M



M



3840


Malignant Hyperthermia Precautions


Definition: Prevention or reduction of hypermetabolic response to pharmacological agents used during surgery


Activities:



• Ask patient about personal or family history of malignant hyperthermia, unexpected deaths from anesthetic, muscle disorder, or unexplained postoperative fever


• Refer patient with family history of malignant hyperthermia for further testing to determine risk (e.g., muscle contracture test, molecular genetic test)


• Notify surgical team of patient history or risk status


• Maintain emergency equipment for malignant hyperthermia, per protocol


• Review malignant hyperthermia emergency care with staff, per protocol


• Monitor vital signs, including core body temperature


• Provide anesthesia machine free of precipitating anesthetic agents for patient at risk for malignant hyperthermia or discontinue use of anesthesia machine for patient experiencing malignant hyperthermia


• Place cooling water mattress under patient at risk for malignant hyperthermia at start of procedure


• Use nontriggering anesthetic agents for patient at risk for or experiencing malignant hyperthermia (e.g., opioids, benzodiazepines, local anesthetics, nitrous oxide, and barbiturates)


• Avoid or discontinue use of triggering agents (e.g., succinylcholine used alone or in conjunction with volatile inhalation agents, such as halothane, enflurane, isoflurane, sevoflurane, or desflurane)


• Monitor for signs of malignant hyperthermia (e.g., hypercarbia, hyperthermia, tachycardia, tachypnea, metabolic acidosis, arrhythmias, cyanosis, mottled skin, muscle rigidity, profuse sweating, and unstable blood pressure)


• Discontinue procedure, if possible


• Provide emergency management supplies


• Obtain blood and urine samples


• Monitor for abnormalities in laboratory values (e.g., increased end-tidal carbon dioxide level with decreased oxygen saturation, increased serum calcium, increased potassium, unexplained metabolic acidosis, hematuria, and myoglobinuria)


• Monitor electrocardiography results


• Intubate or assist with intubation if endotracheal tube is not already in place


• Hyperventilate with 100% oxygen using highest flow rate possible


• Prepare and administer medications (e.g., dantrolene sodium, sodium bicarbonate, insulin, antidysrhythmic agents other than calcium channel blockers, and osmotic or loop diuretics)


• Administer iced saline


• Apply cooling blanket or commercial cooling device over torso


• Rub or wrap extremities with cold, wet, or iced towels


• Lavage stomach, bladder, rectum, and open body cavities with sterile, iced, normal saline


• Insert nasogastric tube, rectal tube, and urinary catheter, as necessary


• Monitor urine output


• Administer sufficient IV fluids to maintain urine output


• Initiate second IV line


• Assist with arterial and central venous pressure line insertion


• Avoid use of drugs, including calcium chloride or gluconate, cardiac glycosides, adrenergics, atropine, and lactated Ringer solutions


• Decrease environmental stimuli


• Observe for signs of late complications (e.g., consumption coagulopathy, renal failure, hypothermia, pulmonary edema, hyperkalemia, neurological sequelae, muscle necrosis, and reoccurrence of symptoms after treatment of initial episode)


• Provide patient and family education (i.e., discuss needed precautions for future anesthetic administration, discuss methods for determining malignant hyperthermia risk)


• Refer patient and family to Malignant Hyperthermia Association of the United States


• Refer for genetic counseling


• Report incident to the North American Malignant Hyperthermia Registry and the Medic Alert Hotline


2nd edition 1996; revised 2013



1480


Massage


Definition: Stimulation of the skin and underlying tissues with varying degrees of hand pressure to decrease pain, produce relaxation, and/or improve circulation


Activities:



• Screen for contraindications such as decreased platelets, decreased skin integrity, deep vein thrombosis, areas with open lesions, redness or inflammation, tumors, and hypersensitivity to touch


• Assess the client’s willingness to have a massage


• Establish a period of time for massage that achieves the desired response


• Select the area or areas of the body to be massaged


• Wash hands with warm water


• Prepare a warm, comfortable, private environment, without distractions


• Place in a comfortable position that facilitates massage


• Drape to expose only area to be massaged, as needed


• Drape unexposed areas with blankets, sheets, or bath towels as needed


• Use lotion, oil, or dry powder to reduce friction (no lotion or oils on head or scalp), assessing for any sensitivity or contraindications


• Warm lotion or oil in palm of hands or by running bottle under warm water for several minutes


• Massage using continuous, even, long strokes; kneading; or vibration with palms, fingers, and thumbs


• Adapt massage area, technique, and pressure to patient’s perception of comfort and purpose of massage


• Massage the hands or feet if other areas are inconvenient or if more comfortable for the patient


• Encourage patient to deep breathe and relax during massage


• Encourage patient to advise of any part of the massage that is uncomfortable


• Instruct patient at completion of massage to rest until ready and then to move slowly


• Use massage alone or in conjunction with other measures, as appropriate


• Evaluate and document response to massage


1st edition 1992; revised 2008




3300


Mechanical Ventilation Management: Invasive


Definition: Assisting the patient receiving artificial breathing support through a device inserted into the trachea


Activities:



• Monitor for conditions indicating a need for ventilation support (e.g., respiratory muscle fatigue, neurological dysfunction secondary to trauma, anesthesia, drug overdose, refractory respiratory acidosis)


• Monitor for impending respiratory failure


• Consult with other health care personnel in selection of a ventilator mode (initial mode usually volume control with breath rate, FiO2 level and targeted tidal volume specified)


• Obtain baseline total body assessment of patient initially and with each change of caregiver


• Initiate setup and application of the ventilator


• Ensure that ventilator alarms are on


• Instruct the patient and family about the rationale and expected sensations associated with use of mechanical ventilators


• Routinely monitor ventilator settings, including temperature and humidification of inspired air


• Check all ventilator connections regularly


• Monitor for decrease in exhaled volume and increase in inspiratory pressure


• Administer muscle paralyzing agents, sedatives, and narcotic analgesics, as appropriate


• Monitor for activities that increase oxygen consumption (e.g., fever, shivering, seizures, pain, or basic nursing activities) that may supersede ventilator support settings and cause oxygen desaturation


• Monitor for factors that increase patient/ventilator work of breathing (e.g., morbid obesity, pregnancy, massive ascites, lowered head of bed, biting of ET, condensation in ventilator tubes, clogged filters)


• Monitor for symptoms that indicate increased work of breathing (e.g., increased heart or respiratory rate, increased blood pressure, diaphoresis, changes in mental status)


• Monitor the effectiveness of mechanical ventilation on patient’s physiological and psychological status


• Initiate relaxation techniques, as appropriate


• Provide care to alleviate patient distress (e.g., positioning, tracheobronchial toileting, bronchodilator therapy, sedation and/or analgesia, frequent equipment checks)


• Provide patient with a means for communication (e.g., paper and pencil, alphabet board)


• Empty condensed water from water traps


• Ensure change of ventilator circuits every 24 hours


• Use aseptic technique in all suctioning procedures, as appropriate


• Monitor ventilator pressure readings, patient/ventilator synchronicity, and patient breath sounds


• Perform suctioning based on presence of adventitious breath sounds and/or increased inspiratory pressure


• Monitor pulmonary secretions for amount, color, and consistency and regularly document findings


• Stop NG feedings during suctioning and 30 to 60 minutes before chest physiotherapy


• Silence ventilator alarms during suctioning to decrease frequency of false alarms


• Monitor patient’s progress on current ventilator settings and make appropriate changes as ordered


• Monitor for adverse effects of mechanical ventilation (e.g., tracheal deviation, infection, barotrauma, volutrauma, reduced cardiac output, gastric distension, subcutaneous emphysema)


• Monitor for mucosal damage to oral, nasal, tracheal, or laryngeal tissue from pressure from artificial airways, high cuff pressures, or unplanned extubations


• Use commercial tube holders rather than tape or strings to fixate artificial airways to prevent unplanned extubations


• Position to facilitate ventilation/perfusion matching (“good lung down”), as appropriate


• Collaborate with physician to use pressure support or PEEP to minimize alveolar hypoventilation, as appropriate


• Collaborate routinely with physician and respiratory therapist to coordinate care and assist patient to tolerate therapy


• Perform chest physiotherapy, as appropriate


• Promote adequate fluid and nutritional intake


• Promote routine assessments for weaning criteria (e.g., hemodynamic, cerebral, metabolic stability, resolution of condition prompting intubation, ability to maintain patent airway, ability to initiate respiratory effort)


• Provide routine oral care with soft moist swabs, antiseptic agent, and gentle suctioning


• Monitor effects of ventilator changes on oxygenation: ABG, SaO2, SvO2, end-tidal CO2, Qsp/Qt, A-aDO2, patient’s subjective response


• Monitor degree of shunt, vital capacity, Vd/Vt, MVV, inspiratory force, and FEV1 for readiness to wean from mechanical ventilation, based on agency protocol


• Document all changes to ventilator settings, with rationale for changes


• Document all patient responses to ventilator and ventilator changes (e.g., chest movement observation/auscultation, changes in x-ray, changes in ABGs)


• Monitor for postextubation complications (e.g., stridor, glottic swelling, laryngospasm, tracheal stenosis)


• Ensure emergency equipment at bedside at all times (e.g., manual resuscitation bag connected to oxygen, masks, suction equipment/supplies), including preparations for power failures


1st edition 1992; revised 2000, 2008




3302


Mechanical Ventilation Management: Noninvasive


Definition: Assisting a patient receiving artificial breathing support that does not necessitate a device inserted into the trachea


Activities:



• Monitor for conditions indicating appropriateness of noninvasive ventilation support (e.g., acute exacerbations of COPD, asthma, noncardiogenic and cardiogenic pulmonary edema, acute respiratory failure due to community acquired pneumonia, obesity hypoventilation syndrome, obstructive sleep apnea)


• Monitor for contraindications to noninvasive ventilation support (e.g., hemodynamic instability, cardiovascular or respiratory arrest, unstable angina, acute myocardial infarction, refractory hypoxemia, severe respiratory acidosis, decreased level of consciousness, problems with securing/placing noninvasive equipment, facial trauma, inability to cooperate, morbidly obese, thick secretions, or bleeding)


• Consult with other health care personnel in selection of a noninvasive ventilator type (e.g., pressure limited [bilevel positive airway pressure], volume-cycled flow-limited, or CPAP)


• Consult with other health care personnel and patient in selection of noninvasive device (e.g., nasal or face mask, nasal plugs, nasal pillow, helmet, oral mouthpiece)


• Obtain baseline total body assessment of patient initially and with each change of caregiver


• Instruct the patient and family about the rationale and expected sensations associated with use of noninvasive mechanical ventilators and devices


• Place patient in semi-Fowler position


• Apply noninvasive device assuring adequate fit and avoidance of large air leaks (take particular care with edentulous or bearded patients)


• Apply facial protection as needed to avoid pressure damage to skin


• Initiate setup and application of the ventilator


• Observe patient continuously in first hour after application to assess tolerance


• Ensure that ventilator alarms are on


• Routinely monitor ventilator settings, including temperature and humidification of inspired air


• Check all ventilator connections regularly


• Monitor for decrease in exhaled volume and increase in inspiratory pressure


• Monitor for activities that increase oxygen consumption (e.g., fever, shivering, seizures, pain, or basic nursing activities) that may supersede ventilator support settings and cause oxygen desaturation


• Monitor for symptoms that indicate increased work of breathing (e.g., increased heart or respiratory rate, increased blood pressure, diaphoresis, changes in mental status)


• Monitor the effectiveness of mechanical ventilation on patient’s physiological and psychological status


• Initiate relaxation techniques, as appropriate


• Ensure periods of rest daily (e.g., 15 to 30 minutes every 4 to 6 hours)


• Provide care to alleviate patient distress (e.g., positioning; treat side effects such as rhinitis, dry throat, or epistaxis; give sedation and/or analgesia; frequent equipment checks; cleansing or change of noninvasive device)


• Provide patient with a means for communication (e.g., paper and pencil, alphabet board)


• Empty condensed water from water traps


• Ensure change of ventilator circuits every 24 hours


• Use aseptic technique, as appropriate


• Monitor patient and ventilator synchronicity and patient breath sounds


• Monitor patient’s progress on current ventilator settings and make appropriate changes as ordered


• Monitor for adverse effects (e.g., eye irritation, skin breakdown, occluded airway from jaw displacement with mask, dyspnea, anxiety, claustrophobia, gastric distension)


• Monitor for mucosal damage to oral, nasal, tracheal, or laryngeal tissue


• Monitor pulmonary secretions for amount, color, and consistency, and regularly document findings


• Collaborate routinely with physician and respiratory therapist to coordinate care and assist patient to tolerate therapy


• Perform chest physiotherapy, as appropriate


• Promote adequate fluid and nutritional intake


• Promote routine assessments for weaning criteria (e.g., resolution of condition prompting ventilation, ability to maintain adequate respiratory effort)


• Provide routine oral care with soft moist swabs, antiseptic agent, and gentle suctioning


• Document all changes to ventilator settings, with rationale for changes


• Document all patient responses to ventilator and ventilator changes (e.g., chest movement observation/auscultation, changes in x-ray, changes in ABGs)


• Ensure emergency equipment at bedside at all times (e.g., manual resuscitation bag connected to oxygen, masks, suction equipment/supplies), including preparations for power failures


5th edition 2008




3304


Mechanical Ventilation Management: Pneumonia Prevention


Definition: Care of a patient at risk for developing ventilator-associated pneumonia


Activities:



• Wash hands before and after patient care activity, particularly after emptying fluids from ventilator circuitry


• Wear gloves and protective equipment and clothing for oral care and change gloves to prevent cross-contamination during oral care


• Monitor oral cavity, lips, tongue, buccal mucosa, and condition of teeth


• Monitor oral cavity for dental plaque, inflammation, bleeding, candidiasis, purulent matter, calculus, and staining


• Brush teeth and tongue with toothpaste or an antiseptic oral rinse using circular motion with a soft toothbrush or suction toothbrush


• Rinse toothbrush after each use and change at regular intervals


• Brush gingiva gently if patient is edentulous


• Assist with the application of a debriding agent or mouth wash to gingiva, teeth, and tongue with swab, according to agency protocol


• Use water rinses instead of a debriding agent with patients who have mucositis or altered oral mucosa


• Assist with swabbing perpendicular to gum line while applying gentle pressure to help facilitate the removal of debris and mucus


• Consider providone-iodine oral antiseptic in patients with severe head injury


• Consult dentistry, if needed


• Apply oral moisturizer to oral mucosa and lips, as needed


• Facilitate use of yankauer or soft suction for oral care, as needed


• Facilitate subglottic suctioning prior to repositioning patient supine (bed, chair, road trip), repositioning endotracheal tube (ET), and deflating the ET cuff


• Suction the trachea, then oral cavity, and then nasal pharynx to remove secretions above the ET cuff to decrease the risk of aspiration


• Rinse yankauer and inline deep suction lines after each use and change every day


• Consider use of continuous subglottic suctioning and drainage with specifically designed ET in patients who have mechanical ventilation longer than 72 hours


• Keep head of bed elevated to 30-45 degrees unless contraindicated (i.e., hemodynamic instability), particularly during enteral tube feedings


• Turn patient frequently (at least every 2 hours)


• Facilitate daily interruptions of sedation, in consultation with the physician team


• Consider using a cuffed ET with in-line or subglottic suctioning


• Maintain an endotracheal cuff pressure of at least 20 cm


• Monitor the depth of the ET


• Consider use of oral intubation over nasal intubation


• Keep ET tapes clean and dry


• Monitor the effectiveness of mechanical ventilation on patient’s physiological and psychosocial status


• Check all ventilator connections regularly


• Monitor daily for evidence of readiness for extubation


• Monitor patient for signs and symptoms of respiratory infection (e.g., restlessness, coughing, fever, increased heart rate, change in secretions, leukocytosis, infiltrates in chest x-ray)


• Monitor and document oxygen saturation


• Avoid histamine receptor blocking agents and proton pump inhibitors unless patient is at high risk for developing a stress ulcer


• Instruct patient and family about oral care routine


6th edition 2013




3310


Mechanical Ventilatory Weaning


Definition: Assisting the patient to breathe without the aid of a mechanical ventilator


Activities:



• Determine patient readiness for weaning (e.g., hemodynamically stable, condition requiring ventilation resolved, current condition optimal for weaning)


• Monitor predictors of ability to tolerate weaning based on agency protocol (e.g., degree of shunt, vital capacity, Vd/Vt, MVV, inspiratory force, FEV1, negative inspiratory pressure)


• Monitor to assure patient is free of significant infection prior to weaning


• Monitor for optimal fluid and electrolyte status


• Collaborate with other health team members to optimize patient’s nutritional status, assuring that 50% of the diet’s nonprotein caloric source is fat rather than carbohydrate


• Position patient for best use of ventilatory muscles and to optimize diaphragmatic descent


• Suction the airway, as needed


• Administer chest physiotherapy, as appropriate


• Consult with other health care personnel in selecting a method for weaning


• Initiate weaning with trial periods (e.g., 30 to 120 minutes of ventilator-assisted spontaneous breathing)


• Alternate periods of weaning trials with sufficient periods of rest and sleep


• Avoid delaying return of patient with fatigued respiratory muscles to mechanical ventilation


• Set a schedule to coordinate other patient care activities with weaning trials


• Promote the best use of the patient’s energy by initiating weaning trials after the patient is well rested


• Monitor for signs of respiratory muscle fatigue (e.g., abrupt rise in PaCO2, rapid, shallow ventilation, paradoxical abdominal wall motion), hypoxemia, and tissue hypoxia while weaning is in process


• Administer medications that promote airway patency and gas exchange


• Set discrete, attainable goals with the patient for weaning


• Use relaxation techniques, as appropriate


• Coach the patient during difficult weaning trials


• Assist the patient to distinguish spontaneous breaths from mechanically delivered breaths


• Minimize excessive work of breathing that is nontherapeutic by eliminating extra dead space, adding pressure support, administering bronchodilators, and maintaining airway patency, as appropriate


• Avoid pharmacological sedation during weaning trials, as appropriate


• Provide some means of patient control during weaning


• Stay with the patient and provide support during initial weaning attempts


• Instruct patient about ventilator setting changes that increase the work of breathing, as appropriate


• Provide the patient with positive reinforcement and frequent progress reports


• Consider using alternate methods of weaning as determined by patient’s response to the current method


• Instruct the patient and family about what to expect during various stages of weaning


• Prepare discharge arrangements through multidisciplinary involvement with patient and family


1st edition 1992; revised 1996, 2008




2300


Medication Administration


Definition: Preparing, giving, and evaluating the effectiveness of prescription and nonprescription drugs


Activities:



• Maintain agency policies and procedures for accurate and safe administration of medications


• Maintain an environment that maximizes safe and efficient administration of medications


• Avoid interruptions when preparing, verifying, or administering medications


• Follow the five rights of medication administration


• Verify the prescription or medication order before administering the drug


• Prescribe or recommend medications, as appropriate, according to prescriptive authority


• Monitor for possible medication allergies, interactions, and contraindications, including over-the-counter medications and herbal remedies


• Note patient’s allergies before delivery of each medication and hold medications, as appropriate


• Notify the patient of medication type, reason for administration, expected actions, and adverse effects prior to administering, as appropriate


• Ensure that hypnotics, narcotics, and antibiotics are either discontinued or reordered on their renewal date


• Note expiration date on medication container


• Prepare medications using appropriate equipment and techniques for the drug administration modality


• Verify changes in medication form prior to administering (e.g., crushed enteric tablets, oral liquids in intravenous syringe, unusual packaging)


• Use bar code assisted medication administration when possible


• Avoid administration of medications not properly labeled


• Dispose of unused or expired drugs, according to agency guidelines


• Monitor vital signs and laboratory values before medication administration, as appropriate


• Assist patient in taking medication


• Give medication using appropriate technique and route


• Use orders, agency policies, and procedures to guide appropriate method of medication administration


• Instruct patient and family about expected actions and adverse effects of the medication


• Validate and document patient and family understanding of expected actions and adverse effects of the medication


• Monitor patient to determine need for PRN medications, as appropriate


• Monitor patient for the therapeutic effect of all medications


• Monitor patient for adverse effects, toxicity, and interactions of the administered medications


• Sign out narcotics and other restricted drugs, according to agency protocol


• Document medication administration and patient responsiveness (i.e., include medication generic name, dose, time, route, reason for administration, and effect achieved), according to agency protocol


1st edition 1992; revised 2013



2308


Medication Administration: Ear


Definition: Preparing and instilling otic medications


Activities:



3rd edition 2000; revised 2004




2301


Medication Administration: Enteral


Definition: Delivering medications through a tube inserted into the gastrointestinal system


Activities:



• Follow the five rights of medication administration


• Note patient’s medical history and history of allergies


• Determine patient’s knowledge of medication and understanding of method of administration (e.g., nasogastric tube, orogastric tube, gastrostomy tube)


• Determine any contraindications to patient receiving oral medication via tube (e.g., bowel inflammation, reduced peristalsis, recent gastrointestinal surgery, attached to gastric suction)


• Prepare medication (e.g., crush or mix with fluids, as appropriate)


• Inform patient of expected actions and possible adverse effects of medications


• Check placement of the tube by aspirating gastrointestinal contents, checking the pH level of the aspirate, or obtaining x-ray film, as appropriate


• Schedule medication to be in accord with formula feeding


• Place patient into high Fowler position, if not contraindicated


• Aspirate stomach contents, return aspirate by flushing with 30 ml of air or appropriate amount for age, and flush tube with 30 ml of water, as appropriate


• Remove plunger from syringe and pour medication into syringe


• Administer medication by allowing medication to flow freely from barrel of syringe, using plunger only as needed to facilitate flow


• Flush tube with 30 ml of warm water, or appropriate amount for age, after medication administration


• Monitor patient for therapeutic effects, adverse effect, drug toxicity, and drug interactions


• Document medication administration and patient responsiveness according to agency protocol

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