggs, that was the concern of healthcare staff when someone comes to get a flu shot. Now it’s the latest guidelines that it’s ok to give the flu shot to population allergic to egg.

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.

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.

  1. Plan of care based on the initial assessment findings aimed to meet all patient’s needs will be done by the admitting team.
  2. Consultation will be requested by the admitting team whenever patient’s condition requires.
  3. Whenever there is a multidisciplinary involvement, proper co-ordination and communication should be done with concerned specialty, to decide whether combined management is needed. If needed, plan of care is developed through a collaborative approach between the healthcare teams.
  4. Patients for combined management will be admitted under the most responsible Physician and documentation should be done about the combined management with the concerned specialty.
  5. The most responsible physician carries the overall responsibility and accountability for the outcome of care provided to the patient.
  6. The most responsible physician provides the principal care plan and co -ordinates when required for additional plans of other healthcare providers.
  7. Multidisciplinary rounds by all the involved specialties should be conducted daily for the critically ill patient.
  8. Consulted specialty is responsible for the follow-up of the patient until patient is clinically stable or free from that specialty and to be document clearly in the patient medical record that this patient need no further acute management from that specialty.
  9. Plan of care is modified as appropriate upon any significant change in the patient condition or when new treatments are added or discontinued and to be reviewed by the most responsible physician on a daily basis. This changes and modifications should be communicated to other specialties.
  10. Information about the patient’s care and response to the treatment is shared between medical, nursing, and other care providers.
  11. Most Responsible Physician is responsible to notify Patient or authorized family member about the condition of patient, ongoing treatments and expected outcome. Other specialty can be involved if needed.

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.

Intravenous Thrombolytic Therapy

CRITERIA FOR THROMBOLYSIS:

  1. Ischemic chest pain of at least 15 minutes duration, and unrelieved with sublingual nitroglycerine (2 times).
  2. 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.
  3. 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.

ABSOLUTE CONTRAINDICATIONS:

  • Any prior intra — cranial hemorrhage.
  • Known structural cerebral vascular lesion (e.g. arterio-venous malformation).
  • Known malignant intra — cranial neoplasm (primary or metastatic).
  • Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours.
  • Suspected aortic dissection.
  • Active bleeding or bleeding diathesis (excluding menses).
  • Significant closed head or facial trauma within 3 months.
  • Acute pericarditis.
  • Esophageal varices.
  • Recent major surgery (within < 3 weeks).

RELATIVE CONTRAINDICATIONS:

  • History of chronic severe poorly controlled hypertension.
  • Severe uncontrolled hypertension on presentation (SBP > 180; DBP > 110 Hg).
  • 3 History of prior ischemic stroke > 3 months, dementia or known intra cranial pathology not covered in contraindications.
  • Traumatic or prolonged (> 10 minutes) cardio — pulmonary resuscitation (CPR) or major surgery (> 3 weeks).
  • Recent (within 2-4 weeks) internal bleeding.
  • Non – compressible vascular punctures.
  • For Streptokinase / Anistreplase; prior exposure (more than 5 days ago) or prior allergic reaction to these agents.
  • Pregnancy
  • Active peptic ulcer.
  • Active peptic ulcer.
  • Current use of anticoagulants; the higher the INR, the risk of bleeding.
  • Potent hemorrhagic focus:
    • Within 6 months of GI hemorrhage or CVA (Stroke).
    • Within 2-4 weeks of
      • Organ biopsy
      • Major trauma
      • Minor head trauma
    • Proliferative diabetic retinopathy.
    • History of bleeding diathesis, hepatic dysfunction and / or malignancy.
#Responsible PartyWhat should be done 
1Medical residentWhile administering thrombolytic therapy attention to control chest pain is most important.
1)       IV nitroglycerine — start at 5 mcg / minute and titrate for control of pain;
2)       Avoid hypotension (systolic pressure less than 90 mmHg.) and sinus tachycardia if more than 110 bpm.
3)       Morphine sulphate — give 2-4 mg IV and repeat every 5 -15 minutes until pain relieved
4)       Beta-blockers should be given if there are no contraindications.
5)       e) Follow ACLS algorhythms for the management of dysrhythmias.
Also;
·          Complete the pre thrombolytic check list.
·          Evaluate any case of chest pain / equivalent referred to him.
·          Establish whether the patient fulfills the criteria of STEMI.
·          Initiate Clinical Pathway for uncomplicated STEMI/ NSTEMI
·          Decide if it is a case of acute STEMI, whether the patient is a candidate for thrombolytic therapy.
·          Explain the risks and benefits of the therapy to the patient / patient representative and may obtain consent verbally and document in the medical record. The patient's signature on a consent form is not required.
·          Fill the Intravenous "Thrombolytic Therapy Reperfusion Check List" and sign, date, time and stamp it.
2consultant cardiologist ConsultationConsultant Cardiologist will be consulted when:
·          The case is not typical
·          Any contraindications are present.
·          All the classic criteria are not met.
·          When there is any doubt.
·          For the choice of thrombolytic agent, follow the Thrombolytic Therapy Standing Order.
·          Initiate and sign the appropriate adapted orders.
3Assigned Nurse·          Assigned nurse will start Pre therapy management:
·          Assess and record baseline data i.e. vital signs, skin color and temperature; CNS: orientation, reflexes; CVS: peripheral perfusion.
·          Review medical history for existing or previous conditions that -
·          Require cautious use of thrombolytic agents.
·          Contraindicate use of thrombolytic agents.
·          Ensure the establishment of Clinical Pathway for uncomplicated STEMI/ NSTEMI.
·          Ensure that one- nurse remains at patient's bed side observing the patient during the administration of thrombolytic agent.
·          Establish minimum two peripheral venous lines, with # 18 or # 20 gauge cannula prior the administration of thrombolytic agent.
·          Ensure emergency trolley is at bedside and ready for use.
·          Medication administration: follow thrombolytic therapy standing order.
·          Follow thrombolytic therapy standing order once it is filled, signed, stamped and timed by the Medical resident on duty.
·          Monitor patient for vital signs every 15 minutes during the therapy and then hourly.
·          Monitor patient for any potential internal or external bleeding.
·          Monitor patient for any signs of allergic reactions and inform doctor promptly.
·          Avoid arterial invasive procedures and IM injections before and during the therapy.
·          Maintain patient on bed rest during entire course of therapy and avoid handling patient unnecessarily because bruising occurs readily.
·          Document appropriately.
4Consultant in- charge / on call·          Respond promptly to the call of Medical resident.
·          Refer the patient to Consultant Cardiology.
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