232 quiz Flashcards
how to begin basic airway management
- 5 moments of hand hygiene
- DRSABC
- Check for danger (in all settings)
- Check for response
- If no response , lie patient plat, send for HELP
- Recommend putting the trolley/ bed sides down as well to allow for easy access top the patient
- Look, listen and feel for 10 seconds
what to look listen and feel for in basic airway management
Look for rise and fall of chest, blood, vomit secretions/ loose teeth. If can see something suction to wear you can see down side, not occluding until actually inside
Listen for breathing sounds
Feel for breath on your cheek
If cant see rise and fall after 10, cant feel breath or hear it?
can do head tild or chin lift ( using 2 finders underneath jaw BONE, placing hand firmly on forehead gently tilting) or if suspect c spine fracture can do jaw thrust- placing thumbs over cheek bones finding angle of jaw, placing 2 fingers under angle of jaw gently lifting forward
Can also use gudel, measure from tragus to tip of incisor, inserting upidedown turning it around or use tongue depressor fto feed it through the right way up
If patient begins to cough spit r gag remove gudel immediately
- Signs of an inadequate airway
* What are they?
Chest and abdominal movements. Significantly compromised airway obstruction in a patient who is making respiratory efforts may lead to paradoxical chest and abdominal movements, described as see-saw breathing. The chest is drawn in and the abdomen expands. The opposite occurs in expiration 3 [Level GPP]
• Tracheal tug – (motion due to the chest wall muscles transmitted through the trachea) noted during severe respiratory distress 4 [Level GPP]
• Use of accessory muscles
• Cyanosis
• Inability to swallow own saliva
• Tongue and facial swelling
• Listen for signs of airway obstruction. Partially obstructed airways will cause noisy breathing, for example 3 [Level GPP]:
• Inspiratory stridor – obstruction at laryngeal level or above
• Expiratory wheeze – obstruction of lower airways which collapse and obstruct during expiration
• Gurgling – usually liquid or semisolid material in the upper airway
• Snoring – pharynx is partially occluded by the tongue or palate
• Crowing or stridor – laryngeal spasm or obstruction
• Feel for air escape around nose and mouth AND for movement of the chest and upper abdomen 5 [Level GPP].
• NB: Listen and feel for air escape around the stoma in the laryngectomy patient (there is no airway to the nose or mouth)
• In incomplete airway obstruction some movement of air will be felt from the mouth. Note: For complete obstruction, no escape of air will be felt from nose or mouth and there will be no sound of breathing
- We have the ability to protect our airway
* How?
Cough swallow reflexes, gag reflex
- Semi-conscious patients may not be able to protect their airway. Unconscious patients (people) cannot.
- Therefore we position them as required in …. Position?
Supine however If the patient is supine and vomits: • Roll the patient into the left lateral position maintaining C-spine precautions as necessary and perform suction as described by RPH
• The aims of airway management
- Accurate patient assessment
2. Implementation of interventions aimed at opening and maintaining the airway
accurate patient assessment during airway management
- Vital signs, objective assessment (as indicated by situation)
- Look listen and feel (part of initial BLS response)
- Activate emergency (MET call/code blue) if required
- Apply oxygen if acute situation
- Basic airway management
implementation of what interventions to open airway during airway management
- Implementation of interventions aimed at opening and maintaining the airway
• Including head tilt and chin lift (and possibly jaw thrust)
• Insertion of an oropharyngeal airway (how is this done?)
• Bag-mask ventilation
• Oral and nasal suctioning
• These will all be demonstrated/practiced in the clinical area
All of these are clinical skills that a nurse needs to know how to conduct safely and effectively
Basic life support steps
danger responsiveness send for help open airway normal breathing start cpr attach defib continue cpr until responsiveness or normal breathing return
Airway management is required to provide an open airway when the person:
: • is unconscious • has an obstructed airway • needs rescue breathing
can ventilation be used in airway management
Ventilation In addition to maintaining the airway, ventilatory support may also be essential, due to inadequate spontaneous ventilation. The effective use of self-inflating bag-mask device is the preferred method for ventilatory support. In its absence a pocket mask can be used
in an unconscious person what takes precedence in airway management
In an unconscious person, care of the airway takes precedence over any injury, including the possibility of spinal injury
in airway management should person be rolled onto side? and what happens when regurgitation or vomiting occurs
The person should not be routinely rolled onto the side to assess airway and breathing— leave them in the position in which they have been found.
In resuscitation, regurgitation and vomiting are managed in the same way: by prompt positioning the person on their side and manual clearance of the airway prior to continuing rescue breathing. If the person begins to breathe normally, they can be left on their side with appropriate head tilt. If not breathing normally, the person must be rolled on their back and resuscitation commenced.
T or F
When someone is unconscious, all muscles are relaxed. If the person is left lying on their back, the tongue blocks the back of the throat and obstructs air entry to the lungs
true
- List three manual techniques for establishing a patent airway in an unresponsive adult.
also how are they adjusted forunresponsive infants
Jaw thrust
Head tilt/ chin lift
Suctioning
Using gudel
In an infant, the upper airway is easily obstructed because of the narrow nasal passages, the entrance to the windpipe (vocal cords) and the trachea (windpipe). The trachea is soft and pliable and may be distorted by excessive backward head tilt or jaw thrust. Therefore, in an infant the head should be kept neutral and maximum head tilt should not be used (Figure 2). The lower jaw should be supported at the point of the chin while keeping the mouth open. There must be no pressure on the soft tissues of the neck. If these manoeuvres do not provide a clear airway, the head may be tilted backwards very slightly with a gentle movement.
Also gudel is inserted differently to protect the soft pallet of children
- What is the preferred method of sizing an oropharyngeal airway (‘OPA’, ‘Guedels’
Line up oropharyngeal airway to the side of patient’s face, with opening at level of patient’s incisors and length of airway to correlate with angle of patient’s jaw
- Describe, step by step, the procedure for inserting an OPA.
Open patient’s mouth and ensure that there is no foreign material that may be pushed into the larynx
• Remove any oral debris with Magill forceps (refer to figure 9) or via suction. The use of finger sweeps to clear a patient’s airway is not advocated in the hospital environment
• If present, remove loose fitting dentures 1
• Insert airway into oral cavity with the end of the airway pointing upwards towards the roof of the mouth.Avoid pushing the tongue into the posterior pharynx (which will worsen the airway obstruction) 7 In the presence of a cervical spinal cord injury, jaw thrust is the safest manual approach for establishing and maintaining a patent airway. Excessive head tilt may aggravate a cervical spine column injury, but establishing a patent airway takes priority over concerns about a potential cervical spine injury 1 [Level GPP]. See Acute Spinal Cord Injury CPS. • Once airway adjunct has passed the junction between the hard and soft palates, rotate the airway 180 degrees (figure 10)
• If patient begins to gag/cough/strain, remove airway immediately • Advance the airway down until it lies within the pharynx. The flattened reinforced section should sit between the patients teeth or gums • Once in position, maintain head tilt chin lift/jaw thrust and reassess airway using the look, listen and feel technique Figure 9: Magill forceps 11. Figure 10: Oropharyngeal airway insertion 7 .
• Remove the airway if the patient gags or strains 3 [Level GPP]
• Apply manual ventilation (mouth to mask or bag to mask) or oxygenation as required
• Remove airway as soon as it is clinically appropriate to do so
• If there are problems ventilating the patient after insertion, the OPA should be removed, the clinician should confirm size (often a larger OPA will succeed where a smaller one fails) and reinsert
• There is no evidence to suggest a “safe” time period to leave an oropharyngeal airway insitu. Prolonged use can result in irritation and ulceration to the mucosal tissues. The presence of a continued poor conscious level would warrant further intervention by medical personnel (i.e. intubation)
• Continuously reassess airway using the look, listen and feel technique • Liaise with MO for ongoing management plan
- As well as maintaining a patent airway, an oropharyngeal airway also provides a passage for …
suctioning of a patient’s secretions as well as any vomiting and blood that may be present.
- Stridor is a …
high-pitched wheezing sound that is often caused by a laryngeal spasm
- Describe the ‘universal choking sign’
The universal sign for choking is hands clutched to the throat. If the person doesn’t give the signal, look for these indications: Inability to talk. Difficulty breathing or noisy breathing
- An absence of noisy or laboured breathing is always a good sign when assessing a person for an airway obstruction. True or False?
true? Partial obstruction can be recognised where: • breathing is labored • breathing may be noisy • some escape of air can be felt from the mouth
- Management of choking (likely caused by a foreign object) is best treated with which two techniques
Back blows and chest thrusts
The primary survey identifies …
identifies life threatening illnesses or conditions and follows ABCDE, purpose is to manage them immediately
primary survey letters meaning
Danger, Response, Send for help A – Airway with cervical spine control B – Breathing and ventilation C – Circulation with haemorrhage control D – Disability (eg neurological) E – Exposure with temperature control
when is primary survery done
Primary survey is conducted prior to a Secondary Survey
(Secondary Survey as described in one of the NUR231 OLTs and 3rd Year)
- Do everyday very quickly with all patients
- Do in order of priority
- Is a cycle
- Each component MUST be fixed before moving onto the next
- It is a dynamic process, you are constantly checking and re-checking
- Conducting a Primary Survey is contextual
- Unconscious patient in ED
- Remote area nurse called to road accident
- Collapsed patient on the ward
- Requires sound assessment skills
- Skills develop with experience
- Grab your learning opportunities on Prac.
steps of primary survery breifly described
Danger- even in hospital;, response “hello can you hear me’’
2.A= airway- any vomit, blood, secretions,loose teeth
3.Don PPE, suctioning, Head tilt chin lift, jaw thrust, oropharyngeal airway/ Guedel
- Suction only as far as can see DOWN SIDES, go in without occluding the suction port- only occlude when going out (suctioning)
- 2 fingers under chin and firm palm on forehead while gently tilting forehead backwards (chin tilt)
- place thumbs either side of patients cheeks, find angle of jaw placing 2 fingers underneath there gently pushing that forwards (jaw thrust)
- measure gudel from ear to middle of incisor, can use gudel to open airway 1) upside down then turn or use tongue compressor and place straight in
Is patient gags, looks like they’ll vomit. REMOVE
- B= Breathing- look, listen and feel for breaths
- Bag valve mask delivers o2, put over nose and mouth, provide breaths for patient using it - C=Circulation- radial pulse on patient, feel for more central pulse such as carotid
- D=Disability- use pneumonic AVPU (alert, to voice, to pain or unresponsive), GCS
- E=exposure- little bit at a time. Face, top half of body, legs, genitalia (usually in conjunction with putting a catheter in if necessary), log roll if necessary and look over posterior surfaces
- What does ‘DRS’ stand for? Discuss some situations where Primary Survey could be conducted and where ‘DRS’ may greatly differ
Danger- response- send for help. Out in the community- schools, shopping centre, the home, in a plane etc.
- Stabilisation of what part of the body is an important part of ‘A’? Discuss your initial actions if you were confronted with an unconscious person lying on the roadside with an obstructed airway. (primary survey)
cervical spine. Look for danger, response, airway, etc. following DRSABC then escalating as required
- List and discuss two simple interventions that will ‘open’ the airway in the majority of people.
Jaw thrust and chin lift/ tilt. And oropharyngeal airway (gudel)
how to do chin tilt
2 fingers under chin and firm palm on forehead while gently tilting forehead backwards (chin tilt)
The head-tilt chin-lift is the primary manoeuvre used in any patient when cervical spine injury is NOT a concern 7 [Level GPP]. • Place one hand on patient’s forehead and tilt the head gently back (the head, not the neck is tilted backwards) • The other hand is used to provide the chin lift. Placing the tips of the index and middle finger of the second hand, lift the mandible at the mentum, which lifts the tongue from the posterior pharynx 7 [Level GPP]. Refer to figures 3 and 4a • Alternatively, the chin is held up by the thumb and fingers in order to open the mouth and pull the tongue and soft tissues away form the back of the throat
how to do jaw thrust
place thumbs either side of patients cheeks, find angle of jaw placing 2 fingers underneath there gently pushing that forwards (jaw thrust
The jaw thrust is an alternative manoeuvre, particularly in the patient in whom cervical spine injury is a concern. This manoeuvre moves the tongue anteriorly with the mandible, minimising the tongue’s ability to obstruct the airway. With the patient supine and the clinician standing at the head of the bed 7 [Level GPP]: • Identify the angle of the mandible • Place index and other fingers behind the angle of the mandible and apply upwards and forward pressure to lift the mandible • Using the thumbs, slightly open the mouth by downward displacement of the chin
- List and discuss four common factors that can impair an individual’s breathing and provide strategies for each factor that are designed to overcome the restriction
Vomit- suctioning
Choking on foreign bodies- chest thrust and back blows, chin tilt/ jaw thrust
Relaxation of airway muscles in unconscious person- oropharyngeal airway
Anaphylactic reaction- oropharyngeal airway
- The initial device to support a person’s breathing is called a …B
a bag valve mask
- Further, more invasive, interventions may be required to maintain the individual’s ventilation and may include insertion of ….. airways
oropharyngeal and nasopharyngeal airways
- List and discuss five observations (vital signs count as only one) that may assist you to elicit information regarding the person’s circulatory status
Vital signs, signs and sources of haemorrhage, mental status, peripheral pulses, skin pallour
- The most common method of fluid replacement is via intra venous transfusion. If this method is not possible then ….
- The most common method of fluid replacement is via intra venous transfusion. If this method is not possible then intra osseous fluid transfusion may be conducted
- ‘D’ for disability includes assessing the person’s neurological status and may initially involve using ‘AVPU’ which stands for …
Alert, voice, pain, unresponsive The pupil response should also be assessed (if possible depending on the situation).
E’ for exposure means that the person has all of their clothing removed (an area at a time) so that a full visual assessment can be conducted. An awareness of the person’s …. is important
- ‘E’ for exposure means that the person has all of their clothing removed (an area at a time) so that a full visual assessment can be conducted. An awareness of the person’s temperature is important as full exposure of the body may quickly result in hypothermia.
how is the primary survey a dynamic process
- Importantly, Primary Survey is what is called a dynamic process You are constantly checking and re-checking, and adapting to each person’s individual situation
what are the 6 rights
6 rights- drug, dose, individual, time, route and documentation
prior to ral medication administration…
identify indication
verify validity of order
wash hands
Check patient’s identification (this may be patient sticker)- check for recorded allergies!
Check drug name, dose, route, time, frequency, indications and prescribers’ signature
Depending on the facility you are working at you may be required to scan or use key access to enter the medication storage room
You will then need to locate the area where the medication you require is stored
Assess the need for physiological observations or drug specific monitoring prior to medication administration. Consider the following:
• Last dose and time medication administered (ensure documented)
• Blood monitoring e.g. International Normalisation Ratio (INR), gentamycin level
• Liaise with Shift Coordinator/MO/NP/Pharmacist as appropriate
• Blood pressure e.g. prior to administering ace inhibitors, beta blockers
• Heart rate e.g. when on beta blockers, or digoxin therapy
• Administering medications pre or post food or fasting states
• Effects on planned procedures e.g. no anti-hypertensives to be administered prior to haemodialysis Retrieve medications from a locked cupboard/drawer and key to be retained by nursing staff.
• Right patient - i.e. check name/unit number/Date of Birth (DOB) on the patient’s identification (ID) band against Medication Chart AND ask patient to state their name and DOB (if able). If no ID band in situ, apply one immediately if applicable.
• There are some situations where a patient may not be able to wear a patient identification band, including: mental health patients, patients who refuse to wear the patient identification band, patients who cannot wear a patient identification band because of their clinical condition or treatment 6 [Level GPP]. In these circumstances, identification confirmation to be sought in the order listed (1) photo identification, (2) verbal identification (incorporating the 3 point identification checks) or (3) visual identification confirmed by 2 clinical staff
• For outpatients (no identification band in situ) the patient’s name, address and date of birth must be verbally confirmed by the patient/carer against the health care record identification label 6 [Level GPP] • If the patient requires any infusions or complex therapies an ID band must be in situ
• Right medication/drug (including expiry date) • Right dose • Right route • Right time • Right documentation •
Check for any allergies/adverse reaction/s
Explain procedure to the patient. Provide specific medications education 1 [Level GPP] • Administer prescribed medication
when looking at oral medication take note of…
Pay attention to drugs with similar names and varying doses
Always check the foil strip inside the box is the correct drug and dose
Check the expiry date on the package
after checking details of oral medications what do you do with them?
Dispense required number of tablets into a medicine cup using non touch technique
Check patient sticker on medication chart against patient identity band and/ or confirm with the patient verbally
Remember to position the patient appropriately for taking medications and assess effectiveness of medication. Use …. Assessment tool (vital signs, pain assessment tool..?)
after administering oral medication what to do?
Finally, will need to sign for the medication, completing date and ensuring to sign for the correct time
Many drugs have specific administration requirements. E.g. Ibuprofen should never e administered on an empty stomach ( always with milk or food). Mims has this information
Sign Medication Chart and lock medication drawer (as appropriate
Oral/Enteral Medication Administration Include
tablets, capsules, lozenges/pastilles, elixirs, linctus/syrups and mixtures.
if patient is not able to tolerate or take oral preparations ?
Liaise with MO if patient is not able to tolerate or take oral preparations and seek alternative prescription
• If patient is unable to swallow tablet (refer to Dysphagia SDLP as patient may be at risk of aspiration):
• Consider use of liquid formula or alternative route
• It is recommended that crushed medications are administered individually to avoid potential drug interactions/compatibility
• Liaise with pharmacist if any concerns
dont crush which tablets
Cytotoxic medications as causes chemotherapy exposure (e.g. methotrexate)
• Modified release (enteric coated or slow release) tablets or capsules as this can alter the rate of release of drug 1 [Level GPP] Enteric coatings allow the medication to remain intact in the stomach and to pass unchanged into the small bowel where the coating dissolves and the drug is released and absorbed 1 [Level GPP]. Slow/sustained release- release the active ingredient over a period of time to extend the duration of effect
what to do with left over tablets/ tablet halves?
• If prescribed dose requires tablet to be halved or quartered, discard any remaining portion into the clinical waste/sharps container ensuring that the medication is not identifiable. Any remaining tablet fragments are not to be kept and/or administered
what syringes to use for enteral liquids
• Enteral syringes MUST be used if administering enteral liquid medications, (refer to figure 5) as the reverse Luer lock connection is NOT compatible with IV tubing Critical incidents have occurred when oral liquid medicines have been administered via both the IV and subcutaneous (subcut) routes
what to do before imi injection
hand hygiene
what is an imi injection, and where are the sites
Intramuscular injections (IMI) deposits medication deep into the muscle layer, where the vascularity of the muscle aids the rapid systemic action and the absorption of relatively large doses of up to 5mL in appropriate sites Sites: deltoid (upper arm), dorsoglutea 9buttocks)l, rectur femoris, vastus lateralis (thigh muscles) and ventrogluteal muscles (side of hip)
IMI injection steps
- All meds should be drawn up in a blue tray, or as per the policy of the hospital
Syringe size should be chosen to match the injection volume as close as possible
-Drawing up (blunt) needles should be used in all cases where the syringe is not pre filled
-Safety needles should always be used (come with caps that flick over the sharp end of the needle after insertion and prior to disposal - 6 rights- time, drug, dose, route, patient, documentation
- Check local policy for cleansing solution to be used
- Ensure needle is 90 degrees to the skin. Hold firmly down with one hand
- Holding firmly in place with 1 hand, check local policy for drawing back on needle- recent evidence suggests not necessary
- Ensure no blood in the syringe, this should be one smooth movement
- Please note that manufacturers advice is to çlick’ the safety device over the used needle on a hard surface- not with your fingers. It is safer to keep your fingers away from the used needle at all times
IMI injection contraindications
IMI injections may be contraindicated in patients who/ have:
• Are immunocompromised • Moderate /severe acute illness • Impaired coagulation mechanisms • Peripheral vascular disease, oedema, shock as these conditions impair peripheral absorption
potential complications of imi injection
Potential Complications
• Fibrosis and contracture of the muscles • Nerve injuries/palsy • Arterial puncture/haematoma formation • Local irritation/infection/abscess • Neuropathy • Abscess
desxcribe ventrogluteal imi injection
Thick muscle, relatively free of major nerves and blood vessels capable of absorbing large volume 2,3 [Level GPP]. Commonly used for antibiotics, antiemetic’s, deep IM and z-track injections in oil, opioids & sedatives 2 [Level GPP]
• Ventroguluteal site is the safest site for an IMI injection and should be used for patients with no muscle wasting in this area 2 [Level GPP]
• Locate ventrogluteal site by placing palm of hand against the greater trochanter of the femur and the index finger on the anterior superior iliac spine of the pelvis (right hand to left hip, left hand to right hip) 3 [Level GPP]
• Extend the middle finger posteriorly along the iliac crest 3 [Level GPP]
• Inject between the ‘V’ of two fingers 3 [Level GPP].
• Up to 2.5 mL can be injected
describe deltoid imi injection
The most accessible site but small area limits the number and volume of injections that can be administered 3 [Level GPP].
• Locate the deltoid muscle - palpate the lower edge of the acromion process which forms the base of the triangle in line with the midpoint of the lateral aspect of the upper arm
• The injection site is in the centre of the triangle, about 2.5–5cm below the acromion process
• Recommended maximum volume of fluid injected into the deltoid is 2 mL5 [Level GPP].Exception: In InvegaTrinza (injection of Paliperidone that lasts for 3 months).The deltoid is the recommended injection site ,despite the highest dose being 2.6ml
describe dorsogluteal imi injection
Use of the dorsogluteal site for IMI injection is not advised, it is accompanied by complications including damage to sciatic nerve and superior gluteal arteries.
Muscle mass may have atrophied in older or non-ambulant patients. This muscle has the lowest drug absorption rate and this can result in a build-up in the tissues, increasing the risk of overdose 3 [Level GPP]. It appears that there is a risk that the medication will not reach the muscle due to the amount of subcutaneous tissue in this area
• Locate the dorsogluteal muscle in the upper, outer quadrant of buttock approximately 5–8cm below the iliac crest
• Palpate the posterosuperior iliac spine/crest and the greater trochanter of the femur. An imaginary line is drawn between the two anatomical landmarks
• The injection site is above and lateral to the line
• Up to 3mL can be injected at this site
describe Vastus Lateralis and Rectus Femoris IMI injection
The rectus femoris - anterior quadriceps muscle is used primarily for antiemetics, opioids, sedatives, injections in oil, deep intramuscular and Z-track injections.
This site is rarely used by nurses but is easily accessible for self-administration of injections
The vastus lateralis - no major blood vessels or significant nerve structures are associated with the site.
Used for deep IMI and Z-track injections GPP].Up to 5mL can be injected
• The vastus lateralis is located on the anterior lateral aspect of the thigh and extends from a handbreadth above the knee to a handbreadth below the greater trochanter of the femur
• The middle third of the muscle is the best site for injection
describe z tract method for imi injections
This technique should be used for all intramuscular injections:
• Pull skin at the injection site taught and to one side (~1–2cm) with the thumb or side of the non-dominant hand and maintain this firm traction of the skin throughout the procedure
• Insert needle with dominant hand into muscle at 90° angle leaving 0.5 cm of shaft exposed. This method prevents back-tracking of medications into tissue, decreases pain and injection site lesions which is essential when administering cytotoxic, iron or oil IMI
• Draw back on plunger to ensure that needle is not in a blood vessel
• If blood returns with draw needle, discard the needle and syringe. Recommence the administration process using a different site 3 [Level GPP]
• If no blood is aspirated, slowly administer medication 1 [Level GPP] to allow the muscle fibres to expand to accommodate the drug
• Wait a further 10 seconds before removing the needle and once it has been removed, only then release the traction (Z Tracking) on the skin 4 [Level GPP].
• DO NOT massage the site 1 [Level GPP]. Sign Medication Chart
How to locate the ventrogluteal site for an IM injection
- Find the trochanter. This is the knobby top portion at the top of the femur
- Find the anterior iliac crest. This is the thick rounded upper part of the ileum
- Position your right hand to the patients left side if using the ventrogluteal site. Place palm of hand over the trochanter, pointing index finger towards anterior iliac crest
- Spread the second finger toward the back of the iliac crest, making a V with your fingers
- The njection site is in the middle of this V, level with the knuckles of your fingles. The thumb should always be positioned towards the front of the patients body.
what is a subcutaneous injection
Subcutaneous (subcut) injections pierce the epidermal and dermal layers of the skin, and medication absorption is relatively slow because of the poor blood supply to the subcut tissue 5 [Level GPP]. Only small volumes of medication up to 2mL to be administer
steps of subcut injection
- gently squeeze the subcutaneous tissue, then inject at 45 degrees (can also be given at 90)
- dispose in sharps bin
Prepare medication according to Preparation of Ampoules and Vials section. Follow Pre-Administration Checking Procedure.
• Select appropriate site for injection and position the patient appropriately
• If the area is not visibly dirty use of chlorhex swab is not required 4 [Level IV]
• If visibly contaminated, clean as appropriate then swab site with chlorhex swab and allow to air dry
• Using 2 finger technique pinch up a skin fold to elevate subcutaneous tissue, and lifts the adipose tissue away from the underlying muscle 5,7 [Level GPP]. Refer to figure 10. NB: For insulin injections using patient pens with Autoshield® safety needle, DO NOT use pinch up technique, brace skin prior to inserting needle unless risk of IMI where 45 degree angle injection may be required. Refer to Blood Glucose Level Management NPS
• Insert needle at a 90° angle 5,7 [Level GPP]
• The needle may be inserted at 45° angle (the skin does not need to be pinched) if the patient is lean or to adjust for needle length (avoids inadvertent IMI administration) 7 [Level IV]
• Depress plunger slowly
• When all medication is injected withdraw the needle
• Release skin fold
• Place needle and syringe in receptacle for safe transportation to disposal Utilise safety needles/syringe if available. An engineered sharps injury prevention device is recommended 5,8 [Level GPP]. If no safety device available, do NOT re-cap used needle to avoid contaminated needle stick injury 5 [Level GPP]. Apply pressure using the gauze for 10-20 seconds till bleeding stops or ask the patient to apply pressure if able to prevent haematoma formation. NB: Do not apply pressure after administration of low molecular weight heparin as this can result in increased bruising
potential complications for subcutaneous injection
Potential complications can include: • Bruising • Inflammation • Tenderness • Swelling • Scarring • Abscess formation Report any adverse events to the MO and document in the patient integrated notes
subcutaneous injection site selection
Subcut injections may be given in the following sites (refer to figure 9):
• Abdomen • The most commonly used site as it has thicker subcut tissue • Avoid the umbilicus by a 5cm radius as well as any scars 5 [Level GPP] • Anterior aspects of thighs • Outer aspect of upper arms • Upper aspect buttock • Upper back
Where multiple injections required, other routes to be considered (e.g. oral, IV, nasogastric tube). Correct site selection is important to ensure absorption and comfort Ensure site is not bruised, tender, hard, swollen, oedematous, inflamed or scarred which could hinder absorption and cause discomfort
angles of needle injectiona
IM-90
SUCUT-45
IV-25
INTRADERMAL-10-15
How to draw up medication fromglass ampule
Use non touch technique to add the drawing up (blunt) needle to the syringe
If there is medication in the lid there are a couple of techniques you can use to move the medication down- tap bottle or slide on table
There is usually a dot (or a number of dots) that indicate the weak part of the ampule. This is where you break the lid open.
Carefully remove the blunt needle from the syringe at the base
Discard the blunt needle in the sharps container
Using non touch technique put a red cap on to the syringe so that it is safe and remains sterile
Fill out identification sticker, these come in different colours depending on the route of administration. Other colours- blue,….?
how to draw up meds from a plastic ampule
Using non touch technique twist the drawing up blunt needle onto the syringe
Gently twist the head off, making sure you do not squeeze the ampoule
Draw up medicine
Remove blunt needle from the syringe and discard in a sharps bin
Apply red cap
how to draw up antibiotics
Find info on what to mix antibiotics up in to on….?
Always wear gloves to draw up antibiotics- to protect skin from absorbing if spills?
Use a drawing up needle blunt to draw up from plastic saline or water for injections ampoule
Some facilities have specific short needles for drawing up from ampules. Others use needles. Use local policy to identify what you should be doing.
Don’t twist your needle on too tightly
Push a small amount of mixing fluid in to the ampoule. Then allow air to come back in to your syringe.
What is MSE
The Mental State Examination (MSE) is a process of obtaining information about specific aspects of individual’s mental experiences and behaviour at the time of the interview. Mental State Examination is only one of a range of data gathering activities that are required to assess an individual.
All clinicians should have a basic knowledge of mental state examination and be able to describe psychiatric phenomena. to be able to carry out their own assessment to determine the severity and nature of the individual’s problems and the risk to self and others.
MSE is a process of obtaining information about specific aspects of individual’s mental presentation & behaviour at the time of the interview
MSE is one method of gathering data required to assess an individual which is commonly used in Western Australia
Therefore all clinicians working in local mental health settings should be able to conduct a mental state examination using a standardised format
MSE is one of a range of measures
Determine medical/ psychiatric emergency
MSE can be completed in the course of taking the history
In emergency situations – MSE may sometimes be brief
MSE is observational & active listening
MSE is a routine part of any interaction with clients
MSE can help or hinder the establishment of rapport
Therefore MSE must be documented in a professional, sensitive & objective manner
Why do MSE
Identify signs & symptoms of mental illness
Monitor change or improvement in mental state
Recognise symptomatology which might assist diagnosis
Might inform treatment and interventions
Provides us with a record of a persons mental state at that particular moment.
When is MSE conducted
During admission
In the course of taking history
If there is any change in clinical presentation
Informally on one to one interaction
Note: It’s important to recognise that although a formal MSE is conducted and recorded at specific intervals during a presentation, that informal MSE is a specific nursing skill which is used constantly when monitoring for even the slightest change in mental state.
What is included in history taking fr MSE
Individual details Identifying the presenting problems History of presenting illness Personal history Previous medical/surgical history Family history Premorbid personality Illicit drug use/ alcohol abuse history Mental State Examination
MSE dos and donts
Please listen actively
Try to use open-ended question e.g Could you tell me about your relationship with your family?
Allow patients to express their concerns and emotions
Try not to interrupt patients or disagree with them about their experience.
Avoid asking “why” questions, as these can feel a little judgemental.
