ALL Clinical Practice Q&A

Question: Can you please provide acceptable standards for use of a telemetry technician? I have reviewed an issue where the technician is not trained in reading rhythms, but would alert the RN if an alarm rings...

Answer: Upon investigation of your clinical question, members of the committee have provided their expertise in regards to the recommendations for telemetry technicians. While querying members of the committee...

Question: Questions About TPN Compatibility

Answer: Many of the members have stated that they will always use a designated port of a multi-lumen catheter specifically for TPN. The reasoning behind...

Are there other facilities that use a symptom driven alcohol withdrawal program in acute care?

Answer: Out of the members, there were no systematic programs that have been initiated in the inpatient units. However, many follow different variations of alcohol assessment tools within their clinical unit...

Have there been any revisions to the standard of care with regard to: TENS application and use, TENS removal, prone positioning and ARDS?

Answer: A majority of the members of committee state that a TENS device is not used within their facility and that it is possible that it is used in a more restrictive environment, in a specialty practice, or most likely, performed at home

What is the best Evidence Based Practice for safe assessment and care of epidurals?

Answer: The standards of care (2014) and practice guidelines (2013) published by the American Society of Anesthesiologists provide guidance about postoperative care for patients who have received general or regional anesthesia, as well as moderate or deep sedation...

Question: I am curious as to the amount of emphasis put on patient acuity ... are there any acuity tools...?

Answer: ... One example of an acuity tool is based on the AACN Synergy Model. This process translates patients score into nurse patient assignments, based on patients’ stability, predictability, vulnerability, complexity, resiliency, patient/family participation in decision making and available resources...

Question: Our staff needs to increase the use of sterile technique when inserting catheters. What would be the best way to approach this when educating the staff?

Answer: It is important to first focus on developing a culture of safety in your area. Nurses and nursing assistants need to be aware of standards of practice and policies related to this aspect of patient care, as well as the notion that they are to be followed...

Question: The pros and cons of Multidisciplinary Walking Rounds

Answer: The Institute for Healthcare Improvement has published a guide for multidisciplinary rounds which may be helpful. It can be downloaded from the website at no cost (IHI, 2015).

Question: What does AMSN recommend for care and maintenance of the small bore feeding tube?

Answer: The AMSN itself does not have any specific standards on this particular practice, however, many organizations state that verification must always be identified with an X-ray, the feeding tube must be marked so dislodgment can be noted and monitoring must be completed at a minimum of every 4 hours (AACN, 2010).

Question: A female patient has CIDP and receives Gamminex C every four weeks... blood tests... symptoms... general treatment...?

Answer: Upon investigation of your clinical question, members of the committee have provided their expertise in regards to Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP). CIDP is closely related to Guillain-Barre syndrome and it is considered the chronic counterpart of that acute disease...

Question: I'm looking for acuity tools for nurse-patient assignments. I live in Maine so staffing isn't based on ratios. Does anyone have a tool or resource that I could use?

Answer: ...There is limited amount of research pertaining to nursing acuity tools. Some tools are geared towards critical care versus acute care...

Question: What are the recommended components of a routine neurological assessment for patients on a general med-surg unit? Are pupil checks part of this assessment?

Answer: ...many organizations queried do not use have a specific policy in regards to a neurological assessment. Most facilities tend to vary in their practice, as most of it based upon the provider’s orders, and dependent on each individual patient...

Question: Enforcing...should the nurse acknowledge PRN medications at the time of order?

Answer: ... After an extensive search for the regulations around order authentication timeframes, it was found that certain states have included time frames in their regulations...

Question: ...how does the RN know what is piggybacked vs. y-sited infused? Meaning - Heparin drip vs. antibiotic vs. potassium infusion.

Answer: Many facilities use referenced materials in order to develop guidelines to be used for clinical practice. It is important that the references are reviewed and approved by the pharmacy, most likely in a venue such as a Pharmacy and Therapeutics committee...

Question: Regarding Clinical Leadership (CL) in the unit... the best way of having everyone on the same page but not meeting with all CL members at the same time...

Answer: ...may be of some help in the preparation of your leadership group. First you will want to make sure that you follow the elements of the Nursing Professional Practice Model...

Question: Regarding high alert medications, ...what the recommendations are for which meds are considered high alert and require a medication double check?

Answer: Most facilities will institute at their own discretion, which medications will require a double check prior to administration. However, the Institute for Safe Medication Practices (ISMP) lists...

Question: What are the latest recommendations for performing a bed bath?

Answer: ... Most healthcare institutions provide available disposable bath wipes for bed bound patients...

Question: When irrigating a Foley catheter, should the nurse deflate the balloon before attempting this? Our procedure manual does not state performing this...

Answer: Many of the members organizations queried do not deflate the balloon prior to irrigation the catheter, as it is not a standard step during catheter irrigation in their hospitals. According to...

Question: Is it appropriate to draw blood for lab work from PICC lines?

Answer: ... According to the CDC, they do not state that it is inappropriate to draw blood from a PICC line. Instead they give the following process as the one to follow when drawing blood from a PICC line...

What are the med/surg units out there doing in regards to IV insulin practice? Are there any restrictions on IV insulin drips and IV bolus push?

Answer: ...members of the committee have provided their expertise in regards to IV Insulin administration on med-surg units...

Question: What can we do to reduce patient falls? (Four questions posed)

Answer: ... It has been identified that is hourly rounds are appropriately and accurately competed, there is a significant reduction in patient falls and outcomes...

Question: What is the standard of practice for connecting a secondary IV medication to a primary bag?...

Answer: Upon investigation of your clinical question, members of the committee have provided their expertise in regards to secondary IV medications, and replacement of IV tubing standards...

Question: Should IV push Lopressor be given on medical/surgical units where there is no cardiac monitoring?

Answer: Our review reveals that the best practice is to ensure the patient receiving Lopressor has a cardiac telemetry monitor in place...

Question: We currently need a MD order to get protein powder for a patient... Is this within the RN's scope of practice to order protein powder?

Answer: The reviewers had difficulty finding references with information about this topic. At their facilities, it is widespread practice that the RN does NOT order protein powder...

Question: Should a medical telemetry unit be allowed to administer non-titrated IV drips such as Cardizem or Dopamine? If so what are the guidelines for administration?

Answer: ...the guidelines for administration on IV drips such as Cardizem or Dopamine varies by entities, the size of the facility, as well as the indication for the medicated drip...

Question: What is the best-practice regarding positioning of a patient for removal of a JP drain?

Answer: ...the patients' positioning in the removal process of a JP drain vary, mainly being dependent on the location of the drain, patient comfort, and provider preference...

Question: When a patient has a PICC line, must all IV push meds be given through a 10-ml syringe?...

Answer: Upon investigation of your clinical question, members of the committee have provided their expertise in regards to the appropriate technique in the administration of medications and flushing of PICC lines...

Question: What is the current practice for giving an IM injection across the lifespan? Should the nurse aspirate the syringe?...

Answer: Upon investigation of your clinical question, members of the committee have provided their expertise in regards to the appropriate technique in administering IM injections. Many of the members'...

Question: What is the best practice to remove sutures/staples from a surgical site? Specifically, should cleansers or antiseptics be used prior to removing the staples/sutures?

Answer: Most members of the Clinical Practice Committee (CPC) have stated that RNs do not routinely remove staples/sutures at their facility. After considerable investigation...

Question: I am looking for information on the following skills for the staff nurse in acute care; ...insert coude catheters, ...maintaining competency, ...reinsert... (four questions were posed)

Answer: At the present time, our staff does not do these procedures. In the past 8 months, we have had 2 requests for insertion of a coude catheter.” After a query of the members of the CPC committee, most have stated that nurses do in fact (as well as medical providers) insert coude catheters.

Question: Are you aware of any guidelines for use of warming blankets on medical-surgical patients?

Answer: Many organizations queried do not use have a specific policy in regards to a warming device (Bair Hugger). Additionally...

Question: How often should Neurovascular checks be done on a post leg bypass patient?

Answer: Many organizations queried do not use have a specific policy in regards to a femoral-popliteal bypass neurovascular assessment. Most facilities tend to vary in their practice, as most of it based upon the surgeon's preference...

Question: ... Do Not Disturb Vest while administering medications are now being implemented within our facility per the director. How many facilities have actually implemented this practice and are there any other alternatives?...

Answer: Many organizations queried do not use “do not disturb” vests as a means to limit distractions for the nurse. However, many organizations have designated “do not disturb” or “no talking” zones and similar practices to achieve this goal, including posting signs that will aid in safety with the medication administration process...

Question: Is it standard practice on a med surg unit to assess patients head to toe every 8 hours when you work a 12 hour shift?

Answer: We queried our member hospitals as well as reviewed what information is in the literature around standard assessments. The following information is based on staffing at 12 hr. shifts on the general Med-Surg unit...

Question: ...how to improve my Ortho unit's press ganey score on "Communication about medications" part.

Answer: ...we queried some of our member hospitals. Most of these provide handouts to their patients about their meds, including a detailed dosing schedule and calendar, with teaching, review, and reinforcement of the education provided...

Question: Is there a position statement/policy or best practice from any organization on a safe communication plan for remote cardiac telemetry monitoring on a med-surg unit?

Answer: The standard of practice is that telemetry technicians are trained either through a hospital-based program or an institutional program (such as those credentialed by the Commission on Accreditation of Allied Health Professionals)...

Question: Delegation of task... do you have any information about whether you can delegate urinary catheter and/or peripheral IV removal to trained nonlicensed personnel?

Answer: Each state board of nursing outlines the tasks that may be performed by, and delegated to unlicensed assistive personnel (UAP). Each state also defines the educational program requirements for nursing assistant programs...

Question: I am researching information on merging Pediatric population within the adult med surg unit. If you have any information/literature to guide this practice...

Answer: The merging of pediatric unit and adult unit can be constraining if not confusing to the nurses. Pediatric nurses have different training than adult medical-surgical nurses. It has proven difficult to find literature on this topic, because...

Question: I'm looking for evidence-based information related to the admission criteria for med/surg units.

Answer: With the differences in patient populations, proximity to surgery and other invasive procedure services, telemetry, staffing, staffing mix and overall geographical differences in medical or surgical units, we find no literature that provides a detailed answer to your question. However, we did locate references...

Question: Does the AMSN recommend specific nurse/patient ratios, and if so, what is the evidence-based research to support it?

Answer: The AMSN Position Statement on Workplace Advocacy does address safe and adequate staffing practices. However it does not recommend a specific nurse to patient ratio because...

Question: Should patients with less than 20 weeks gestation be admitted on a regular medical surgical unit?

Answer: The guidelines that address this practice are the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women's Health, Obstetrics and Newborn Nurses.

Question: ...best practice r/t venous thrombolytic event prevention... (four questions posed)

Answer: I will address your questions below as you have them numbered: 1. We are questioning if the use of PCDs at other facilities is nurse driven or is a physician's order required? Pneumatic compression devices (PCDs) are placed on surgical...

Question: Looking for clinical practice guidelines or evidence regarding the use of a continuous bladder irrigation?

Answer: Review of the literature shows that continuous bladder irrigation is necessary following certain urological procedures (e.g., prostatectomy) to prevent formation of blood clots that could restrict or block urine flow...

What is the recommendation for post-op vital signs within the first 24 hour period?

Answer: Your question did not state specifically that you wanted information for pediatrics or adults, so our response will be generalized to any hospitalized post-operative patient...

Question: My hospital is currently analyzing our IV medication push policy...

Answer: I have summarized the responses from our members, and added my details for you, in order to have a record of this for your answer and our CPC minutes... Refer to the drug manufacturer recommendations and organizational guidelines (AHA, Infusion Nurses Society, etc.)...

Question: Should float staff be required to care for arterial lines on a patient in a post ICU setting?

Answer: Your question did not identify the "post-ICU setting" as a step-down unit, or a med-surg unit. For the purposes of this response, we will consider both unit types. We find that the standard of practice is that patients with arterial lines are...

Question: Do you support the removal of central lines on a med-surg floor by non-ACLS trained staff?

Answer: Organizational practices vary from allowing Med-Surg staff RNs to D/C a CVC, to requiring that their IV Resource Teams remove all CVCs, to Staff RNs being permitted to D/C CVCs once competency is established...

Question: I am curious if the nurses on the CPC work at hospitals where whipple surgery is performed...

Answer: For the CPC members that work at hospitals where whipples are performed, all pts. go to ICU from PACU...

Question: I am looking for best practice articles on abdominal or pelvic drain irrigation.

Answer: If seeking literature to support or prohibit the practice of abdominal or pelvic drain irrigation in the Med-Surg arena, we suggest you perform a literature search, and evaluate the evidence for or against. As a result of that process, follow up with establishing appropriate practice protocols within your organization.

Question: What is the correct terminology for fine crackles? Is it crackles or rales? I have seen both terms used and it is confusing for students.

Answer: Crackles, formerly referred to as "rales", it the term used to describe the adventitious sound of cracking/clicking/rattling usually heard on inspiration, that result from the re-opening of deflated airways...