ICU HCMANE NOV

May 2025

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CT ICU

HC-MANE Revalidation November 2024

CICU

HC-MANE Patient Monitoring Activity

Who is NOT required to participate in admission handoff when the patient arrives from the OR?

CT Surgical Fellow

7W Pharmacist

7W APP and RN

Your Admission:

A 61 YO female arrives to 7W01 post AVR & CABG x3 (LIMA to LAD, SVG to OM2, & SVG to PDA) with Dr. Smith. PMHx: HTN, DM, CAD, Aortic Stenosis, Fall 2mo ago, and Generalized anxiety disorder (GAD)

Which is the correct Alaris pump guardrail for this patient?

Next up:

The second RN is getting your labs as you assess the patient. Chest tubes are to suction, OGT is to intermittent suction, 2A2V wires are secured and the foley is below the bladder. You level and zero your A-line and ensure that your alarm parameters are set appropriately and the volume is on. Next you complete your gtt check with your buddy. Your order is for dopamine 5mcg/kg/min. T.B. weighs 73.4 kg. You scan the dopamine and continue to the alaris pump:

When assessing the chest tubes and atrium q4, the nurse confirms A & B & C are all correct.

The mediastinal atrium is full and needs to be changed. You are orienting a new nurse and notice that the chamber is dry.

Check on the back of the atrium for the ampule of sterile water and add it to the chamber.

Leave it dry and wait for respiratory compromise

Chest Tubes

Chest tubes are used to drain excess fluid, air and blood. Patent chest tubes are necessary to alert the RN to bleeding, anastomotic leaks, and air leaks. Any occlusion or blockage can lead to life threatening complications! Confirm: A. Chest tubes are to the correct amount of suction per order B. The suction indicator is visible to the white triangle (the chest tube is to suction) C. The sterile water has been instilled into the chamber to create the water seal

You assess your patient and notice that his heart tones are a bit muffled, your BP is 90/52, and your CVP is increased to 20. Why are you concerned?

You are worried about bleeding and are closely monitoring the H&H on this patient because of the CT output.

Steady CT ouput followed by zero output is concerning - patient is exhibiting S/S of tamponade

You are finishing up your assessment and you assess the chest tube atrium for hr 2: For the first 30 minutes, output was 150 at 1 hr there was another 150. Now you are assessing hour 2, and there is no additional output. You assess the system: -20 suction, indicator is visible, water seal with tidaling. You assess the CT sites, they are without obvious drainage at the insertion sites.

What is the correct action for the 1115 am dose of VANCOMYCIN?

GIVE the dose

HOLD the dose & notify the provider

First - Draw the Trough. Second - check your med administration instructions Third - GIVE Vancomycin or HOLD

Your patient is asking you how frequently they need to complete the incentive spirometry exercises. What is your response?

As much as possible

10x every hour

When ever you want

The patient is doing much better and you continue to provide evidenced based care in the post-surgical period. This includes: 3x/day mobility, incentive spirometry, pain control, early diet progression and bowel regimen. These evidence based care activities promote an earlier return to normal activities, reduce complications and improve outcomes!

48 hours

How long do you have to ensure the admission navigator is complete?

Your Admission:

68 y/o Female arrives to your unit post-PCI of RCA in the Cath Lab. PMH: CAD, hypertension, Type 2 diabetes , A1c 7.8%, former smoker, quit ~2 years ago, NSR on tele, HR: 55, BP 85/63, RR 14 2L NC, SpO2 98%. Foley catheter, PIV x 2, A&0 x 3. TR band with 10 ml air to left radial artery, clean, dry, intact, no hematoma.

24 hours

Which is the correct Alaris pump guardrail for this patient?

Next up:

The second RN is helping the patient transfer to the bed and get settled. You quickly assess that the foley is below the bladder and your PIVx2 flush well and give blood return. You ensure that your alarm parameters are set as ordered and that the volume is on. Next the provider orders a dopamine infusion. Your order is for dopamine 5mcg/kg/min. T.B. weighs 73.4 kg. You scan the dopamine and continue to the alaris pump:

To ensure that the pericardial drain catheter is free of clots and draining appropriately, when flusing turn the stopcock.....

Off to the tubing, to flush toward the patient

Off to the patient, to flush toward the vacutainer

Pericardial Drain

• A stopcock is connected directly to the pigtail to facilitate flushing or sampling.
• Orders for frequency and amount of flush – if no orders, follow up with providers.crub the access site for at least 15 seconds to prevent infection when flushing or sampling.
• The side arm of the sheath is capped and turned off to the patient.
• DO NOT flush, transduce or draw samples from the sheath.
• Verify the presence of negative pressure from the vacutainer (the green plunger is down)
• DO maintain the patient on bedrest while on continuous suction

When assessing the chest tubes and atrium q4, the nurse confirms A & B & C are all correct.

You receive a patient from interventional pulmonology and notice that the chamber is dry. What do you do?

Check on the back of the atrium for the ampule of sterile water and add it to the chamber.

Leave it dry and wait for respiratory compromise

Chest Tubes

Chest tubes are used to drain excess fluid, air and blood. Patent chest tubes are necessary to alert the RN to bleeding, anastomotic leaks, and air leaks. Any occlusion or blockage can lead to life threatening complications! Confirm: A. Chest tubes are to the correct amount of suction per order B. The suction indicator is visible to the white triangle (the chest tube is to suction) C. The sterile water has been instilled into the chamber to create the water seal

Location B: PrismaSate 4/2.5

Location C: PrismaSol 4/2.5

Which combination below represents what and where you would hang replacement fluids (see image)?

Location A: PrismaSate 4/2.5

Dispose of the wrist band immediately. Armbands must be physically secured to the patient.

What do you do?

Verify that the armband is for this patient and then proceed with administration.

Citrate

Yep, you read that right. Your patient has clotted off one too many filters, so the team would like to transition them to Regional Citrate Anticoagulation. The citrate & calcium chloride infusion are both at the bedside. You call over your buddy to help you double check the infusions because you've not worked with the citrate protocol in a while. You have the MAR pulled up, then you notice that there is a patient armband taped to the head of the bed.

You recognize that your iCa Patient is too low, what rate and which medication should you increase per the protocol and when should you recheck iCa?

Calcium Chloride: increase by 10 ml/hr, re-check in 1 hr

Citrate: increase by 10ml/hr, re-check in 1 hr

Citrate

You start the infusion and check an iCa (machine and patient) 1 hour later.

Administer 12.5g (25mL) of D50 IV x 1

Three hours later..... You check a POC glucose & the glucometer results 46. You repeat the test to confirm, 46 again. You check your orders and see the Hypoglycemia Protocol ordered.

What is your next step to prevent further hypoglycemia?

Administer 25g (50mL) of D50 IV x 1

Give 2 units (BG 215) and have another RN signoff the administration

How would you document the insulin scheduled at 0600?

Mr. A had a hypoglycemic event. Giving insulin would perpetuate hypoglycemia – even if you’ve given D50 !!! DO NOT ADMINISTER THE INSULIN! Don't forget to document a hypoglycemia SmartPhrase in Maestro Care: .rnhypoglycemia

Not given (order parameters not met)

Dopamine, Dobutamine, Norepinephrine, Epinephrine, Nitroglycerine

All continuous IV medications, Tube Feeding, CRRT fluids

Almost Done!! Shift handoff - Continuous IV Infusions

Which fluids and medications must be included in the shift handoff of continuous infusions?

Nurse at bedside will: 1. Scan patient's arm band (Make sure armband is attached to patient and identifiers are correct) 2. Check MRN is programmed in the pump and read it out loud to confirm correct MRN 3. Scan each medication individually, read out loud the drug name and concentration on each bag and check the tubing label expiration date/time. RN at computer will verify this is accurate per order 4. For each medication go into set up and read out loud the concentration, dose, rate and weight (if applicable). RN at computer will verify this is accurate per order 5. Trace the line to the patient and identify where it is infusing. RN at computer will verify that the line is linked correctly in the MAR. 6. Verify compatibility though Trissel’s IV compatibility chart-this can be pulled up on the computer or printed (If you know that the medications are compatible be sure to verbalize this aloud to acknowledge that this step has been completed and confirm that both RNs agree with the compatibility) 7. Complete hand off documentation with dual signature/comment of verification in MAR

How frequently does patient education & care plans need to be documented in Maestro Care?

Q 24 hours

Q Shift

Now that you are almost done with your shift, you turn to documenting your education assessment & care plan for this patient. Don't forget!! You can initiate and discontinue care plans to ensure that they are appropriate for your patient!

Take a look at which bag is located where!

The dialysis fluid (PrismaSATE) contains electrolytes, glucose, buffers & solutes. It DOES NOT cross the filter into the bloodstream if hung in the correct location with the correct tubing set. The Pre and Post pump fluids (Prisma Sol) are administered in the blood and are RETURNED to the PATIENT!

TRY AGAIN

OOPS! Location is key!

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Try Again!

Alert the provider

Give PRN ativan

You start to notice that your patient is complaining of SOB and is restless. Her SpO2 is 98%, but she's on 6L now. She's a bit hypotensive and her CVP is climbing. You assess muffled heart sounds.... what is your next step?

That's right!!