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Simulations for Clinical Excellence
in Nursing Services
Infusion: Heparin
Infusion: Heparin
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Simulations for Clinical Excellence in Nursing Services: Heparin Infusion Training, Study notes of Nursing
Information on a simulation training program for nursing staff to effectively initiate intravenous access and administer Heparin infusion therapy. learner objectives, scenario purpose, and instructions for setting up the simulation. It is intended for use by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Unlicensed Assistive Personnel (UAP, if facility protocols allow). The scenario lasts approximately 55 minutes, including setup, scenario, debrief, and reset/breakdown.
What you will learn
- What staff members are qualified to initiate Heparin infusion therapy according to the provided protocol?
- What communication skills are required when caring for a patient receiving Heparin infusion therapy?
- What documentation is required with Heparin infusion therapy according to the provided protocol?
- What interventions should be performed for a patient experiencing bleeding associated with Heparin infusion therapy?
- What is the purpose of the simulation training program for nursing staff?
Typology: Study notes
2021/2022
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in Nursing Services
Infusion: Heparin
Infusion: Heparin
Insert photo here
in Nursing Services
Infusion: Heparin
Instructor Information Patient Name: Harrison, Betsy Simulation Developer(s): Melissa Brickner, Bridgett Everett, Debra A. Mosley, Beverly Snyder-Desalles, and Judy Young Scenario Purpose: To assist nursing staff to effectively initiate intravenous access and administer antibiotic infusion therapy Learner(s): Registered Nurses (RN), Licensed Practical Nurses (LPN), Unlicensed Assistive Personnel (UAP) Others as desired, depending on facility protocols Recommend no more than 6 learners (3 of which can be observers) Time Requirements: Setup: 5 minutes Scenario: 25 minutes Debrief: 25 minutes Reset/Breakdown: 5 minutes
Confederate(s): Clerk Dr. Santana – via telephone Family member
Scenario Prologue: Sixty-five (65) year-old female is directly admitted from the outpatient clinic for deep vein thrombosis and Heparin infusion. Patient is s/p right hip fracture with open reduction internal fixation (ORIF) three (3) weeks ago. She just returned from a ten (10) hour car trip. The time is
- The simulation begins when the learners are receiving report from the nurse
Patient information: General: Alert, oriented and calm Weight/Height: 81.8kg (180lbs) 177.8cm (70in) Vital Signs: BP 140/84; Temp 97 ; HR 92 ; RR 22 ; O2 Sat 9 7 % Pain: 5/10 right lower extremity Neurological: Unremarkable Respiratory: Eupneic Cardiac: Unremarkable Gastrointestinal: Unremarkable Genitourinary: Unremarkable Musculoskeletal: Right calf red, swollen, and warm to the touch. Pulses +2 bilaterally. Skin: Redness on calf of right lower extremity Past Medical History: Hypertension, hyperlipidemia, osteoarthritis, right hip fracture d/t fall three (3) weeks ago Past Surgical History: Appendectomy, S/P open reduction internal fixation (ORIF) of the right hip three (3) weeks ago Green Text Confederate
Red Text Physiology Change
Medications:
Metoprolol 50mg one time daily Simvastatin 40mg in the evening Ibuprofen 400mg three times a day for pain Allergies:
No known drug allergies (NKDA)
in Nursing Services
Infusion: Heparin
Discuss the scenario and ask the learners what the main issues were from their perspective Ask what was managed well and why. Ask what they would want to change and why. For areas requiring direct feedback, provide relevant knowledge by stating “I noticed you [behavior]…” Suggest the behavior they might want to portray next time and provide a rationale. “Can you share with us?” Indicate closing of the debriefing but provide learners with an opportunity to voice one or two take-aways that will help them in future practice Lastly, ask for any outstanding issues before closing the debrief Critical Actions/Debriefing Points :
- Verify orders
- Perform patient/ family teaching prior to initiating Heparin Infusion protocol
- Obtain baseline information per Heparin Infusion protocol
- Perform medication safety check with another RN per Heparin protocol
- Perform rights of medication administration
- Ensure antidote is readily available
- Initiate Heparin therapy with initial bolus according to protocol
- Assess bleeding lab draw site/blood on sheets and obtain vital signs
- Stop Heparin Infusion per protocol for bleeding and high aPTT or Anti-Xa result
- Notify healthcare provider of bleeding and high aPTT or Anti-Xa using ISBAR tool
- Complete facility specific documentation
in Nursing Services
Infusion: Heparin
Simulation Set-Up
Patient Name : Betsy Harrison (ALS Mannequin) Simulation Developer(s): Melissa Brickner, Bridgett Everett, Debra A. Mosley, Beverly Snyder-Desalles, and Judy Young Room Set-up : Set up like an inpatient room Patient Preparation : The patient is wearing a hospital gown Saline lock is in place At 1330, lab draw site is bleeding and there is blood on the sheets from rectal bleeding (see flowchart) Have the following equipment/supplies available : Gloves IV catheter Saline lock with female luer-lock adapter Tape or IV securing device Clear occlusive dressing IV label IV primary tubing (compatible with the pump) Male luer-lock adapter Bag for Heparin infusion (500mL or 250 mL bag) Medication label for Heparin Bloody 2x2 dressing for lab draw site (the family member will discretely apply at 1:30) Simulated blood in a small container or ziplock bag (the family member will discretely empty contents on the pad under patient at 1:30) IV pump Medications : Heparin infusion **Calibration will be required if using radiofrequency identification (RFID)
Note: 5.8 Simpad software update is required to load scenarios (http://cdn.laerdal.com/downloads/f4343/simpad-upgrade.vs Scenarios may be used with Laerdal or LLEAP software
Scenario Supplements : Confederate scripts Confederate name tags Patient Identification Band Medication label for Heparin infusion (facility specific-example provided) Nurse Driven Heparin Protocol (pages 1 and 2) PTT results Heparin protocol (facility specific-example provided) ZZ test patient/Demo patient in CPRS (if desired)
in Nursing Services
Infusion: Heparin
Supplements
Confederate Scripts
Confederate Name Tags
Patient Identification Band
Nurses Notes
Orders
Heparin Protocol Clinical Process Map Example
Nurse-Driven Heparin Protocol Example (pages 1 and 2)
Medication Label
in Nursing Services
Infusion: Heparin
Confederate Scripts
Betsy Harrison: Patient
Medical/Surgical History: Hypertension, hyperlipidemia, osteoarthritis, right hip fracture d/t fall three (3) weeks ago. Appendectomy, S/P open reduction internal fixation (ORIF) of the right hip three (3)
weeks ago Medications: Metoprolol 50mg one time daily Simvastatin 40mg in the evening Ibuprofen 400mg three times a day for pain
Allergies: NKDA
If the learner did not perform patient/family teaching or safety check, the patient will become increasingly anxious stating “What is that? You can’t just put medicine in my IV without telling me what it is! Do you know what you are doing?” **After the clerk hands the learner(s) the aPTT results at 1:30, the patient will state “Somebody came and drew my blood and now look at my arm! I need my sheets changed. They got wet after I went to the restroom.”
Family Member** **At 1:30, the clerk will enter the room, distract the learner and hand him/her the aPTT result while the family member places the bloody lab draw dressing on the patient’s arm and empties contents of simulated blood on bed pad under the sheets
Clerk** At 1:30, the clerk will enter the room, distract the learner and hand him/her the aPTT result while the family member places the bloody lab draw dressing on the patient’s arm and empties contents of simulated blood on bed pad under the sheets **Clerk will notify learner Dr. Santana is returning their call
Dr. Santana-Via telephone** The learner(s) will place a call to Dr. Santana Dr. Santana will state “Follow the Heparin protocol, I am getting off the elevator now. I will be there is a minute.”
in Nursing Services
Infusion: Heparin
Patient Identification Band
Harrison, Betsy
Dr. M. Santana
Age: 65 000-00-
Allergic: NKDA
Patient Identification Band
in Nursing Services
Infusion: Heparin
Nurses Notes Date : Today Patient Name: Betsy Harrison Mode of Arrival : Personally owned vehicle Accompanied by : Family member
Chief Complaint: Direct admit from the outpatient clinic for deep vein thrombosis and Heparin Infusion. Patient is s/p right hip fracture with open reduction internal fixation (ORIF) three (3) weeks ago. She just returned from a ten (10) hour car trip complaining for right calf pain. Active Problems: Hypertension, hyperlipidemia, and osteoarthritis Patient information: General: Alert, oriented and calm Weight/Height: 81.8kg (180lbs) 177.8cm (70in) Vital Signs: BP 140/84; Temp 97 ; HR 92 ; RR 22 ; O2 Sat 9 7 % Pain: 5/10 right lower extremity Neurological: Unremarkable Respiratory: Eupneic Cardiac: Unremarkable Gastrointestinal: Unremarkable Genitourinary: Unremarkable Musculoskeletal: Right calf red, swollen, and warm to the touch. Pulses +2 bilaterally. Skin: Redness on calf of right lower extremity Past Medical History: Hypertension, hyperlipidemia, osteoarthritis, right hip fracture d/t fall three (3) weeks ago Past Surgical History: Appendectomy, S/P open reduction internal fixation (ORIF) of the right hip three (3) weeks ago
SCREEN FOR ABUSE/NEGLECT: N/A Does the patient show any evidence of abuse? No Does the patient feel safe in his/her current living arrangements? Yes Suicidal or Homicidal Ideation in the past two weeks? No Is the patient currently enrolled in primary care? Yes Diagnostic Procedures Ordered: ( ) X-Ray ( ) Labs ( ) None ( ) EKG ( ) Head CT without contrast ( ) Other Triage Classification: Emergency Severity Index Patient Disposition: Medical-Surgical Unit Signed by : /DM/
Insert picture of patient here
Medications:
Metoprolol 50mg one time daily Simvastatin 40mg in the evening Ibuprofen 400mg three times a day for pain Allergies:
No known drug allergies (NKDA)
in Nursing Services
Infusion: Heparin
Nurse-driven Heparin Infusion Protocol Clinical Process Map Example Purpose:
- Process to ensure accurate and safe Heparin Infusion administration
- Standardize an aPTT time process that is congruent with lab processes and clinical practice to effectively track results
- Nurses can confidently and skillfully manage Heparin Infusion protocol
- Consistent with National Patient Safety Goal 03.05.01 – Improving the Safety of Using Medications Licensed healthcare provider initiates Nurse Driven protocol Heparin orders verified by pharmacy Nurse reviews and verifies the order Nurse verifies baseline aPTT and platelet level Nurse calculates initial bolus and infusion rate based on protocol using a standardized tool (signature/initials required) Second Nurse calculates initial bolus and infusion rate using a separate tool (signature/initials required) Nurse documents initial bolus and infusion rate and time of initiation into template Patient education about IV Heparin completed Nurse administers appropriate bolus and infusion aPTTs are drawn by nurse at scheduled times aPTTs are run STAT by lab personnel and results available within one (1) hour Nurse review aPTT result and makes adjustments per Heparin Infusion Protocol If result is “critical, Nurse caring for patient is contacted by lab personnel, Nurse contacts healthcare provider using ISBAR format and makes adjustments per order Nurse completes “critical lab documentation”
in Nursing Services
Infusion: Heparin
Nurse-Driven Heparin Protocol Example (page 1)
Initiation of Heparin Therapy: Patient Admission (dry) Weight: _______ kgs
Date: _______
Time: _______
Initial Bolus Dose: 80units/kg = ____ units
Rounded to nearest 500 Units
(Not to exceed 10,000 units for any patient)
Nurse Initials: ______
2 nd^ Nurse Initials:_____
Initial Infusion Dose: 18 units/kg/hr then
adjust per chart below.
(20,000 units per 500 ml D5W)
NOTE : 2nd^ nurse must double check the 9 rights (Patient, Drug, Route, Time, Dose, Documentation, Action, Form,
Response)
Adjust Heparin infusion using the following :
1. Obtain PTT q6h starting 6 hours after start of infusion for 24 hours, or longer, or
until two consecutive therapeutic PTTs are obtained
2. Therapeutic range is 60-.
3. Thereafter obtain PTT daily for the duration of heparin therapy.
4. In addition, following ANY dose change draw PTT q6h until 2 consecutive
therapeutic PTTs are obtained.
**It is important to remember that PTTs are drawn 6 hours from the time of
the dose change – NOT 6 hours from the last PTT drawn.
Maintenance of Heparin Therapy: ***NOTE : If first PTT post-initiation or post-bolus is
greater than 99, and there are no signs or symptoms of bleeding, DO NOT lower dose,
as this PTT result may still reflect the bolus dose. Follow guidelines for subsequent
PTT results.
Heparin Infusion Dose Change Guidelines
PTT (seconds) Bolus (units) Hold Infusion Dose Change
PTT monitoring until 2 consecutive results are within therapeutic range
Less than or equal
to 45
Repeat initial
bolus
No +3 units/kg/hr Q6H
Give ½ initial
bolus
No +2 units/kg/hr Q6H
60 - 99 0 No No change None
100 - 109 0 No - 1 unit/kg/hr Q6H
110 - 127 0 Hold 30 minutes -2 units/kg/hr Q6H
128 and/ or
comment of
“unable to clot in
150 seconds”
Verify sample is
not from
contaminated
line
Hold and call
MD
Redraw if
necessary
Per MD
(Typically Provider will hold x1 hour
then decrease dose - 3units/kg/hr and
recheck in 4-6 hours)
Initials Signature Initials Signature
in Nursing Services
Infusion: Heparin
Medication Label
in Nursing Services
Infusion: Heparin