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Education & Competency

MANUAL 2019


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Table of contents 1

Infusion Therapy

5

2

Nasogastric Tube Care

29

3

Dialysis Care

45

4

Tracheostomy Care

59

5

EKG

69

6

Telemetry

77

7

Trilogy

81

8

Life Vests

87

9

CADD Pumps

95

10

Wound Vacs

99


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INFUSION THERAPY Please refer to your local pharmacy’s policies on IVs (peripheral, central venous, midline)


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Administration of IV Fluids DESCRIPTION: Directions: The following table lists the steps that are expected of you in order to administer IV fluids. The table also provides rationales that explain why you perform some of these steps. References and Adapted from: INS 2011 Standard 61; Infusion Nursing – An Evidence-Based Approach, Perry, A.G., Potter, P.A., Ostendorf, W.R. (2015). Clinical Nursing Skills & Techniques (8th Ed.). St Louis: Mosby. Disclaimer: The use of this content is for educational purposes only and should only be used as a guide in performing the below skill, subject to the terms and conditions of the Master Services Agreement.


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Not Met

Title

Description

Rational

Verify Order

Verify the physician’s order for the type and amount of IV fluid, medication additives, infusion rate and length of therapy. Pay special attention to length of administration, compatibility, and any other required filters or tubing. Determine the flow or drip rate.

Before administering solutions or medications an order from a physician is required.

Gather Supplies

Gather your supplies, including antiseptic swabs, gloves, IV pole, sharps container, IV fluid, prefilled normal saline syringe, and IV tubing.

Ensures you have the proper supplies.

Introduction

Provide privacy and dignity. Introduce yourself to the patient and explain the procedure. Identify two (2) patient identifiers per organizational policy.

This allows you to maintain the individual’s rights. This minimizes anxiety.

Hand Hygiene

Perform hand hygiene and follow any necessary infection control guidelines. Apply gloves.

This prevents the spread of harmful pathogens. Exposure to bodily fluids and blood will be present, so standard precautions should be taken.

Medication Reconciliation

At the bedside, compare Medication Administration Record (MAR) with the medication and the patient identifiers. Ensure all medication administration rights are followed.

Ensures correct patient, medication, time, dosing, route.

Medication Education

Discuss the purpose and rationale for each medication and the side effects that may occur with the patient.

Patient has the right to be informed, and patient’s understanding of each medication improves adherence to drug therapy.


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Not Met

Title

Description

Rational

Check Solution

Check IV solution using the rights of administration. Check solution for color, clarity, and expiration date. Check bag for leaks.

Ensures IV solution is not compromised.

Check IV Site

Evaluate the site. Do not use the device if signs of infection, phlebitis or infiltration are present.

Ensures patency of IV site.

Procedure

Using aseptic technique, close the clamp on the primary tubing set, then connect to the infusion bag by inserting the spike into the appropriate port. Hang the bag on the IV pole, then compress the drip chamber until it’s about 1/2 full. Prime the tubing with the fluid by opening the clamp until no air is left in the tubing, then reclamp. Be sure you turn the Y connector upside down to remove air. If air bubbles are present, tap the tubing to remove them. If using an IV pump, attach the tubing to the pump according to the manufacturer’s instructions. Wipe the needleless connector on the IV device with an antiseptic swab and allow it to dry. Attach a prefilled saline syringe, check for blood return, then flush. Detach the syringe and discard it. Remove the cap from the end of tubing, cleanse the needleless connector with an antiseptic swab, and connect the tubing.

Ensures proper procedure.


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Not Met

Title

Description

Rational

Procedure Continued

If using an IV pump, open clamp, set appropriate infusion rate, and start pump. If doing a gravity infusion, adjust the primary tubing clamp to regulate the flow rate according to the desired rate of infusion. Observe the infusion site for signs and symptoms of infiltration, including edema, pain, coolness and blanching of the skin, and a sluggish or stopped infusion. When the infusion is complete, disconnect, flush, and perform a saline or heparin lock as required by the device. If you’ll be administering another infusion within 24 hours, leave the bag and tubing hanging on the IV pole with the end covered with a cap. Otherwise, discard the bag and tubing.

Ensures proper procedure.

Disposal

Properly dispose of any used/ soiled supplies per infection control guidelines.

Reduces transmission of microorganisms; prevents accidental needlestick injuries.

Patient Safety

Perform final safety steps (i.e., lower bed height and position side rails as appropriate, place call light and water within patient’s reach, ask patient if anything else is needed.)

Promotes comfort and sense of well-being.

Hand Hygiene

Remove gloves and perform hand hygiene.

Prevents transmission of microorganisms.


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Not Met

Title Documentation

Description Document the following: Date and time of procedure. Type of IV fluid infused Infusion rate and total volume infused Condition of the IV device and insertion site, pre- and post-infusion. Individuals response to the procedure.

Rational Record findings immediately so you won’t forget. Accuracy is necessary because decisions regarding resident’s care may be based on your report. What you write is a legal record of what you did. If you don’t document it, legally it didn’t happen.

Your signature and credentials It is important to note that when using an IV pump for the infusion of IV fluids, you should always document the total volume infused as indicated by the IV pump. Additionally, after documentation, be sure to reset this to zero.

Administration of IV Fluids Requirements Met Administration of IV Fluids Requirements NOT Met.

________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date


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Observer Notes:


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Administration of Medications via an IV DESCRIPTION: Directions: The following table lists the steps that are expected of you in order to administer medications via an IV. The table also provides rationales that explain why you perform some of these steps. References and Adapted from: Intravenous Infusion Therapy for Nurses – Principle and Practice Infusion Nursing – An EvidenceBased Approach, Perry, A.G., Potter, P.A., Ostendorf, W.R. (2015). Clinical Nursing Skills & Techniques (8th Ed.). St Louis: Mosby. Disclaimer: The use of this content is for educational purposes only and should only be used as a guide in performing the below skill, subject to the terms and conditions of the Master Services Agreement.


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Not Met

Title

Description

Rational

Preparation

Gather your supplies, which for primary and secondary infusions will include: antiseptic swabs, gloves, IV pole, sharps container, IV fluid, prefilled normal saline syringe, and IV tubing for primary and secondary infusion procedures.

This step ensures you have the proper supplies.

Supplies for IV push will include: a watch with second hand, gloves, alcohol preps, a 10 mL syringe containing medication, two 10 mL syringes filled with 0.9% saline, and a 10 mL syringe filled with 10 units/mL heparin, if needed Verify Order and determine pertinent medication information

Ensure this task is within your scope of practice. Check the individual’s plan of care, your organization’s policies and procedures, and the physician’s order. Determine pertinent medication information, including calculating the needed infusion, drip, IV push rate and dosage. Pay special attention to length of administration, compatibility, potential adverse reactions, and any required filters or tubing.

Introduction

Provide privacy and dignity. Introduce yourself to the patient and explain the procedure. Identify two (2) patient identifiers per organizational policy.

Before administering solutions or medications, an order from a physician is required and the task must be within your scope of practice. This ensures the proper rate, dose, and equipment.

This allows you to maintain the individual’s rights. This minimizes anxiety.


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Not Met

Title

Description

Rational

Hand Hygiene

Perform hand hygiene and follow any necessary infection control guidelines. Apply gloves.

This prevents the spread of harmful pathogens. Exposure to bodily fluids and blood will be present, so standard precautions should be taken.

Medication Reconciliation

At the bedside, compare Medication Administration Record (MAR) with the medication and the patient identifiers. Ensure all medication administration rights are followed. Compare the medication label to the medication administration record, or MAR, three times.

Ensures correct patient, medication, time, dosing, route.

Medication Education

Discuss the purpose and rationale for each medication and the side effects that may occur with the patient.

Patient has the right to be informed, and patient’s understanding of each medication improves adherence to drug therapy.

Ensure Patency

Evaluate the site. Do not use the device if signs of infection, phlebitis or infiltration are present.

Prevents complications of IV therapy by ensuring patency.

Administering as primary infusion.

Using aseptic technique, close the clamp on the primary tubing set, then connect to the infusion bag by inserting the spike into the appropriate port. Hang the bag on an IV pole, then compress the drip chamber until it’s about 1/2 full.

Ensures proper technique.

Prime the tubing with the fluid by opening the clamp until no air is left in the tubing, then re-clamp it. Be sure you turn the Y connector upside ...


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Not Met

Title

Description

Rational

Administering as primary infusion. continued

down to remove air. If air bubbles are present, tap the tubing to remove them. If using an IV pump, attach the tubing to the pump according to the manufacturer’s instructions.

Ensures proper technique.

Wipe the needleless connector on the IV device with an antiseptic swab and allow it to dry. Attach a prefilled saline syringe, check for blood return, then flush the line. Detach the syringe and discard it into the appropriate container. Remove the cap from the end of tubing, cleanse the needleless connector with an antiseptic swab, and connect the tubing to the needleless connector. If using an IV pump, open clamp, set appropriate infusion rate, and start pump. If doing a gravity infusion, adjust the primary tubing clamp to regulate the flow rate according to the desired rate of infusion. Observe the infusion site for signs and symptoms of infiltration, including edema, pain, coolness and blanching of the skin, and a sluggish or stopped infusion. When the infusion is complete, disconnect, flush, and perform a saline or heparin lock as required by the device. If you’ll be administering another infusion within 24 hours, leave the bag and tubing hanging on the IV pole with the end covered with a cap. Otherwise, discard the bag and tubing.


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Not Met

Title

Description

Rational

Administering as secondary infusion

Using aseptic technique, close the clamp on the secondary tubing set, then connect to the infusion bag by inserting the spike into the appropriate port. Hang the secondary infusion bag above the primary infusion bag on the IV pole. If doing a gravity infusion, use a hook to lower the primary bag below the secondary infusion bag.

Ensures proper technique

Compress the drip chamber until it is about ½ full, prime the tubing with fluid by opening the clamp until no air is left in the tubing, then re-clamp it. Be sure you turn the Y connector upside down to remove air. If air bubbles are present, tap the tubing to remove them. Remove the cap from the end of the tubing and wipe the appropriate port on the primary tubing with an antiseptic swab and allow it to dry. Connect the secondary tubing to the primary tubing port. If using an IV pump, set the appropriate infusion rate and start the pump. If doing a gravity infusion, adjust the secondary tubing clamp to regulate the flow rate according to the desired rate for infusion. Observe the infusion site for signs and symptoms of infiltration, including edema, pain, coolness and blanching of the skin, and a sluggish or stopped infusion. Once the secondary fluid has infused, check the primary infusion to ensure flow has resumed appropriately. Leave the secondary tubing connected for later use or discard the tubing and empty bag.


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Title

Description

Rational

Preventing infection

Change continuous administration sets every 72-96 hours. Change intermittent administration sets every 24 hours.

Reduces risk of infection related to microorganism growth in IV tubing.

Maintain closed systems when possible.

Administering an IV push with no infusion running

If diluting medication from an ampule: Place a filter needle on the appropriate syringe given the method of administration. Tap the top of the ampule lightly with your finger until any fluid in the neck moves down into the ampule. Place the gauze pad around the top of the ampule, near the neck. Snap the neck of the ampule quickly and firmly away from your hands and body. Discard the neck and gauze in a sharps container. Holding the ampule upside down or placing it on a flat surface, insert the filter needle into the center of the opening. Do not let the needle touch the rim of the ampule. Aspirate the medication, keeping the needle tip under the surface of the liquid. Do not push air into the ampule. Withdraw the needle from the ampule. Discard the ampule in the sharps container. Holding the syringe upright, tap on it to allow any air bubbles to rise to the top; then, expel the air, being careful not to eject any fluid. If the syringe contains extra fluid, angle it toward a sink to expel the fluid. Intermittently check the level with the syringe pointed vertically until ...

Ensures proper technique


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Not Met

Title

Description

Rational

Administering an IV push with no infusion running continued ...

you get the correct dose. Scoop the protective cap onto the filter needle, then remove it from the syringe. Discard the needle in a sharps container.

Ensures proper technique

If diluting medication from a vial: Remove the protective caps on the medication vial and saline vial. Cleanse both with an alcohol wipe. Apply a needleless vial adaptor to each vial and cleanse with an alcohol wipe. If needleless vial adaptors are not used, attach a needle to a 10 mL syringe. Attach the syringe to the needleless vial adapter or insert the needle into the medication vial. Invert the vile and withdraw the appropriate amount of medication. Attach the syringe to the needleless vial adapter, or insert the needle into the saline vial. Invert the vial and withdraw the appropriate amount of saline. Detach or remove the syringe. Remove any air bubbles present in the syringe. If using a needle and multi-dose saline vial, it is recommended to change the needle between withdrawing the medication and withdrawing the saline to prevent contamination of the saline. IV push procedure: to begin, cleanse the needleless connection device with an alcohol prep and allow it to dry. Attach the saline syringe, gently draw back on the plunger to check for blood return, and then flush with 10 mL of saline. Detach the syringe and discard in the appropriate discard in the container.


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Not Met

Title

Description

Rational

Administering an IV push with no infusion running continued ...

Attach the medication syringe and administer the medication over the amount of time recommended by the medication reference manual, organization policy or pharmacist. If at any time the needleless connection device becomes contaminated, you must cleanse it with an alcohol prep and allow it to dry.

Ensures proper technique.

While administering the medication, monitor for signs of anaphylactic reaction, infiltration, and extravasation. Signs of an anaphylactic reaction can include sudden fever, joint swelling, rash, hives, dyspnea, and wheezing. Signs of infiltration may include swelling, discomfort, burning, tightness, cool skin, or blanching at the IV site. Signs and symptoms of extravasation can include blanching, burning, or discomfort at the IV site; cool skin around the site; or swelling above the site. Should the individual experience any of these signs or symptoms, immediately stop the infusion and notify the physician. Do not remove the IV line until otherwise directed by the physician. Detach the syringe and discard. Flush with saline using the same rate as the medication delivery, then remove the syringe and discard. If recommended by the manufacturer, follow with a heparin flush. Use this same procedure when administering an IV push medication when the individual is receiving incompatible IV fluids. Be sure to stop fluids and clamp the line as well as flush it before and after administration of the medication. the line as well as flush it before and after administration of the medication.


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Title Administering IV push with infusion running

Description Use the procedure checklist above for diluting medication from an ampule or a vial, then return here. The primary infusion should be paused during this procedure. Select the port on the administration set closest to the person. Cleanse the port with an alcohol prep and allow it to dry. Attach the medication syringe to the port. Occlude the administration set by pinching or kinking just above the port and gently draw back on the plunger to check for blood return. Administer the medication over the amount of time recommended by the medication reference manual, organization policy, or pharmacist. Keep the administration set pinched when pushing the medication. While administering, monitor for signs of anaphylactic reaction, infiltration, and extravasation. Signs of an anaphylactic reaction can include swelling, discomfort, burning, tightness, cool skin, or blanching at the IV site. Signs and symptoms of extravasation can include blanching, burning, or discomfort at the IV site; cool skin around the site; or swelling at or above the site. Should the individual experience any of these signs or symptoms, immediately stop the infusion and notify the physician. Do not remove the IV line until otherwise directed by the physician. After administration, detach the syringe and discard. If any time the port becomes contaminated, cleanse it with an alcohol

Rational Ensures proper technique


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Met

Not Met

Title

Description

Rational

Administering IV push with infusion running continued ...

prep and allow it to dry. Flush the line with saline using the same rate as the medication delivery, remove the syringe, discard, unkink the line, and recheck the infusion rate.

Ensures proper technique

Disposal

Properly dispose of any used/ soiled supplies per infection control guidelines.

Reduces transmission of microorganisms; prevents accidental needlestick injuries.

Patient Safety

Perform final safety steps (i.e., lower bed height and position side rails as appropriate, place call light and water within patient’s reach, ask patient if anything else is needed.)

Promotes comfort and sense of well-being.

Hand Hygiene

Remove gloves and perform hand hygiene.

Prevents transmission of microorganisms.

Post-procedure Documentation

Post-procedure documentation to include:

Record findings immediately so you won’t forget. Accuracy is necessary because decisions regarding resident’s care may be based on your report. What you write is a legal record of what you did. If you don’t document it, legally it didn’t happen.

Date and time of procedure

Name of the medication and dose

Type of diluent used, if applicable

Condition of the IV device and insertion site, pre- and post-infusion.

Individuals response to the procedure.

Your signature and credentials


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Administration of IV Fluids Requirements Met Administration of IV Fluids Requirements NOT Met.

________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date


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Observer Notes:


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Administration of Parenteral Nutrition Met

Not Met

Task • Remove TPN/PPN from refrigerator, if applicable, and allow warming to room temperature. Add additives per procedure, if applicable. • Verify physician/licensed independent practitioner order. • Identify resident using appropriate identifiers. • Explain procedure to resident. • Obtain vital signs. • Verify the proper dosage and dose calculations. • Wash hands. • Assemble equipment and supplies on clean work surface. • If adding additives to parenteral nutrition solution, refer to your pharmacy’s parenteral nutrition guide in regards to additives and follow pharmacist recommendations. • Don gloves. Assess venous access site. • Inspect medication/solution container for leaks, clarity, color, precipitants, and expiration date. Do not use if the container is leaking, the solution is discolored or cloudy, particles are noted in the solution, or the container has expired. Notify pharmacy of product problem and return to pharmacy. • Close clamp on administration set and attach appropriate filter, if not integrated. • Remove protective cover from access port, maintaining asepsis.


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Met

Not Met

Task • Using aseptic technique, insert spike into solution container access port. • Hang new medication/solution container on IV pole. • Prime medication/solution container on IV pole. • Program electronic infusion device. Insert administration per manufacturer’s instructions. • Program electronic infusion device. Insert administration set per manufacturer’s instructions • Attach new primed needleless connector to catheter lumen. • Vigorously cleanse needleless connector with alcohol. Allow to air dry. Attach administration set to needleless connector. • Open clamp and begin infusion. • Verify that the solution is infusing at the prescribed rate. • Assess venous access site. • Secure administration set. • Label medication additives/solution container and administration set with date, time and nurses initials. • Observe for any signs or symptoms of complications per procedure and report if appropriate. • Dispose of used supplies. • Remove gloves. • Wash hands. • Document in the resident’s medical record.


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________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date


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Observer Notes:


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NASOGASTRIC TUBE CARE


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Nasogastric Tube Care Preparation 1. Verify that there is a physician’s order for nasogastric tube care. Check the order for the following tube specifications: a. Type of tube; b. Size of tube; c. Purpose of tube (decompression vs. feeding); and d. Tube replacement guidelines. 2. Assemble equipment and supplies needed. 3. Many varieties of tubes are available. Always read the manufacturer’s recommendations for guidelines and suggestions (i.e., some tubes are self-lubricating, others require water soluble lubricants). 4. Check the resident record for any documented contraindications to a nasogastric tube, including: a. Recent nasal surgery; or b. Esophageal strictures or varices (or recent surgical correction of).

Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure. 1. Soap and water. 2. Towel or linen saver; 3. Water soluble lubricant; 4. Enteral syringes (with transition adapter if necessary); 5. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).

Steps in the Procedure for Nasogastric Tube Care 1. 2. 3. 4. 5. 6.

Arrange the supplies so they can be easily reached. Explain procedure to resident. Assist the resident to a sitting or high Fowler’s position, as tolerated. Put on clean gloves. Place a towel over the resident’s chest. Clean skin around the NG tube with warm water and a clean wash cloth. Remove any crust or secretions in or around the nose. 7. If you need to replace or remove a dressing or bandage around the nose, loosen it first with a lubricant. Then gently remove the dressing/bandage from the nose and clean the lubricant off the skin. 8. Notify the MD if the following occurs: 9. Redness, swelling or irritation in one or both nostrils; 10. The tube is clogged and you are unable to flush it with water; 11. Vomiting 12. Bloated stomach 13. Provide mouth care as needed. 14. Wash hands.


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Verification of Placement 1. Verify placement of the feeding tube prior to initiating water flushes via auscultation and aspiration of stomach contents. Obtain x ray to verify placement of tube if ordered by medical practitioner.

Ongoing Care of the Resident and the Nasogastric Tube 1. Provide frequent nose and mouth care while tube is in place. 2. Check placement of tube prior to flushes, administration of feedings or medications. 3. Flush tube according to flushing protocol.

Steps in the procedure of Nasogastric Tube Flushing 1. 2. 3. 4.

5. 6. 7. 8.

Wash hands and apply clean gloves. Connect syringe to the NG tube port. Add warm water as ordered into the syringe. Let it run through the NG tube via gravity. If the water flows too slowly or does not flow at all, place the plunger into the syringe. Gently push the plunger a small amount. Do not push hard and do not push the plunger all the way into the syringe. To improve the flow, you may need to change the resident’s position. Remove the syringe. Close the NG tube clamp. Ensure resident is comfortable. Wash hands.

Documentation The person performing this procedure should record the following information in the resident’s medical record: 1. The date and time the procedure was performed. 2. The size and length of the nasogastric tube and the length of the external portion of the tube. 3. Verification of tube placement. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken.

Reporting 1. Report complications promptly to the supervisor and the medical practitioner. 2. Notify the supervisor and medical practitioner if the resident refuses the procedure.

Reviewed 01/2017


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Nasogastric Tube Removal Preparation 1. Verify that there is a physician’s order for this procedure. 2. Assemble equipment and supplies needed.

Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure. 1. Soap and water; 2. Wash cloth and towel; and 3. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).

Steps in the Procedure for Nasogastric Tube Care 1. Arrange the supplies so they can be easily reached. 2. Explain procedure to resident. 3. Wash and dry hands thoroughly. 4. Wear clean gloves. 5. Assist the resident to a sitting of high-fowler’s position. 6. Untape the tube from resident’s nose and unpin tube from resident’s gown. 7. Place a towel over the resident’s chest. 8. Clamp tube. 9. Ask resident to inhale deeply and slowly exhale as the tube is being removed. 10. Gently and quickly remove the tube in one steady motion. 11. Discard tube in designated container. 12. Cleanse nasal area with soap and water. Pat dry with towel. 13. Wash your hands.

Documentation The person performing this procedure should record the following information in the resident’s medical record: 1. The date and time the procedure was performed. 2. Reason the feeding tube was removed. 3. How the resident tolerated the procedure. 4. If the resident refused the procedure, the reason(s) why and the intervention taken.

Reporting 1. Report complications promptly to the supervisor and the medical practitioner. 2. Notify the supervisor and medical practitioner if the resident refuses the procedure.


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NG Tube Care Skills Checklist Met

Not Met

Task • Gather supplies.

• Wash hands and apply gloves.

• Explain procedure to resident.

• Clean skin around the NG tube with warm water and a clean wash cloth. Remove any crust or secretions in or around the nose. • When removing a dressing or bandage from the nose, loosen it first with a lubricant. Then gently remove the dressing/bandage from the nose and clean the lubricant off of the skin. • Notify the MD if the following occur: - Redness, swelling or irritation in one or both nostrils, - If the tube is clogged and you are unable to flush it with water, - The tube falls out, - Vomiting, - Bloated stomach.

• Provide mouth care.

• Document in the resident record.


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________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date


35

Observer Notes:


36

Nasogastric Tube Flushing Met

Not Met

Task • Gather supplies.

• Wash hands and apply gloves.

• Explain procedure to resident.

• Connect syringe to the NG tube port.

• Verify placement of NG tube via auscultation and aspiration of stomach contents. • Add warm water as ordered into the syringe. Let it run through the NG tube via gravity.

• If the water flows too slowly or doesn’t flow at all, place the plunger in the syringe. Gently push the plunger a small amount. Do not push hard, and do not push the plunger all the way into the syringe. To improve the flow, you may need to change the resident’s position. • Remove the syringe.

• Close the NG tube clamp.

• Ensure resident is comfortable.

• Wash hands.


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________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date

Observer Notes:


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Nasogastric Tube Removal Met

Not Met

Task • Gather supplies.

• Wash hands and apply gloves.

• Explain procedure to resident.

• Assist resident in an upright sitting position.

• Carefully remove the tape from the resident’s skin to free the tube. Unpin the tube from the resident’s clothing. • Place a towel over the resident’s clothing.

• Clamp tube.

• Ask resident to inhale deeply and slowly exhale as the tube is being removed. Gently and quickly remove the tube in one steady motion. • Discard tube in designated container.

• Cleanse nostrils and nose with soap and water. Pat dry.

• Wash hands.


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________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date

Observer Notes:


40

NG Tube: Continuous Feeding Met

Not Met

Task • State name and purpose of procedure to the resident. • Gather supplies: - Stethoscope - Feeding solution - 60 cc catheter-tipped syringe - Pump (if used) - Tap Water - Pole to hold pump • Wash hands. • Position the resident in an upright position. • Check for proper NG tube placement: - Connect syringe to NG tubing - Place stethoscope over mid-left abdomen and gently push in 5-10 cc of air with syringe - Listen with stethoscope and identify sounds heard with proper placement • Aspirate stomach contents by pulling plunger back. • Measure stomach contents and return to stomach.

• Clamp/Pinch NG tubing. • Insert feeding solution tubing into NG tube. • Tape securely. Unclamp NG tubing. • Wash hands.


41

NG Tube: Continuous Feeding Met

Not Met

Task • Open clamping on feeding solution tubing and administer prescribed feeding solution at prescribed rate per physician’s orders. • Wash hands.

• Check flow and rate of nutrition as needed.

• Keep resident in upright position throughout the feeding and for at least 30 minutes after the feeding is completed. • Notify MD of any concerns.

• Document procedure.

________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date


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Observer Notes:


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DIALYSIS CARE


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Peritoneal Dialysis

(CONTINUOUS AMBULATORY) Preparation 1. This procedure must be performed by a nurse who has been specifically trained in peritoneal dialysis procedures, complications, and infection control for dialysis. 2. Review all existing orders and instructions for care pertaining to the resident’s dialysis. Verify the following: a. Dialysate solution/concentration; b. Number of exchanges and infusion, dwell, and drain times; c Monitoring parameters; and d. Lab orders.

General Guidelines 1. Monitor the resident for the following problems associated with renal failure and/or dialysis: a. Pain; b. Infection; c. Altered nutrition; and d. Immobility. 2. Maintain strict asepsis when adding medications to the dialysate. 3. Use sterile technique when connecting the dialysis catheter to the Y tubing/dialysate. 4. Do not administer dialysate that is too cold. Do not warm dialysate by immersing in warm water. Use a warmer per dialysis center instructions. 5. CAPD dwell times generally are 3-6 hours during the day and 8-12 hours at night.

Equipment and Supplies 1. 2. 3. 4.

Dialysate (with medication added by Dialysis Center when ordered) Warmer (per dialysis center instructions); Syringe (if applicable) Personal protective equipment: a. Face masks (3); b. Sterile gloves (1); c. Clean gloves (2); and d. Gown (1). 5. Sterile drape; 6. IV pole; 7. Connective (Y) tubing with clamps; 8. Sterile drainage bag; 9. Sterile 4 x 4 gauze (6-8); 10. Povidone-iodine sponges or solution; 11. Povidone-iodine ointment; and 12. Alcohol Reviewed 01/2017


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Steps in the Procedure Assessment 1. 2. 3. 4. 5. 6. 7.

Introduce yourself to the resident. Provide for the resident’s privacy. Explain the procedure. Wash your hands. Obtain the resident’s baseline weight and vital signs. Measure the abdominal girth. Observe for signs and symptoms of fluid volume overload (hypervolemia) including, labored breathing, increased blood pressure, edema, and neck vein distension. 8. Observe for signs and symptoms of hypovolemia including poor skin turgor, tachycardia, and hypotension.

Prepare Supplies and Equipment 1. 2. 3. 4. 5.

Wash your hands. Put on a face mask. Warm the dialysate solution, per dialysis provider’s instructions. Remove the dialysate bag from the warming device and remove the protective wrapper. Check the dialysate bag for the following: a. Cloudiness, precipitate, leaks. b. Expiration date. c. Solution and concentration. 6. Insert the Y connector into the dialysate bag and hang the bag and tubing on the IV pole. 7. Open the clamp and prime the tubing. Close the clamp. 8. Place a disinfectant soaked gauze pad on the distal end of the Y connector. Cover the pad with a dry gauze pad and secure with tape. 9. Tear some tape to prepare for the dressing change. 10. Remove your face mask.

Create a Sterile Field 1. 2. 3. 4. 5. 6. 7.

Wash your hands. Place resident in semi-Fowler’s or high-Fowler’s position. Prepare a sterile field by placing a sterile drape on a dry surface near the resident. Place the sterile container on the field and pour disinfectant into the container. Drop several sterile gauze pads into the solution. Drop the remaining (dry) gauze pads on the sterile field. Loosen the cap on the alcohol container and place next to the sterile field.


48

Catheter Care and Site Observation 1. Put a clean mask on yourself and the resident. 2. Put on clean gloves. 3. Remove the dressing from the peritoneal catheter and discard. Do not touch the catheter tip or the skin. 4. Inspect the catheter site and surrounding skin for the following: a. Purulent drainage (obtain a swab sample of the drainage if ordered by medical practitioner); b. Redness; c. Pain or tenderness. 2001 MED-PASS, Inc. (Revised October 2010) 5. If there are signs/symptoms of infection or the catheter is cracked or torn, contact the medical practitioner for further instructions. 6. Remove gloves and wash your hands. 7. Put on sterile gloves. 8. Wrap one disinfectant soaked gauze pad around the catheter tip and place on sterile field. Leave in place for 5 minutes. 9. Clean the catheter site with another disinfectant soaked pad. Move in concentric circles away from the insertion site. Repeat. 10. Place the second sterile drape under the catheter. Clean the catheter with another disinfectant soaked gauze pad. Start at the base of the catheter and move outward, using a clean side of the pad for each stroke. Repeat. 11. Apply sterile dressing over the catheter insertion site.

Infuse Dialysate 1. Remove gauze from the end of the catheter after 5-minute soak. Remove gauze from distal end of the Y connector. 2. Remove the cap from the catheter. Clean the open end of the catheter with disinfectant soaked gauze. 3. Attach the catheter end to the Y connector. Make sure that the drain bag clamp is closed. 4. Open the clamp from the dialysate container and allow the solution to flow into the peritoneal cavity over a period of 5-10 minutes, or as ordered by medical practitioner. Close the clamp. 5. Fold the bag and tuck the bag, Y connector and catheter into the resident’s clothing. 6. Remove gloves and wash your hands.


49

Drain Fluid from Peritoneal Cavity After the prescribed dwell time (3-6 hours during the day or 8-12 hours at night), unfold the bag and attach the drain bag to the Y connector. 7. Open the clamp to the drain bag and allow the fluid to drain into the bag. 8. Record the amount of drainage collected in the drain bag. Note the color and clarity of returned fluid, and the presence of mucus, blood or pus. Notify medical practitioner if mucus, blood or pus is present in returned fluid. 9. Notify the medical practitioner if there is a discrepancy between the fluid intake and output. 10. Weigh the resident, as ordered. 11. Repeat infusion/drainage steps, as prescribed.

Temporarily Disconnect the Peritoneal Dialysis System 1. Wash hands. 2. Apply sterile gloves. 3. Clean the junction of the catheter and 6 inches of the Y connector with disinfectant soaked gauze for at least 1 minute. 4. Disconnect the catheter from the connector and tubing. 5. Securely fasten sterile catheter cap to the catheter. 6. Discard bags and fluid in bio-hazard container. 7. Remove gloves and wash your hands. Reviewed 01/2017

Documentation The following information should be recorded in the resident’s medical record: 1. The date and time infusion was started and stopped (fill time). 2. Amount of dialysate infused. 3. The time drain was started (dwell time). 4. The amount of dialysate that was drained. 5. The number of exchanges. 6. The resident’s weight before and after the procedure. 7. The condition of the catheter, insertion site and surrounding skin. 8. Signs and symptoms of complications and or infection. 9. How the resident tolerated the procedure. 10. Any medical practitioner or dialysis center notification and response.


50

Hemodialysis Access Care Guidelines 1. Verify with state Nurse Practice Act regulations regarding scope of practice for licensed staff in the care of residents with Central Catheters 2. Hemodialysis access devices are surgically placed and removed. 3. Vascular access may be accomplished in one of three ways: a. Arterio-venous fistula (AVF) b. Arterio-venous graft (AVG) c. Central catheters

Arterio-Venous Fistula 1. Access is created by surgically connecting an artery and vein. 2. The AVF is usually placed in the arm.

Arterio-Venous Graft 1. The AVG uses a synthetic or animal-derived tubing to connect the artery and vein. 2. The arm is the preferred site but the graft may also be placed in the leg.

Central Catheters 1. Central catheters for hemodialysis are generally inserted in the neck, chest or groin area. 2. This is not the preferred site for long-term placement. There is more risk of clotting and infection than with either fistulas or grafts. Central dialysis catheters are used for short term dialysis (less than three weeks) while AVF or AVG is healing. 3. Central dialysis catheters are recognized by the following characteristics: a. There are two catheters exiting from the insertion site. The lumen of the arterial catheter is usually a. RED and the lumen of the venous catheter is usually BLUE. b. The lumens are short and made from heavy thick rubber. This is so they can withstand high pressure b. volumes from the dialysis machine. c. There are clamps on the lumens.

Steps in the Procedure Care of AVFs and AVGs 1. After placement of the fistula or graft, the site cannot be accessed until it matures. This may take 2-3 weeks for a graft and 6-12 weeks for a fistula. 2. The site may not be used for dialysis until a written order is received from the nephrologist or surgeon. 3. Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots).


51

4. To prevent infection and/or clotting: a. Keep the access site clean at all times. b. Do not use the access site arm to take blood samples, administer IV fluids or give injections. c. Check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and when palpating for thrill and listening for bruit. d. Do not use the access arm to take blood pressure. e. Advise the resident not to sleep on, wear tight jewelry or lift heavy objects with the access arm. Reviewed 01/2017 Check the color and temperature of the fingers, and the radial pulse of the access arm when: f. performing routine care and when palpating for thrill and listening for bruit. Palpate the site to feel the “thrill,” or use a stethoscope to hear the “whoosh” or “bruit” of blood flow g. through the access every shift.

Care Immediately Following Dialysis Treatment 1. The dressing change is done post-treatment as ordered by medical practitioner. 2. If dressing becomes wet, dirty, or not intact, the dressing shall be changed as ordered. 3. Mild bleeding from site (post-dialysis) can be expected. Apply pressure to insertion site and contact dialysis center for instructions. 4. If there is major bleeding from site (post-dialysis), apply pressure to insertion site and contact emergency services and dialysis center. Verify that clamps are closed on lumens of central catheter. This is a medical emergency. Do not leave resident alone until emergency services arrive.

Care of Central Dialysis Catheters 1. The central catheter site must be kept clean and dry at all times. Bathing and showering are not permitted with this device. Sponge baths must be given. 2. Catheter lumens should be capped and clamped when not in use. 3. Dialysis catheters should be marked for dialysis use only so they are not confused with central venous access devices. 4. Flushing, drawing blood or administering medications via central hemodialysis catheters require specialized training and/or certification of an RN. Do not allow non-dialysis personnel to access the catheter. 5. Those caring for the catheter site must wear a mask and gloves when doing so. Dressing changes, if ordered, should be done using sterile technique. 6. Never pull or tug on the catheter. Do not use scissors near the catheter.


52

Documentation The nurse should document in the resident’s medical record: 1. Presence of thrill and bruit if access is a shunt or graft. 2. Appearance of site if access is a central catheter. 3. If resident refuses notify supervisor and/or medical practitioner. 4. Notify medical practitioner of any issues with dialysis access site.

For PD Patient

CCPD Technique Assessment Objectives: 1. Learner will demonstrate safe connection and disconnection from the system. 2. Learner must complete critical behaviors safely; if unable to do so: 1. Schedule a re-education session 2. Consider retraining on assist devices, (EZ-Aide) if using Baxter and patient is not already using the EZ-Aide 3. Consider training care partners

Teacher Materials: Practice apron, mask and vendor specific necessary exchange supplies and/or equipment (for example, caps, solution bags, tubing, cycler, etc.)

Teacher Steps: CCPD •

Observe Learner perform Alcavis scrub to the Transfer/Extension Set, prior to any connect or disconnect.

Observe connection to cycler tubing system

Observe learner disconnect from the cycler tubing system (for Hi-Dose therapy, observer learner disconnect, apply appropriate cap; then reconnect.)


53

CCPD Baxter Setup or N/A

CCPD Baxter Disconnection or N/A

Controls airflow in the treatment area

Controls airflow in the treatment area

Washes hands, cleans work surface, gathers supplies

Washes hands, cleans work surface, gathers supplies

Masks and washes hands

Masks and washes hands

Removes pull ring from solution bag connector

Removes end cap from solution bag

Removes pull ring from set connector

Removes end cap from tubing

Completes safe connection of bag(s) and tubing without contamination; breaks frangible(s)

Completes safe connection of bag(s) and tubing without contamination; breaks cone(s)

Verifies transfer set is closed and performs Alcavis scrub to the end of the transfer set

Performs Alcavis scrub to the end of extension set

Completes safe connection without contamination

Completes safe connection without c ontamination

CCPD Baxter Disconnection or N/A

CCPD Frensenius Disconnection or N/A

Washes hands, cleans work surface, gathers supplies

Washes hands, cleans work surface, gathers supplies

Masks and washes hands

Masks and washes hands

Opens new Mini-cap and inspects

Opens new Stay Safe cap and places in organizer

Closes transfer set and performs Alcavis scrub to the PD catheter Transfer Set

Performs Alcavis scrub to the PD catheter Extension Set

Disconnects tubing from the transfer set, keeping Baxter Transfer Set pointing down

Disconnects by clamping white clamp, inspects extension set pin was released by organizer

_____________________

_____________________

_____________________

_____________________

_____________________

_____________________

Nurse Name Printed Patient Name Printed Care Provider Name Printed

Nurse Signature Patient Signature

Care Provider Signature

______________

Date

______________

Date

______________

Date


54

Observer Notes:


55

Hemodialysis Care Skills Checklist Met

Not Met

Task •

Explain procedure to resident.

Wash hands and apply gloves.

Check site for signs of infection, such as warmth, redness, tenderness, or edema. Call MD if there are any signs of infection.

The site must be kept clean and dry at all times. If dressing becomes wet, dirty, or not intact, the dressing shall be changed as ordered. Call dialysis center in regards to dressing change orders.

If the resident has a shunt or graft, assess for bruit and thrill. Stethoscope must be placed over the resident’s shunt or graft to verify bruit. The site should be palpated to verify thrill.

Assess site for any bleeding. Mild bleeding post dialysis can be expected. If there is major bleeding from site (post-dialysis), apply pressure to insertion site and contact emergency services and dialysis center. Verify that clamps are closed on lumens of central catheter. Do not leave resident alone until emergency services arrive.

Ensure catheter lumens are capped and clamped when not in use. Never pull or tug on the catheter. Do not use scissors near the catheter.

Ensure dialysis catheters are marked for dialysis use only so they are not confused with central venous access devices.

Check color and temperature of resident’s fingers and the radial pulse of the access arm.

Do not use the access site arm to take blood samples, administer IV fluids or give injections. Do not use the access arm to take blood pressures.

If necessary, advise resident to not sleep on, wear tight jewelry or lift heavy objects with the access arm.

Remove gloves and wash hands.

Document assessment findings in the resident’s record. Notify provider of any issues.


56

________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date


57

Observer Notes:


58


59

TRACHEOSTOMY CARE


60

Tracheostomy Care Š2001 MED-PASS, Inc. (Revised August 2013)

Purpose The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas.

Equipment and Supplies 1. 2. 3. 4. 5. 6. 7.

Gloves (clean and sterile); Mask and eyewear (as indicated); Tracheostomy care kit; Sterile water or normal saline; Suction catheter; Suction machine; Extra gauze dressing.

General Guidelines 1. Aseptic technique must be used: a. During cleaning and sterilization of reusable tracheostomy tubes; b. During all dressing changes until the tracheostomy wound has granulated (healed); and c. During tracheostomy tube changes, either reusable or disposable. 2. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures. 3. A mask and eyewear should be worn if splashes, spattering, or spraying of blood or body fluids is likely to occur when performing this procedure. 4. Tracheostomy tubes should be changed as ordered and as needed. 5. Tracheostomy care should be provided as ordered. 6. A replacement tracheostomy tube must be available at the bedside at all times. 7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times.

Procedure Guidelines Preparation and Assessment 1. Check physician order. 2. Explain procedure to resident. 3. Wash hands. 4. Put exam gloves on both hands. 5. Remove supplemental oxygen mask from tracheostomy. 6. Inspect skin and stoma site for signs or symptoms of infection, leakage, or dislodged tube. 7. Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle. 8. Wash hands.


61

Reviewed 01/2017

Clean the Removable Inner Cannula 1. Open tracheostomy cleaning kit. 2. Set up supplies on sterile field. 3. Maintaining sterile field, pour normal saline in both compartments of opened kit. 4. Open gauze pads and saturate with antiseptic solution. 5. Open gauze pads and saturate with sterile saline. 6. Open gauze pads; keep them dry. 7. Put on sterile gloves. 8. Secure the outer neck plate with non-dominate gloved hand. 9. Unlock the inner cannula with gloved dominate hand. 10. Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident. 11. Soak the cannula in saline. 12. Clean with brush. Rinse with saline and dry with pipe cleaners. 13. Remove and discard gloves into appropriate receptacle. 14. Wash hands and put on fresh gloves. 15. Replace the cannula carefully and lock in place. 16. Ensure there is an emergency tracheostomy set up at resident’s bedside.

Site and Stoma Care 1. Apply clean gloves. 2. Clean the stoma with saline soaked gauze pads (using a single sweep for each side). 3. Wipe with dry gauze (using a single sweep for each side). 4. Remove neck ties and replace with clean ones. a. Apply new ties before removing old ones. 5. Apply a fenestrated (split gauze) gauze pad around the insertion site. 6. Replace supplemental oxygen mask over tracheostomy if ordered. 7. Remove gloves and discard into appropriate receptacle. 8. Wash hands. 9. Document the procedure, condition of the site, and the resident’s response.


62

Equipment/Supplies for Trach Patient… •

Aerosol Tubing

Aerosol Drain Bag

Air Compressor

Tracheostomy Mask

Oxygen Bleed in Tee

Oxygen Tubing

Aerosol Bottle (Refillable or Prefilled)

Suction Machine – Aspirator

Oxygen Concentrator or Liquid Tank with Flow gauge

Pulse Oximeter

Oxygen Analyzer

Oxygen Nipple Adapter

Manual Resuscitator (single resident use)

Tracheostomy Tubes (Spare and one size smaller)

Tracheostomy Ties

Suction Catheters

Tracheostomy Care Kits

Suction Bottles

Suction Tubing (6 foot and 18 inch)

Sterile Water

Transport E Cylinder with Venti/Mixing mask set for current oxygen percentage

Orders require documentation of desired oxygen percentage to be delivered:____________________%


63

Providing Tracheostomy Care Met

Not Met

Title

Description

Verify order.

Verify actual physician’s orders.

Explain procedure.

Explain procedure to the resident.

Wash hands.

Apply gloves.

Remove supplemental oxygen mask from tracheostomy. Inspect skin and stoma site.

Remove old dressings.

Remove gloves.

Wash hands.

Open tracheostomy cleaning kit. Set up supplies on sterile field.

Inspect skin and stoma site for signs or symptoms of infection, leakage, or dislodged tube.

Rationale


64

Met

Not Met

Title Empty saline into both compartments.

Open gauze pads and saturate with antiseptic solution. Open gauze pads and saturate with sterile saline. Open gauze pads; keep them dry. Put on sterile gloves.

Secure the outer neck plate with non-dominate gloved hand. Unlock the inner cannula with gloved dominate hand. Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident Soak the cannula in saline.

Clean with brush. Rinse with saline and dry with pipe cleaners Remove and discard gloves into appropriate receptacle. Wash hands and put on fresh gloves.

Description Maintaining sterile field, pour normal saline in both compartments of opened kit.

Rationale


65

Met

Not Met

Title

Description

Replace the cannula carefully and lock in place. Apply clean gloves.

Clean the stoma with saline soaked gauze pads (using a single sweep for each side). Wipe with dry gauze (using a single sweep for each side). Remove neck ties and replace with clean ones. Apply a fenestrated (split gauze) gauze pad around the insertion site. Replace supplemental oxygen mask over tracheostomy if ordered. Remove gloves and discard into appropriate receptacle. Wash hands.

Document the procedure, condition of the site, and the resident’s response.

Apply new ties before removing old ones.

Rationale


66

________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date


67

Observer Notes:


68


69

EKG Please Refer to the EKG Machine Manufacturer’s Policy and Procedures


70

EKG PATIENT PREPARATION The EKG traces quality depends very much on the stability and conductivity of the electrodes during the test, especially during high stages when the patient movements can cause artifacts. Here are some basic rules to ensure good electrical contact: • Shave hair at the electrode contact points • Use high quality liquid gel electrodes • Make sure that the lead wires do not swing Attach the leads as shown in Figure 16, below (RA=right arm, LA=left arm, RL=right leg, LL=left leg) .

Figure 16: Electrode Placement


71

12 Lead ECG Competency Checklist Instructions: Instructor will supervise performance of skills by employee. All steps must be performed as indicated in order for competency to be determined adequate. Instructor will sign off step as it is performed correctly.

REQUIRED PERFORMANCE Procedure Check the accuracy of participant’s name and birthdate per identification policy before starting the procedure. Wash hands.

Explains procedure to patient.

Maintains privacy for patient.

Demonstrates proper preparation of skin prior to placing leads on patient. Check the accuracy of participant’s name and birthdate per identification policy before starting the procedure. Places lead on proper anatomical location on patient.

Properly attaches correct leads to patient.

Presses power key to turn ECG machine on.

Verifies wave quality.

Can correctly identify and use the following keys on the keypad: copy, ECG, rhythm, stop, enter, return, arrow pad, escape, function keys, power and delete.

PROFICIENT Yes

No


72

REQUIRED PERFORMANCE Procedure Inputs • • • • •

data into ECG machine: Last name First name Patient ID # eliminate the check digit Referring physician Operator initials

Checks for loose lead message and corrects. Presses the ECG rhythm key to initiate a tracing. Presses ‘Copy’ button if second copy is requested by nurse/physician. Presses ‘Rhythm’ button if rhythm strip is requested. Turns ECG machine off. Locates power supply connection and plugs in when not in use. Documents the completion of the ECG machine on patient flow sheet. Makes certain 12 lead ECG printout is given to RN/MD. Know when to ask for an accompaniment. What would be the parameters to report in an urgent fashion? Who should you report the urgent findings to?

PROFICIENT Yes

No


73

Observed/ verbalized

Applying 12 Lead ECG

Performed

Verbalizes steps to include in proper skin preparation for lead placement a. Clean area with alcohol swab b. Clip excess hair as necessary Demonstrates proper lead placement for 12 Lead ECG a. V1 – 4th ICS; right sternal border b. V2 – 4th ICS; left sternal border c. V3 – Midway between location of V2 and V4 d. V4 – 5th ICS; mid-clavicular line e. V5 - 4th ICS; to the right of V4 (anterior axillary line) f. V6 – 4th ICS; mid-axillary line g. Right arm, left arm, right leg, and left leg Demonstrate ability to obtain a 12 lead ECG using the ECG machine.

________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date


74

Observer Notes:


75


76


77

TELEMETRY Please Refer to your Telemetry Device Policy and Procedures


78

Telemetry-New Patient Monitoring Met

Not Met

Task •

Device set up.

Electrodes to be changed Q24 hours.

Battery to be changed Q12 hours.

Extra battery to be plugged into charger to recharge.

Ensure battery is charged before changing. Green light means charged, Red means charging.

Ensure resident compliance Q shift.

Ensure proper lead placement Q shift.

Red lead is placed on left side of chest below left breast.

Black lead is placed on left side of chest above left breast.

White lead is placed on right side of chest above right breast.

Remove monitor before resident shower.

Call manufacturer for any issues.

Remove monitor before resident leaves facility, either for discharge or appointment.

Document in resident’s record.


79

________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date

Observer Notes:


80


81

TRILOGY Please Refer to your Trilogy Policy and Procedure Manual


82

Trilogy Quick Guide •

Trilogy = BiPAP with the guarantee of a consistent breath size.

Better O2/CO2 management.

Enhanced patient comfort and compliance.

Portable with up to 6 hours of battery power.

An alarm sounding means there is a leak or resident disconnect.

Facial oil contributes to poor seals and increases chances of a leak. Make sure face is clean to minimize leaks.

Wash mask cushion daily.

You can have a Trilogy in a building with no generator due to the battery life. The order should read that the resident will be sent to the hospital if the building loses power for more than 6 hours. The Trilogy has to be plugged in at all times to keep the battery fully charged in case of power outage.


83


84


85


86


87

LIFE VESTS

Refer to Life Vest Manufacturer for Policies and Procedures if not using ZOLL brand


88

Wearable Defibrillators BY: DR. JOEL OKNER MD INVASIVE CARIOLOGIST | CHIEF CARDIOLOGY

Objectives • • • •

Describe the evolution of the Zoll Life Vest Explain the components of the Life Vest and how it works Demonstrate assembly and application of Life Vest Describe the elements of effective patient education and teaching

Evolution of the Zoll Life Vest • •

1956 - Dr. Paul Zoll- First doctor to use an external defibrillator to correct a patient’s life threatening rythm 1986 - The wearable cardioverter device later to become known as the Life Vest, was developed by Stephen Heilman, through his company, Lifecore.


89

Evolution of the Zoll LifeVest • • • • •

1996 - Zoll Medical Corp, makes an equity investment in Lifecor 2001 - The LifeVest recieves approval from the U.S. Food and Drug Administration 2005 - Medicare approves reimburstment 2006 - Zoll competes the aquisition of assets of Lifecore, Inc. 2008 - LifeVest Wearable Defibrillator exceeds 10,000 prescriptions.

Sudden Cardiac Arrest •

• •

SCA is a condition in which the heart suddenly and unexpectedly stops beating. If this happens, blood stops flowing to the brain and other vital organs. SCA usually causes death if not treated within MINUTES. SCA is caused by abnormal rythms of the heart muscle, called arrhythmias Risk Factors Include Congenital defects Congestive heart failure Coronary artery disease

Life Threatening Arrythmais Ventricular Fibrillation

Ventricular Tachycardia


90

How Does It Work? • • • • • • • •

Alarm sequence Arrythmia detected, activating the vibration alert Siren alert begins Siren alert gets louder Patient audible promp “Electrical shock possible” Gel release Bystander audible prompt “Do not touch patient” Treatment shock

Responding to LifeVest Alerts • •

The alerts are part of the normal functioning of the LifeVest There are three different types of alerts a. Gong Alert: low pitch gong sound- not part of the treatment sequence; accompanied by a message monitor letting you know the device needs your attention b. Vibration Alert: comes from the vibration box on the electrode belt. Press and hold both response buttons when you hear an alert c. Siren Alert: this is letting you know that the device is about to deliever a shock

Assembly of LifeVest 1. Lay both the electrode belt and the garment on a flat surface 2. Insert the pair of therapy pads into the large pockets of the garment labeled “1” - secure into place 3. Attach the vibration box and secure into place “2” 4. Insert single therapy pad into front pocket labeled “3” secure into place 5. Attach the electrodes by matching the colors


91

Application • • • • •

Removing all clothing Slide the LifeVest on as if it is a backpack and secure the hooks to the front of the vest Connect electrode belt to the monior, then insert a fully charged battery You will hear a gong alert and a vibration Press both response buttons to activate the LifeVest

WEAR • • • •

W - Wear it all day and night E - Every 24 hours change the battery A - Act quickly for SIREN alerts. Press the response buttons R - Read the display for GOING alerts and follow the instructions on the screen

Key Points 1. Turn on the LifeVest by inserting the Battery. Always have the garment on before you insert the battery 2. There are two batteries, always charge one while using the other 3. If conscious when a SIREN alert goes off, press the response buttons 4. Wash the garment every 1-2 days, do not bleach, do not use softner. Only wash the garment and not the electrodes 5. Always call your physician or go to the ER after you recieve treatment. Do you not remove LifeVest even though gel may feel cold. It will continue to monitor your heart rythm; then once stable, call Zoll for a new belt

TeleMedico Physicians Cardio Division Contact Clinical Office: 847.386.7132 Business Office: 847.386.7744 www.telemedicophysicians.com


92

Applying LifeVest Met

Not Met

Task •

Introduce yourself and explain the procedure to the resident.

Wash hands.

Remove resident’s clothing.

Slide LifeVest onto resident like a backpack. Secure hooks to the front of the vest.

Connect electrode belt to the monitor and then insert a fully charged battery. The LifeVest should always be on before inserting the battery.

Press button to activate the LifeVest.

The other battery should be charging while the other battery is in use.

If the garment needs to be washed it can be. Do not bleach. Only the garment should be washed and not the electrodes.

Call MD if treatment is received. LifeVest should not be removed.

Call MD if any complications are noted.

Wash hands and document.


93 ________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date

Observer Notes:


94


95

CADD PUMPS Refer to CADD Pump Manufacturer’s Policy and Procedures


96

CADD Pumps Met

Not Met

Task •

Explain procedure to resident.

Gather supplies.

Wash hands.

Verify medication label contains correct information. Verify orders.

Remove cap from end of cassette and connect pump tubing.

Close clamp on pump tubing

Attach a saline syringe to IV line and flush the IV line. Leave syringe attached to IV line.

Remove prior cassette from pump and discard tubing and cassette.

If battery needs replaced do so during this time.

Attach new cassette of medication into pump. Make sure cassette is flush against pump.

The pump will show a message confirming it is latched.

Program prescribed orders in the machine pump.

Prime tubing through machine pump.

Remove saline syringe from IV line. Remove protective cap from end of pump tubing and attach to the IV line.

Open clamp on tubing.

Program pump via prescribed orders and begin administration.

Dispose prior materials.

Wash hands.


97 ________________________________

________________________________

Learner’s Name

Learner’s Signature

________________________________

________________________________

Observer’s Name

Observer’s Signature

________________________________ Observation Date

Observer Notes:


98


99

WOUND VACS


100

MODEL #: CMPP-100 Revision 1.7 2018_0724

Nisus ®_

NEGATIVE PRESSURE WOUND THERAPY SYSTEM

Instructions for Use

2_ _


101

Table of Contents: Clinical Safety and Precautions •

Clinical Safety and Precautions

Increased Risk of Bleeding

Infected Blood Vessels, Wound Complications

Protect Vessels, Organs, Tendons, Ligaments, and Nerves

Large Wounds

Infected Blood Vessels

Hemostasis, Anticoagulants, and Platelet Aggregation Inhibitors

Hemostatic Agents

Sharp Edges

Vascular Surgical Wounds of the Lower Extremities

Infected Wounds

Osteomyelitis

Tendons, Ligaments and Nerves

Foam Placement

Foam Removal

Defibrillation

Universal Precautions

Patient Size and Weight

Spinal Cord Injury

Bradycardia

Enteric Fistulas

Operating Precautions

Continuous Therapy Versus Variable Intermittent Therapy

Protect Periwound Skin

Circumferential Dressing Application

Physician Orders

User, Indications for Use, Contraindications


102

Table of Contents: Use of Device •

Use of Device

Introduction, Symbols, Warnings and Safety Standards

Canister Full Alarm Troubleshooting

Nisus NPWT System Components and Accessories

Troubleshooting Malfunction Pump Startup

Maintenance

Nisus NPWT Pump Features

Servicing the Device

Battery Power and Charging

Cleaning

Device Operations

Returning the Device

Applying NPWT Wound Dressing

Disposal of Device

Attaching the Drainage Canister to Pump

Electromagnetic Compatibility

Nisus NPWT Pump – General Settings

Technical Specifications

Nisus NPWT Pump – Therapy Mode Settings

Nisus NPWT Canister

Continuous Mode

Variable Intermittent Mode

Nisus NPWT Wound Dressing Kit

Navigating Troubleshooting Information

Nisus NPWT Pump

Alarm Settings

Dimensions / Weight

What Happens When Device Alarms

Environmental Conditions

Alarm Types

Storage and Shipping Conditions

Low Battery Alarm Troubleshooting

Patient Protection

Leakage Alarm Troubleshooting

Compliance

Blockage Alarm Troubleshooting

Limited Warranty


103 Clinical Safety and Precautions The following types of patients are at an increased risk of bleeding, which if not controlled could be potentially fatal: • Patients who would have weakened or friable blood vessels or organs in or around the wound as result of, but limited to suturing of blood vises, infection, trauma, and radiation • Patients without adequate wound hemostasis • Patients who have been administered anticoagulants or platelet aggregation inhibitors • Patients who do not have adequate tissue coverage over vascular structures If active bleeding develops suddenly or large amounts of frank (bright red) blood is seen in the tubing or canister, immediately stop therapy, leave dressing in place, take measures to stop the bleeding, and seek immediate medical assistance. The Nisus NPWT System should not be used to prevent, minimize or stop vascular bleeding. Protect Vessels and Organs: All exposed or superficial vessels and organs in or around the wound must be completely covered and protected prior to the administration of the Nisus NPWT. Large Wounds: Caution should be taken when treating large wounds that may contain hidden vessels which may not be readily apparent. The patient should be closely monitored for bleeding in a setting deemed appropriate by the treating physician. Infected Blood Vessels: Infection may erode blood vessels and weaken the vascular wall which may increase susceptibility to vessel damage through abrasion or manipulation. The patient should be closely monitored for bleeding in a care setting deemed appropriate by the treating physician. Hemostasis, Anticoagulants, and Platelet Aggregation Inhibitors: Due to the increased risk for bleeding, consideration should be given to the negative pressure setting and therapy mode used when initiating therapy. These patients should be treated and monitored in a care setting deemed appropriate by the treating physician. Hemostatic Agents Applied at the Wound Site if disrupted, may increase the risk of bleeding which, if uncontrolled, could be potentially fatal. Consideration should be given to the negative pressure setting and therapy mode used when initiating therapy. Sharp Edges or bone fragments must be covered or eliminated from the wound area to prevent them from puncturing blood vessels or organs prior to the application of the Nisus NPWT System. Use caution when removing dressing components from the wound so that the wound tissue is not damaged by unprotected sharp edges. Vascular Surgical Wounds of the Lower Extremities: Regardless of the treatment, wound complications from peripheral vascular surgery, especially those situated in the groin, are not uncommon and have the potential for severe consequences including significant blood loss. Infected Wounds: Wound infections should be closely monitored and may require more frequent dressing changes. If there are any signs of the onset of systemic infection or advancing infection at the wound site, contact the treating physician immediately to determine if the Nisus NPWT Pump should be discontinued.


104 Clinical Safety and Precautions Osteomyelitis: Nisus NPWT should not be initiated on a wound with untreated osteomyelitis. Tendons, Ligaments and Nerves: Protect exposed tendons, ligaments and nerves with natural tissue, meshed non-adherent material or bio-engineered tissue to help minimize risk. Foam Placement: Always use dressings from sterile packages that have not been opened or damaged. Do not place foam dressing into blind/unexplored tunnels. Always count the total number of pieces of foam used in the wound and document on the patient chart. Foam Removal: Always count the total number of pieces of foam removed from the wound and ensure the same number of foam pieces are removed as were placed, as the dressings are not bio-absorbable. Regardless of treatment, disruption of the new granulation tissue during any dressing change may result in bleeding at the wound site. Keep Nisus NPWT System turned on: Never leave the foam dressing in place without the Nisus NPWT System for more than 2 hours if therapy is turned off. If the therapy is off for more than 2 hours, remove the wound dressing and irrigate the wound; either apply a new Cork Medical NPWT wound dressing and restart the unit, or apply alternative dressing at the direction of the physician. Defibrillation: If defibrillation is required in the area of dressing placement, remove the dressing immediately, as failure to remove may inhibit transmission of electrical energy and/ or patient resuscitation. Precautions should be taken for patients who are or may be receiving anticoagulant therapy, patients with known hemolytic disease, untreated for malnutrition, and who are non-compliant or combative. Universal Precautions: Hand washing must be performed prior to starting any procedure. Gloves must be donned prior to any direct patient contact. In addition to gloves, use gown and goggles if exposure to body fluid is likely. Always follow your institutional guidelines on infection control practices. Patient Size and Weight: The size and weight of the patient should be considered when prescribing negative pressure wound therapy. Infants, children, certain small adults and elderly patients should be closely monitored for fluid loss and dehydration. Also, patients with highly exudating wounds or large wounds in relation to the patient size and weight should be closely monitored, as they may have a risk of excessive fluid loss and dehydration. When monitoring fluid output, consider the volume of fluid in both the tubing and canister. Spinal Cord Injury: In the event a patient experiences autonomic hyperreflexia (sudden elevation in blood pressure or heart rate in response to stimulation of the sympathetic nervous system), discontinue therapy immediately and seek immediate medical assistance. Bradycardia: The dressing should not be placed near the vagus nerve as this may cause bradycardia. Enteric Fistulas: Nisus NPWT System is not intended for containment of drainage of enteric fistulas. Nisus may be used with enteric fistulas in the aid of promoting wound healing and not the sole purpose of containment of drainage. The physicians ordering the Nisus for enteric fistulas need to closely monitor the patient for any complications that may occur.


105 Clinical Safety and Precautions Operating Precautions When operating, transporting, repairing, or disposing of Cork NPWT devices and accessories, the risk of infectious liquid being aspirated, or contamination of the device assembly through incorrect use, cannot be eliminated. Universal precautions should be observed when working with potentially contaminated parts or equipment. In the event materials of the Nisus NPWT System cause skin irritation or an allergic reaction, cease use immediately and contact a physician. Use of the Nisus NPWT System must be prescribed by a physician per the stated indications for use. As a condition of use, the Nisus NPWT System should only be used by qualified and authorized personnel. The user must have the necessary knowledge of the specific medical application for which negative pressure wound therapy is being used. The Nisus NPWT System should remain on and in use for the duration of the prescribed treatment. If the patient must disconnect the pump from the NPWT wound dressing, the ends of the tubing should be clamped prior to disconnecting. The length of time a patient may be disconnected from the Nisus device is a clinical decision based on individual characteristics of the patient and the wound. Factors to consider include the location of the wound, the volume of drainage, the integrity of the NPWT wound dressing seal, the assessed bacterial burden, and the patient’s risk of infection. The Nisus NPWT pump is not intended to be in use during transport or ambulatory use. In the event a patient using the Nisus NPWT System needs to be transported or ambulatory, the ends of the tubing should be clamped and disconnected from the NPWT wound dressing. The length of time a patient may be disconnected from the Nisus device is a clinical decision based on individual characteristics of the patient and the wound. Factors to consider include the location of the wound, the volume of drainage, the integrity of the NPWT wound dressing seal, the assessed bacterial burden, and the patient’s risk of infection. Ensure all components of the Cork NPWT Wound Dressing Kit are installed correctly and that the port pad assembly tubing is not kinked to avoid leakage and blockage during NPWT therapy. Position the Nisus NPWT System and drainage tubing appropriately to avoid the risk of causing a trip hazard. When possible, position the pump device and drainage tubing at or below the level of the wound. Tubing from the Cork NPWT Wound Dressing Kit and wound drainage canisters are long and represent a possible strangulation hazard. The battery charger cable also represents a possible strangulation hazard. Position the Nisus NPWT System, its tubing, and cables appropriately to avoid the risk of strangulation. Ensure the environment where Nisus NPWT System is to be used is clean and free of excessive dirt, lint, dust, and debris. Avoid using or storing Nisus NPWT System in an unclean environment. When not in use, store the device and accessories in a cool, dry place. Continuous Therapy Versus Variable Intermittent Therapy: Continuous Therapy is recommended for unstable structures, such as an unstable chest wall or non-intact fascia. Continuous Therapy is also generally recommended for patients at risk of bleeding, highly exudating wounds, fresh flaps and grafts, and wounds with acute enteric fistulae.


106 Clinical Safety and Precautions Protect Periwound Skin: Consider the use of a skin preparation product to protect periwound skin. Do not allow wound filler to overlap onto intact skin. Protect fragile/friable periwound skin with additional hydrocolloid or other transparent film. • Multiple layers of the transparent film dressing may decrease the moisture vapor transmission rate, which may increase the risk of maceration. • If any signs of irritation or sensitivity to the film dressing, wound filler or tubing assembly appear, discontinue use and consult a physician. • To avoid trauma to the periwound skin, do not pull or stretch the transparent film over the wound filler dressing during film application. • Extra caution should be used for patients with neuropathic etiologies or circulatory compromise. Circumferential Dressing Application: Avoid use of circumferential dressings except in the presence of anasarca or excessively weeping extremities, where a circumferential film technique may be necessary to establish and maintain a seal. Consider using multiple small pieces of transparent film rather than one continuous piece to minimize the risk of decreased distal circulation. Extreme care should be taken not to stretch or pull the film when securing it, but let it attach loosely and stabilize edges with an elastic wrap if necessary. When using circumferential film techniques, it is crucial to systematically and recurrently palpate distal pulses and assess distal circulatory status. If circulatory compromise is suspected, discontinue therapy, remove dressing and contact a physician. Physician Orders Caution: Federal Law (USA) restricts this device to sale by or on the order of a licensed physician. Use of the Nisus NPWT System must be prescribed by a physician per the stated indications for use. As a condition of use, the Nisus NPWT System should only be used by qualified and authorized personnel. The user must have the necessary knowledge of the specific medical application for which negative pressure wound therapy is being used. Prior to placement of the Nisus NPWT System, the medical professional treating the patient must assess how to best use the system for an individual wound. It is important to carefully assess the wound and patient to ensure clinical indications for negative pressure wound therapy are met. All orders should include: • • • • •

Wound location, size, and type Dressing kit type Negative pressure settings Frequency of dressing changes Secondary dressings


107 Clinical Safety and Precautions: User The Nisus NPWT System is designed for use by licensed healthcare professionals only. Patients may be trained to perform some limited functions, but the keypad and device menus are locked by the healthcare professional to prevent the patient from changing the setting prescribed by the physician. NOTE: Patient functions are limited to power on/off, ability to respond to any alarm condition, and navigating to troubleshooting screen (should an alarm occur). Indications for Use The Cork Medical Products Nisus Negative Pressure Wound Therapy System is indicated for use in patients who would benefit from negative pressure wound therapy particularly as the device may promote wound healing by the removal of excess exudates, infectious material, and tissue debris.

Contraindications The Nisus NPWT System is contraindicated for patients with: • Malignancy in the wound • Untreated osteomyelitis • Non-enteric and unexplored fistulas • Necrotic tissue with eschar present (NOTE: After debridement of necrotic tissue and complete removal of eschar, Nisus NPWT system may be used.) Caution, do not place dressing directly in contact with: • Exposed blood vessels • Anastomotic sites • Organs • Nerves

Contact Information Cork Medical Products 8000 Castleway Drive, Indianapolis, IN 46250 Toll Free: 866.405.6138 Fax: 1.866.429.55241


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Use of Device: Introduction The Nisus Instructions for Use provides information regarding safe and effective operation of the Nisus Negative Pressure Wound Therapy System. This manual may be used in training of personnel and reference for the caregiver/beneficiary. Disregarding the information on safety and use of this device is considered abnormal use.

Warnings DO NOT OPERATE THIS EQUIPMENT WITHOUT FIRST READING AND UNDERSTANDING THIS MANUAL. IF YOU ARE UNABLE TO UNDERSTAND THE WARNINGS, CAUTIONS AND INSTRUCTIONS, CONTACT A HEALTHCARE PROFESSIONAL, DEALER OR TECHNICAL PERSONNEL IF APPLICABLE BEFORE ATTEMPTING TO USE THIS EQUIPMENT. OTHERWISE INJURY OR DAMAGE MAY RESULT. REFER SERVICING TO QUALIFIED PERSONNEL ONLY BEFORE PERFORMING ANY MAINTENANCE TO THE CONSOLE, DISCONNECT THE POWER CORD FROM THE WALL OUTLET. GROUNDING RELIABILITY DEPENDS UPON A PROPERLY GROUNDED WALL OUTLET. DO NOT POWER UNIT IN THE PRESENCE OF FLAMMABLE GASES SUCH AS ANESTHETIC AGENTS WARNING/CAUTION NOTICES APPLY TO HAZARDS OR UNSAFE PRACTICES WHICH COULD RESULT IN PERSONAL INJURY OR PROPERTY DAMAGE.

Symbols Class II, Internally Powered Applied Part, Type BF Read Instructions as a mandatory action Do not dispose Ingress protection - protected against insertion of fingers and will not be damanaged or become unsafe during a specified test in which it is exposed to vertically or nearly vertically dripping water Intertek registered certification mark of nationally recognized testing labratory (NRTL) Used canisters are considered biohazardous and should be disposed of accordingly after use. Caution: Federal Law (USA) restricts this devise to sale by or on the order of a licensed physician. MR Unsafe - keep away from magnetic resonance imaging (MRI) equiptment


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Nirus NPWT System Components and Accessories

WOUD DRESSING KIT

NISUS PUMP

500 ML CANISTER

Nirus NPWT System Accessories •

Cork Medical Products NPWT Wound Dressing Kits

Cork Medical Products Canisters

Cork Medical Products NPWT Wound Dressing Accessories

250 ML CANISTER


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Competency Checklist for Nisus NPWT System Dressing Application Staff Member’s Name: ________________________________________ Procedure: Before you begin, verify the physician’s order and review the contraindications for Negative Pressure Wound Therapy (NPWT). 1. Cleanse the wound and periwound area according to the institution guidelines and physician’s order and let dry. 2. Use transparent drape to window the periwound area. This should extend out 1 - 2 inches from the wound. 3. Cut the black foam to the shape of the wound and ensure that entire wound will be covered with the foam. (Always cut the foam away from the wound to prevent any unwanted debris from falling into the wound bed.) Ensure that no foam comes in contact with the periwound area. 4. If required, cut the drape to size where indicated prior to removing the backing film. The drape should only be cut in the direction as indicated by the dotted line on the transparent drape. Remove the backing film labeled with “1” by grasping the folded tab and peeling the backing off. Hold left and right sides of the drape at the same time while placing the drape over the wound. 5. Once in place, remove the tabs on either side labeled with “2” by grasping the folded tab and peeling the backing off. Ensure entire drape is securely sealed. Remove the top cover labeled with “3” by peeling the tab on either side of the drape. Remove the paper tabs labeled with “Cork Medical Products” from both sides of the drape. 6. Gently lift the drape with your thumb and forefinger over the center of the black foam and cut a 2 cm round hole on the top of the drape. (Do not slit drape because the slit will reseal itself when NPWT is on.) 7. To apply the suction port, remove the paper backing labeled “remove first.” Hold both ends of the suction port skirt by the folded tabs and center the dome pad above the hole cut in dressing. Tack the skirt in place. 8. Once in place, remove the paper tabs on each side of the skirt. Ensure entire skirt is securely sealed. Remove the top cover of the skirt by peeling back the paper using the squiggle cuts near the center. 9. Connect the tubing to the canister tubing via the luer lock method and start the NPWT per physician’s order. Refer to the User Manual for the Cork NPWT pump on how to operate the pump device. “The staff member has demonstrated competency of performing a Nisus NPWT system dressing changed by following the above steps. By signing this competency form you acknowledge that you understand and have been trained on the Nisus NPWT system dressing change.” Staff’s Signature:______________________________________

Date:__________________________

Instructor Signature: ___________________________________

Date:__________________________


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