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As experienced nurses, we do nursing procedures every day and they become routines over time. But do you know that there are common nursing procedures that sometimes we do wrong?

Medication mishaps

1. Not all oral medications can be crushed.

Nurses usually crush medications into powdered form so it can be administered via NGT. But according to Royal Pharmaceutical Society (2011) crushing an oral solid dosage form may have a negative impact on the stability of the drug substance. If an enteric coating, which protects a drug from the acidic environment in the stomach, is removed by crushing the tablet, the in vivo drug degradation will increase, with less drug available to produce the desired clinical effect. Nifedipine is an example of a drug that is highly light sensitive after tablets have been crushed.

Extended-release products are formulated to release the drug over an extended period of time. Remember, their usual product names have CR, ER, LA, SR, XL or XR.

Another example is the oral tablet called ACCUPRIL (quinapril). Crushing an Accupril tablet and dissolving it in water for enteral administration allows the carbonate to increase the pH of the solution, causing the drug to rapidly degrade into a poorly absorbed metabolite, (Institute for Safe Medication Practice, 2010).

If you happen to have a patient with NGT and has any of these medications, discuss with the physician and suggest a different formulation compatible for NGT administration. You may also inquire from your pharmacist which medication formulation he/she can recommend.

To be guided which tablets are not to be crushed, click this link below:

http://www.ismp.org/Tools/DoNotCrush.pdf

2. Enoxaparin is kept at room temperature, not on fridge or freezer.

Nurses usually store enoxaparin at the refrigerator. Drugs.com suggests to store enoxaparin at room temperature, between 15 and 25 degrees C. Store away from heat, moisture, and light.

3. Mannitol should not be administered with crystals.

Drugs.com recommends to inspect Mannitol bottle for crystals prior to administration. If crystals are observed, the container should be warmed by appropriate means to not greater than 60°C, shaken, then cooled to body temperature before administering. If all crystals cannot be completely dissolved, the container must be rejected. Administer intravenously using sterile, filter-type administration set.

Electrolyte-free Mannitol Injection should not be given conjointly with blood. If it is essential that blood be given simultaneously, at least 20 mEq of sodium chloride should be added to each liter of mannitol solution to avoid pseudoagglutination.

4. Medications, as much as possible, should not be crushed using mortar and pestle.

Nurses usually crush tablets using mortar and pestle since they are the most convenient tools to convert tablet to powdered form. However, Institute for Safe Medication Practice (2010) do not recommend crushing tablets using such tools since there is the possibility of powder loss. Example: about 25% of aspirin was lost when a mortar and pestle was used to crush tablets prior to suspending the powder in water.

5. As much as possible, do not split tablets using a knife or pill cutter. If possible, prescribe medication with the exact dosage.

According to ISMP (2010), splitting tablets with a splitting device, may result to tablet pieces that are not the same size, and whose weight can vary by 15% to 20% of the theoretical weight i.e. half the weight of the intact tablet.

Red Lights in caring patients with endotracheal tube

6. Instilling normal saline in the endotracheal tube is a no, no!

As nurses, we have this practice of instilling normal saline for about 1-2 cc, because we believe that it may loosen secretions, increase the amount of secretions removed, and aid in the removal of tenacious secretions. However, there is insufficient evidence to support this premise.

According to American Association of Respiratory Care (AARC), routine use of normal saline instillation may be associated with the following adverse events: excessive coughing, decreased oxygen saturation, bronchospasm, dislodgement of the bacterial biofilm that colonizes the ETT into the lower airway, pain, anxiety, dyspnea, tachycardia, and increased intracranial pressure.

7. Routine suctioning is not a good habit.

The reason for this is because there is considerable risk with using “routine” suctioning. In a literature review by Hahn (2010), it recommended that ETS should be performed as infrequently as possible—yet as much as needed.

8. Avoid using catheters larger than one-half the diameter of the airway.

Nurses have the tendency to use suction catheter which are readily available without considering the diameter of the endotracheal tube. According to Hahn (2010), if a suction catheter is too large for the ETT, and/or there is too much vacuum pressure, massive atelectasis may occur. Therefore, the general recommendation is to use a suction catheter that has an external diameter less than 50% of the size of the ETT inner diameter.

9. Minimize the frequency and duration of suctioning when patient is on positive end-expiratory pressure (PEEP) greater than 5 cm or continuous positive airway pressure (CPAP).

Small suctioning-induced changes may have profound effects on these marginally oxygenated patients.

10. Close suction is more recommended that open suction.

According to AARC (2010), the use of closed suction is suggested for adults with high FIO2, or PEEP, or at risk for lung decruitment, and for neonates. Endotracheal suctioning without disconnection (closed system) is suggested in neonates.

11. Use of shallow suction is suggested instead of deep suction

The drawback with deep ETS is that there is some degree of mucosal injury and the potential for bleeding, as well as the possibility of vagal stimulation and bradycardia, (Hahn, 2010).

12. Airway obstruction management has an algorithm. Do not panic!

Hosking et al have proposed a practical algorithm for the management of airway obstruction. Hyperinflation of the ETT cuff for a short period of time, followed by reevaluation by a FOB (to prevent tracheal mucosal injury) and the maneuver to rotate the ETT to move the bevel away from the tracheal wall are incorporated in the algorithm of the steps taken for airway obstruction in an intubated patient.

13. Cuff over-inflation

The inability of nurses to determine endotracheal tube cuff pressure by the traditional standard method of palpation of the pilot balloon has been addressed according to Johnson & Lehman (2012). The use of pressure manometer or noninvasive manometers can be used to properly measure cuff-pressures.

14. Don’t bag too much with manual resuscitator.

When using a bag valve mask, provide a volume of 6-7 mL/kg per breath (approximately 500 mL for an average adult) to the patient. Bosson & Mosinefar (2015) recommends that for a patient with a perfusing rhythm, the nurse should ventilate at a rate of 10-12 breaths per minute. During cardiopulmonary resuscitation (CPR), give 2 breaths after each series of 30 chest compressions until an advanced airway is placed. Then ventilate at a rate of 8-10 breaths per minute. Give each breath over 1 second. If the patient has intrinsic respiratory drive, assist the patient’s breaths. In a patient with tachypnea, assist every few breaths.

15. Using alternative sites for testing blood sugar is commendable but may cause “lagged” results.

Blood testing are usually done on patient’s fingertips but there are other alternate sites including: earlobe, upper arms, forearms, hands, thighs, and calves.

However, alternate test sites are not all the same. With all meters, routine testing on an unrubbed forearm, upper arm, thigh or calf gives a test result that is 20 to 30 minutes old. According to an article by BD (n.d) the fingertips and the palm hold the most recent ‘memories’ of a patient’s blood glucose. On the other hand, lagging test sites such as the forearm or thigh is the blood glucose of the patient around 20 to 35 minutes ago.

As nurses, we have this culture to adapt what has been practiced for many years by our particular institution. Nonetheless, it also important to investigate regarding new studies and updates to guide us with new trends in the nursing practice. Because what we have believed to be correct 10 years ago can be obsolete now.

Is there anything you want to share? Feel free to comment below.

References:

  • American Association of Respirator Care (2010). Endotracheal Suctioning of Mechanically Ventilated Patients With Artificial Airways 2010. AARC Clinical Practice Guidelines. Retrieved from http://www.rcjournal.com/cpgs/pdf/06.10.0758.pdf
  • BD (n.d). Alternate blood glucose testing on arms, thighs, and legs. Retrieved from https://www.bd.com/us/diabetes/blood-glucose-monitoring/how-to-test/alternate-site/
  • Bosson, N & Mosinefar, Z. (2015). Bag-valve-mask ventilation. Medscape. Retrieved from http://emedicine.medscape.com/article/80184-overview#a7
  • Drugs.com (n.d). Mannitol injection. Retrieved from https://www.drugs.com/pro/mannitol-injection.html
  • Hahn, M. (2010). 10 Considerations for Endotracheal Suctioning. RT Magazine. Retrieved from http://www.rtmagazine.com/2010/07/10-considerations-for-endotracheal-suctioning/
  • Hosking MP, Lennon RL, Warner MA, Gray JR, Masley P, DeLuca, LA, Didier EF: Endotracheal tube obstruction: Recognition and management. Mil Med 1989; 154: 489 Retrieved from https://www.webmedcentral.com/wmcpdf/Article_WMC00536.pdf
  • Institute for Safe Medication Practice (2010). Preventing Errors When Administering Drugs via an Enteral Feeding Tube. Retrieved from https://www.ismp.org/newsletters/acutecare/articles/20100506.asp
  • Johnson, K & Lehman, R. (2012). Acute Management of the Obstructed Endotracheal Tube. Respiratory Care. Vol. 57 No. 8. DOI: 10.4187/respcare.01040. Retrieved from https://www.navicenthealth.org/pdf/acute-management-of-an-obstructed-ett.pdf
  • MICU nursing. (2010). Pulmonary Concepts In Critical Care Airway Management. Retrieved from http://micunursing.com/airway.htm
  • Royal Pharmaceutical Society (2011). Pharmaceutical Issues when Crushing, Opening or Splitting Oral Dosage Forms. Retrieved from http://www.rpharms.com/support-pdfs/pharmaceuticalissuesdosageformsjune-2011.pdf
  • Stockport NHS Foundation trust (n.d). A patient guide to home use Clexane (Enoxaparin). Stepping Hill Hospital. Retrieved from  https://www.stockport.nhs.uk/documents/PIL/34646_Med44.pdf
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Rina Malones is currently working as a critical care/acute stroke nurse. Besides from blogging, she's also studying International Health at University of the Philippines Open University.