0.1 to 0.3 mg/kg IV or IM Beginning a few millimeters distal to the anticipated site of the vessel puncture, insert the needle bevel-up, at a 10- to 20-degree angle, depending on location of vein. 3. Most secretions can be cleared in one or two passes. c. If a scalp vein will be cannulated, trim hair with scissors rather than shaving to help visualize and secure IV tubing. Has not been established as safe for use in very preterm infants due to risk of benzyl alcohol toxicity. h. Location of catheter tip on radiograph. The infant’s condition should be stabilized with bag-and-mask ventilation between attempts. Monitor for bradycardia and hypoxia during procedure. The person performing intubation must have easy access to the airway and equipment while positioned at the patient’s head. Never pull the catheter back through hollow needle introducer because of the risk of damage or shearing of catheter. h. Sterile tourniquet (optional with preterm infants). 10. In very small infants, breath sounds may seem audible even with an ETT in the esophagus. May cause apnea, hypotension, and CNS depression. To perform resuscitation. Deep suctioning should be avoided as this has been shown to cause tissue damage and inflammation. c. Neuromuscular blocking agents (optional): Muscle relaxants are contraindicated in situations where intubation may be difficult, such as micrognathia and cleft lip/palate or with health care providers with limited neonatal intubations. 6. Obtain parental informed consent for PICC insertion prior to the procedure per institutional policy. Commercially prepared catheter insertion kit, or the following: a. Laryngeal mask airway (LMA) should be available at all intubations in the event intubation is unsuccessful (Kumar et al. Pharmacologic interventions performed should also be documented. Remove and don sterile gloves, then remove catheter. 1. 8. The effect of hyperventilation alone in neonates is unclear and therefore discouraged (Davis and Rosenfeld, 2005). Hyperoxygenation in preterm neonates is discouraged owing to risk of retinopathy of prematurity (ROP). Apply warm compress for 5 minutes if needed to help dilate veins and make them more visible. Provide pain management such as pacifier for nonnutritive sucking, sucrose pacifier, and/or developmental care with facilitated tucking or swaddling. The American Heart Association (AHA) Neonatal Resuscitation Program use the 7-8-9 Rule (AAP and AHA, 2011). Avoid tension on catheter and tubing. Medications given, if any, should also be documented. Suction catheters (size 5 F to 10 F) and suction source set at 60 to 100 mm Hg of negative pressure. Appropriately sized padded armboard, if necessary. 100% oxygen source with blender providing an appropriate Fi. 12. Most common sites for neonates include the cephalic, basilic, and greater saphenous. Set up sterile field and open catheter kit, maintaining sterility of contents. Protection of the airway is required. 3. Reconstitute product with NS. ANALGESICS This should position the tip of the tube midway between the thoracic inlet and the carina, approximately at the second and third thoracic vertebrae. 3. 8. Different types of catheter introducers are available, depending on manufacturer: Breakaway needle—the vessel is cannulated and the catheter advanced through the needle to the premeasured distance. Position the patient supine on a flat surface, with the head midline and the neck slightly extended (optional: place a soft flat roll under neck) in a “sniffing” position. 1. The stylet must be secured so that its tip does not extend below the tip of the ETT and also so the stylet cannot advance during the procedure. Catheter sizes include single-lumen 1.2 F and single- or double-lumen 1.9 F to 5 F (Alexander and INS, 2011). Size 00 blade for preterm infants weighing less than 1000 g. In some cases, patients seek treatment for medical purposes and for others the procedures … A variety of methods has been reported for predicting insertional length such as nasal–tragus length, sternal length, foot length, and weight. Expose the pharynx by lifting the entire blade upward in the direction in which the handle is pointing. a. Transilluminate to locate vein, if necessary (use caution to avoid skin burns from heated device). Consider use of 1% lidocaine injected intradermally or topical lidocaine cream, or a systemic analgesic such as fentanyl. For best results, use hyaluronidase within 1 hour of infiltration but may be given up to 3 hours after infiltration. Discussion with family is key, even if signed informed consent is not required. 2. Consider use of topical lidocaine cream if appropriate. Only gold members can continue reading. If institutional policy, use with care in premature infants or infants under 2 months of age as these products may cause irritation or chemical burns (U.S. Food and Drug Administration, 2012). For MLC (peripheral venous access) insertion: (1) Upper body insertion: Tip should end in the upper arm, distal to the head of the humerus. Additional tubing and infusate as indicated per hospital policy. 27. a. Bradycardia. Nurse Practitioners. 23. Use aseptic technique during insertion and care of PICC/MLC. When feasible, use two caregivers to perform endotracheal suctioning if the closed (in-line) system is not in use. Aspirate on catheter to confirm blood return. Have all equipment necessary for intubation prepared and in working order prior to initiating procedure. 16. 3. Treatment for infiltration/extravasation (Fox, 2011; Sawatzky-Dickson and Bodnaryk, 2006; Thigpen, 2007): a. Cover skin with room-temperature saline-soaked dressing and elevate affected extremity. 1. 12. A nurse practitioner can evaluate symptoms and test for common infections. Return infant to previous oxygen requirement as tolerated, if applicable. The closed-system suction technique is preferred as it allows the infant to be suctioned without being removed from the ventilator. b. Intermediate or long-term IV therapy (> 6 days). However, if unable to visualize landmarks, a size 1 blade may be necessary. Know your institution’s protocols about the qualifications needed to perform any procedure. 7. g. Agitation. Determine suction catheter insertion depth by summing the length of the ETT and its adapter. 1. 11. As a certified Acute Care and Family Nurse Practitioner, I work most of my time in an acute care/critical care setting. Advance the catheter to the premeasured distance, then retract the plastic cannula from the vessel and pull the catheter apart along its longitudinal axis and discard. 26. 5. Skin antiseptics according to hospital policy. If resistance is met or vein is not punctured, withdraw needle slowly to just below the level of the skin, relocate vein, and advance the needle again. Duration of Action Use caution with high-frequency ventilation as pressure changes within the chest may lead to catheter migration, particularly with upper body insertions. Verify order from licensed health care provider for placement of a vascular access device. Use 6 F for ETT less than 3.5 mm. 1. f. Remove the ETT and discard it and hand ventilate with bag and appropriate-sized mask. f. Changes in respiratory rate and pattern. Deep suctioning should be avoided as this has been shown to cause tissue damage and inflammation. 8. Ingestion/aspiration of laryngoscope bulb. All patients under the age of 18 seeking a major procedure must be referred for evaluation to identify any underlying psychological problems which may make them an unsuitable candidate for the procedure. (a) Measure from the insertion site to the desired site of catheter tip. m. Select an introducer of appropriate size to accommodate catheter. 8. Obtain informed consent whenever required for an invasive procedure. 1. A. ■ Obtain informed consent whenever required for an invasive procedure. Medications given, if any, should also be documented. (a) Measure from the insertion site to the desired site of catheter tip. 25. Additional tubing and infusate as indicated per hospital policy. 2. Minimal cardiovascular side effects; however, decrease in heart rate and blood pressure has been observed when used concurrently with narcotics. b. Skin antiseptics according to hospital policy. Keeping the cords in view, pass the ETT between the cords 1 to 2 cm into the trachea on inhalation (level of the vocal cord guide mark on the ETT). ■ Know your institution’s protocols about any specific ways in which procedures differ from the descriptions included here. Trauma/edema to oropharyngeal and laryngeal tissues. Suction at 60 to 100 mm Hg or with just enough suction to extract secretions through catheter. 1. 6. 11 scalpel blade or straight needle. (1) Upper body insertion: Tip should be in the superior vena cava. 4. a. 3. 12. Although the BON may state that the performance of a particular procedure or provision of a specific patient care activity is within an advanced practice registered nurse's professional scope of practice, the advanced practice registered nurse may not perform the procedure … 3. 6. Check for blood return and obtain another chest radiograph to confirm satisfactory position. Use of a smaller gauge may allow the inserter to access a smaller vessel, and minimizes vessel and surrounding nervous tissue trauma and hematoma formation. After identifying the vocal cords, and with the cords in clear view, place the ETT into the right side of the patient’s mouth with the right hand. 8. Maintain thermoregulation, provide environmental support by protecting infant’s eyes from bright lights. A stylet may make advancing a catheter easier, and there is no evidence to support concerns that the stylet will damage or perforate vessels when used with care (Paulson and Miller, 2008). (2) Lower body insertion: Tip should be in the inferior vena cava above the L4-L5 vertebrae or iliac crest and below the right atrium. Peripherally Inserted Central Catheter and Midline Catheter: Advanced Practice Procedure 5. g. Enlarge the insertion site by 1 to 2 mm. Local anesthetic, tuberculin (TB) syringe with small-bore needle, if medical condition permits. k. Thread the catheter into the vein as previously described, to premeasured depth. This month’s [HealthStream’s] Journal Alert asks whether nurses can safely perform diagnostic angiography. If using a closed-system (in-line) catheter device, change per manufacturer’s recommendation or per institution’s policy if sooner. e. Notify physician or advanced practice nurse immediately. Palatal grooves from prolonged intubation. 12. Avoid hyperoxygenation, hyperinflation, and hyperventilation techniques if possible. Pain/developmental management: pacifier, sucrose pacifier, blankets for developmental swaddling, eye protection from bright lights. Consider deferring placement for at least 24 to 48 hours after antibiotic dosing is started. d. Video laryngoscopes. Avoid placement of a PICC in an extremity with inadequate or poor circulation. 4. Many nurse practitioners working in specialty areas, and especially primary care, must become skilled at using and interpreting a wide range of diagnostic tools. 1. Identify vessel, trim catheter, and prepare the insertion site as previously described for PICC insertion. 3. 16. If the tube is in the esophagus: 3. Tape catheter in position that is developmentally appropriate and per hospital policy. 22. Recommended for short-term IV therapy (< 1 week). 1. In a study recently published online in the Journal of the American College of Radiology, colleagues from the Neiman Health Policy Institute, Emory University, and I mined Medicare claims data from 1994 through 2012, focusing on imaging-guided procedures widely considered within the domain of radiologists—services like paracentesis, thoracentesis, and fine needle aspiration biopsies. The nursing Scope of Practice is defined by the American Nurses Association (ANA) as, "the ‘who,' ‘what,' ‘where,' ‘when,' and ‘how' of nursing." 1. Keep infant’s head midline during suctioning to prevent jugular vein distention, which can increase intracranial pressure (ICP). 13. After skin puncture, pause and let infant relax to prevent vasoconstriction. 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