IICU Staff Meeting Minutes May 15 and 16, 2013 IICU Conference Room

Transcription

1 IICU Staff Meeting Minutes May 15 and 16, 2013 IICU Conference Room 1) Decreasing Telemetry Alarms Janice Marlett, BSN, RN, Nursing Staff Educator To decrease tele alarms: Properly prep the skin Shave if necessary Cleanse area with alcohol prep pad to remove oils Rub skin using bumps on the back of the EKG patch to remove dead skin cells Adjust alarm limits appropriately per patient if > 5 alarms and pt is stable; document alarm adjustments Check lead connections to the pt and to the monitor Discontinue order when pt no longer needs to be monitored 2) HiFlow Oxygen David Boston, RRT, Pulmonary Therapy See handout attachment HiFlow O2 heats and humidifies to optimal oxygen concentration, simulating what actually is happening in healthy lungs Heats oxygen to actual body temp Offers 100% humidification For every 10 l of flow, pt gets 1 cm of pressure so you are simulating PEEP Indications: Patient not maintaining saturation Increased work of breathing Pt facing possible need for reintubation Contraindications Nasal obstructions Possible facial fractures Obtunded patients Start at 35 l/min up to 65 l/min at 100% FiO2 adjusting up until pts work of breathing begins to decrease; then FiO2 will start to be weaned down according to the ordered level of desired saturation Pulmonary therapist will check on HiFlow set up a minimum of 3 X s/8 hour shift

2 Call pulmonary for any needed adjustments nursing is NOT to make any adjustments on the HiFlow set up Pts on HiFlow to stay in critical care area due to equipment needed both oxygen and air hook-up 3) Care of the Fracture Hip Pateint Ingelis Ahlseen, BSN, RN, Staff RN 4 North Pts to 4 North preop with goal of preop clearance time < 24 hrs Trying to get Vitamin K given in ED to facilitate decreasing inr within 24 hrs Pts need turned pre-op every two hours; support fracture and immobilize when turning Caution use of MSO4 in elderly as this has been found to increase delirium post-op Recommend Tylenol 1000 mg IV/po every 6 hours this has proven to provide effective pain management If delirium post op, conider Haldol low-dose around the clock (if prn dosing, ECF may not accept pt); often this is just needed for 1-2 days post-op UTI can compound delirium Bucks traction used to decrease muscle spasm; if OR within 24 hours, may not be ordered Keep heals off bed with a pillow Activity keep in bed OR day; POD #1 OOB 2 hours at a time; weight bearing status will be ordered by physician; may need walker Change dressing POD #2 Call 4 North with any questions 4 North has info packet that includes brochures for patient and tip sheet for nurses (see attached) 4) Skin Care Update Ursula Hohman, RN, IICU Skin Care Committee Representative We tend to score patients to high on the Braden Scale than they need to be Each month education related to one area of the Braden scale will be provided to help us get to more accurate documentation This month s topic is moisture See attached Ppt: YEAST The Fungus Among Us Calazime cream for yeast no order needed Baza cream (Micronazole) - antifungal skin barrier; need MD order; apply BID; clean Calazime off prior to applying Baza; can use this in the pt folds Do not hesitate to consult the wound nurse to verify wound vs pressure ulcer do not need physician order to consult wound nurse Consult PT/OT for seating they will bring a Roho cushion for pt to use if pt unable to reposition self in chair; Roho cushion does NOT go home with pt If PT/OT not an appropriate consult for pt, consider Kinair bed

3 Department of Pulmonary Medicine High Flow Nasal Cannula (HFNC) Purpose: To deliver heated and humidified oxygen at high flow rates with a large-bore NC device. Indications: 1. Patients not maintaining oxygen saturation on current high flow oxygen devices 2. Increased work of breathing 3. Alternative to NIV post extubation Contraindications: 1. Nasal obstructions 2. Suspected facial or skull fractures 3. Obtunded patient Performance: 1. Delivers up to 100% oxygen accurately by meeting or exceeding the patient s inspiratory demand, which minimizes air dilution. 2. Flushes anatomical dead space with delivery of high flows to upper airway, which creates a reservoir of fresh oxygen available for each breath. 3. Delivers positive airway pressure throughout respiratory cycle, which is similar to the boost effect of PSV to work of breathing during conventional ventilation. 4. Optimizes mucociliary clearance by delivering optimal humidity to the airways, which emulates the process of healthy lungs and prevents the drying effect. Settings: 1. FiO 2 starts at 100% and flow rate at 35 lpm unless ordered otherwise by physician. 2. Flow rate is titrated to decrease work of breathing with a maximum flow rate = 60 lpm. 3. FiO 2 is adjusted to maintain oxygen saturation guidelines per physician order. 4. All checks and changes are recorded on the Oxygen Therapy doc flow sheet in Epic. 5. Settings will be documented at least three (3) times per 8 hour shift. 6. RT must be contacted for setting adjustments. Weaning: 1. FiO 2 is weaned per pulse oximetry while flow rate remains at current lpm.

4 2. Flow rate is weaned in 5 lpm increments after FiO 2 is weaned to 35%. 3. If SpO 2 drops, flow rate will returned to prior setting before FiO 2 is increased. 4. Patient may be placed on standard oxygen device or mask after flow rate = 10 lpm. Outcomes: 1. Improved patient comfort and tolerance 2. Greater therapy success than with face masks 3. Improved lung volumes 4. Improved respiratory rates 5. Improved oxygenation with fewer desaturations 6. Improved secretion clearance

5 BENEFITS OF HIGH FLOW NASAL CANNULA WITH OPTIMAL HUMIDITY Patient Comfortable oxygen delivery, reducing the likelihood of treatment failure Continue to eat, drink, talk and sleep A broad range of flows and oxygen concentrations can be delivered, providing both versatility and continuity of care as patients wean or their condition becomes more acute May displace the need for noninvasive or invasive ventilation through better patient tolerance Improved respiratory efficiency Better secretion clearance, reducing the risk of respiratory infection Clinician Less attendance time assisting uncomfortable patients No need to change between multiple oxygen delivery devices and interfaces Increased confidence in the actual fraction of inspired oxygen (FiO 2 ) being delivered to the patient Easier oral care, maintaining the moisture in the oral mucosa May be used to wean patients off noninvasive or invasive ventilation Less need for mucociliary clearance modalities and antibiotic therapy

6 Sterile Water Supply Large-Bore Nasal Prongs Oxygen Blender with High LPM Flowmeter Heated Wire Circuit Humidification System with Water Chamber Temperature Probes

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