nursing pearls for the new pa

For anyone who is coming to the hospital world right out of PA school it can sometimes be difficult to navigate the essentials of inpatient medicine. The language that is used and the equipment in the room is often foreign. While we are usually not the main people that mess with pumps/IVs/etc it is important to recognize what things are so you can communicate with your colleagues and understand barriers to taking care of the patient.

Mediation Formulations

Medications often come IV push (IVP), continuous or piggybacked.

  • Piggyback Medications: A piggyback is a secondary line; it pauses your primary line to run your secondary line automatically. For example, if you had keppra on piggyback, the keppra will run for 15 min without anything else then after it is done IVF will automatically run. The point of doing it is to save channels (which can be hard to come by) and overall be less annoying; it frees up an IV site. You don’t have to go in there and physically turn it off when it is done, it doesn’t beep at a patient.

  • Continuous infusions: just a single primary line, intermittent infusion.

  • IVP: you push it once, usually by followed by a flush to clear the line tubing

IV Compatibility

  • Nurses know this by looking at lexi-comp

  • Medications don’t always play well with each other.

    • For example

      • amiodarone must be run in a line by itself and must be filtered; in contrast, you can run vasopressors all together in the same line.

      • insulin must be ran by itself

  • Medications that are compatible join together at a “y-site”, but you also have to be careful with the “y-sites” itself. They are sequentially down the IV tubing starting from closest to the patient to farthest away (closest to the pump).

    • For example if you have vasopressors going and you have fluids started as well it will bolus the vasopressor in; be careful at how far down the line you are (or which y-site you put your medication in) - but your nurses should be good at this

IV pumps

IMG_4354.jpg
  • The brand name for the pumps at Piedmont is Alaris

    • Brain: main part of the pump that you use to program the channels

    • Channels: part of the pump where IV lines run; they are programmed for the drug running through them

  • You cannot have more than four channels on one brain; it doesn’t matter what side they are on

    • There is two ways to program brain: critical care and acute care

      • If a patient is on the floor, it is programmed for acute care and they cannot give critical care medications

  • Common error beeps:

    • Air in line: there is a bubble potentially in the actual channel itself , will stop medication

      • Tubing can be dry, bubble can be somewhere; champagne bubbles are okay but not big bubbles. To get it out tap it

    • Occluded line: often AC IVs when patient bends arm, or it can be pinched in side rails

    • Infusion complete: the volume set in the channel has been delivered; make sure this isn’t your vasopressors, if it is grab your nurse

    • If any doubt grab your nurses

An open channel where you place the IV tubing

An open channel where you place the IV tubing

The brain will list what medications are running and what their dosages are (what they’re running at)

The brain will list what medications are running and what their dosages are (what they’re running at)

Example of a “Y-site” (where two medications join) - this is propofol and fentnyl

Example of a “Y-site” (where two medications join) - this is propofol and fentnyl

Multiple “Y-Sites” with the one on the right closer to the patient and the one on the left farther away (and unused)

Multiple “Y-Sites” with the one on the right closer to the patient and the one on the left farther away (and unused)

The clamp - somewhat of a moot point if there is a channel above it, but if a bolus is running this helps dictate the flow. Move it down to clamp it (slower flow) and move it up to open it up (faster flow)

The clamp - somewhat of a moot point if there is a channel above it, but if a bolus is running this helps dictate the flow. Move it down to clamp it (slower flow) and move it up to open it up (faster flow)


Lab Draws

  • Some labs are special

    • Labs that must be drawn and then immediately placed on ice: lactic acid, ammonia

    • Ionized calcium is dark green unlike most other chemistry levels which are pistachio

  • Often tubes are called by the color. For example, when you need a “pistachio” it means you need a light green topped tube

  • When a lab is ordered a ticket is printed out that the nurses place on the tubing; the ticket will say what it is, what color tube it needs and any other special instructions

  • You don’t have to worry too much about knowing this off the top of your head but it’s good to recognize

    • If you forget to order a lab you can sometimes “add it on” to the blood already sent down (what is called an “add on”)

    • for example, you cannot add on a lactic acid to a BMP you drew earlier (you can only add on labs that are in the same tube color)

phlebotomy-tubes-colors-chart-bd-vacutainer-blood-collection-tubes-order-of-draw-vacutainer-tube.jpg

random Nursing Terms

  • INT = autoclaves = “intermittent”, basically just means non-used IV

  • Trialysis = central line (three ports)

  • Straight cath = intermittent emptying of the bladder

  • Nurse draw = nurses able to draw labs instead of lab tech

  • Dinomap = portable vital sign monitor w/automatic blood pressure, often blue in color

  • “Pressure bag” - they actually put a thing around the medication/fluid that places pressure on it and causes it to go in very fast; must request this, if you don’t have one can squeeze with hands

  • OGT = oral gastric tube, placed in mouth usually on vented patients

  • DHT = dob hoff tube, essentially a smaller OGT/NGT; super tiny and can only do feeds in it, cannot suction

  • TPN/PPN = forms of nutrition; one is peripheral (PPN) one is central (TPN), gives nutrition and electrolytes, nursing/dietary/pharmacy collaborates. Can increase risk of bacteremia

  • Rectal tube = tube that goes off anus to collect feces. Do not use on GIB, abdominal infections, anyone at high risk of perf/bleeding

  • Purewick = for women; catches the pee and sucks it up, sits between the legs. Looks like a huge tampon

  • Condom cath = non-invasive condom that drains pee from the male; attached to a foley bag/tubing

  • IPCs (intermittent pneumatic compression) = leg squeezers, prevent clots

  • Dial-flow: special tubing often in the ED where you can control continuous flow so you don’t need a brain/channel to use it; but if you bend arm/etc it does not alarm because there’s no computer to alarm

  • Admixture: you can add two things in the same bag, usually mixed by pharmacy

  • Yankauer = apparatus that attaches to suction tubing and is your handle

  • Curos caps = cap that has alcohol embedded into it and sits on the line while not being used; keep the y-sites clean so you don’t have to scrub it every time, must place a new one every time

  • Pigtail = squishy rubber band thing you pull to flush anything your transducing (think a-lines)

  • Claves = attaches to attachments on line, blood/meds can’t come out but you can push meds in

Yankauer

Yankauer

Other Pearls

  • Places for IVs - anywhere you can get them; but wrist/forearm preferred, AC can be annoying

  • Blood cultures cant be drawn from IVs/CVLs -must be stick

  • Switching from regular to quad strength vasopressors, or switching from regular IV to central line IV - must change IV tubing!

  • Some oral medications can be crushed down OGT/NGT once patient is intubated. You cannot crush extended release medications