ECMO: The Role of the Bedside Nurse Their Importance Mentoring and their Education Optimizing The Mentor-Protégé Relationship
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1 ECMO: The Role of the Bedside Nurse Their Importance Mentoring and their Education Optimizing The Mentor-Protégé Relationship Amal Ghadban Clinical Resource Nurse: Cardiac PICU Sheikh Khalifa Medical City Abu Dhabi, United Arab Emirates Presentation Title l Date l 1
2 Objectives Increase nursing knowledge on how to provide safe and effective care for patients who require ECMO Enhance Mentoring nursing skills to provide and maintain: A high Optimizing standard The of care Mentor-Protégé when caring Relationship for life threating patient on ECMO An organized approach in completing tasks in ECMO emergencies Identify and describe the importance of a comprehensive physical assessment for patient on ECMO Increase and optimize early detection and intervention Prevention or minimization of complications Improve caregiver/family support and education Presentation Title l Date l 2
3 Mentoring Optimizing The Mentor-Protégé Relationship ECMO: THE TEAM Presentation Title l Date l 3
4 Respiratory Therapist Perfusionist Bedside Registered Nurse Dietician Surgeon ECMO Specialist Medical Intensivist Patient & Family Radiologist Presentation Title l Date l 4
5 ECMO: The Team Requires EXCELLENT: Communication Coordination Collaboration Teamwork Presentation Title l Date l 5
6 Mentoring Optimizing The Mentor-Protégé Relationship ECMO: THE DETAILS Presentation Title l Date l 6
7 ECMO: Like No Other ICU Patient Mentoring Optimizing The Mentor-Protégé Relationship Presentation Title l Date l 7
8 Types of ECMO VV ECMO = Veno-Veno For lung support VA ECMO = Veno-Arterial For heart AND lung support ECMO Presentation & Nursing Title l Date l 8
9 Types of ECMO ECMO Presentation & Nursing Title l Date l 9
10 Purpose of ECMO Improvement of oxygenation Improvement of tissue perfusion Removal Mentoring of carbon dioxide Restart aerobic metabolism Optimizing The Mentor-Protégé Relationship Presentation Title l Date l 10
11 ECMO: Complex Nursing Care The Bedside Nurse Is *CRITICAL THINKING* alone enough to care for these patients? Mentoring The ECMO Specialist Nurse Optimizing The Mentor-Protégé Relationship Select group of highly-skilled and high-functioning ICU nurses Receive extensive specialized training in the care of patients receiving ECMO Increased and earlier recognition of changing patient assessment, as well as interpretation of these changes Advanced understanding of the complexities of interventions and treatments required, including emergency situations Receiving continuous evidence-based education and simulation labs Presentation Title l Date l 11
12 ECMO: Goals of Nursing Care GOAL: Optimize patient outcomes Achievement of goal is dependent on: Mentoring Assessment, planning, intervention, and evaluation Stable Optimizing oxygenation, The Mentor-Protégé hemodynamic function, Relationship and anticoagulation Correct actions during an emergent situation Prevent and/or minimizing number or severity of complications Comfort and support during the healing process For the patient For the family and caregivers Presentation Title l Date l 12
13 ECMO: Goals of Nursing Care Assessment and Interventions: Neurological Neurological injury is COMMON in ECMO patients Mentoring Risk of cerebral vascular injury from stroke (ischemic or hemorrhagic) Pupillary Optimizing reaction The Mentor-Protégé Relationship Painful stimuli and response!! Sedation Assessment: SAS: Sedation-Agitation Scale Bis: Bispectral Index TOF: Train of Four GCS not helpful as these patients are all sedated and non-responsive NIRS: Near infrared spectroscopy Imaging: Daily ultrasound Seizure Monitoring Continuous EEG monitoring Presentation Title l Date l 13
14 ECMO: Goals of Nursing Care Assessment and Interventions: Respiratory Impaired gas exchange Mentoring Oxygen Carbon Optimizing dioxide The Mentor-Protégé Relationship Auscultation: Ventilator on low setting Monitoring: ABGs: Patient and post-oxygenator VBGs: Patient and post-oxygenator SpO 2 SaO 2 SvO 2 EtCO 2 Lung recruitment, chest physio, suctioning Imaging: Daily CXR Presentation Title l Date l 14
15 ECMO: Goals of Nursing Care Assessment and Interventions: Hemodynamic VV ECMO = Does NOT affect hemodynamics Mentoring VA ECMO = Effect dependent on percentage of ECMO support ECMO Optimizing CO > The 60% Mentor-Protégé + Native circulation Relationship < 40% Discernable pulse contour Tissue Perfusion Cardiac Function: ECG, HR, ABP, MAP, CVP, Arterial waves, CO, CI Temperature: The lower the temperature, the higher SvO 2, and the lower the oxygen consumption Respiratory Function: SaO 2,SvO 2 NIRS Imaging: Echocardiogram Observe for HYPOvolemia CVP Monitoring: Low preload Assess ECMO drainage line: Swinging or shaking Presentation Title l Date l 15
16 ECMO: Goals of Nursing Care Assessment and Interventions: Renal/Urinary Decreased perfusion to the kidneys = Increased risk for acute renal Mentoring failure Assure Optimizing and maintain The Mentor-Protégé patency of urinary Relationship catheter Monitor HOURLY urine output and characteristics Monitor HOURLY overall fluid balance Diuretic(s) for any observable signs of edema or fluid retention/overload Monitor labs and physical assessment for electrolytes imbalance Peritoneal Dialysis or CRRT Presentation Title l Date l 16
17 ECMO: Goals of Nursing Care Assessment and Interventions: Gastrointestinal If NPO with NGT, monitor NGT drainage color Mentoring Monitor bowel sounds and movement, assess stool color Administer Optimizing H2 blockers The Mentor-Protégé or PPI Relationship Consult Dietician: Monitor calorie count Provide nutrition as soon as possible NGT feeds TPN Monitor blood glucose: Insulin protocol Weight daily if possible Presentation Title l Date l 17
18 ECMO: Goals of Nursing Care Assessment and Interventions: Dermatological Mentoring Assess skin for redness, blisters, or breakdown Keep Optimizing skin clean The and Mentor-Protégé dry Relationship Change body position AT LEAST every two hours Use of pressure relief devices and/or mattress Keep sheets dry and wrinkle-free Float heels and elbows Careful PRONE position = Stabilized line and cannula, check ECMO flow Presentation Title l Date l 18
19 Mentoring Optimizing The Mentor-Protégé Relationship COMPLICATIONS OF ECMO Presentation Title l Date l 19
20 ECMO: Complications Ischemia and Thrombosis Bleeding Air Embolism Mentoring Infection Emergencies Optimizing The Mentor-Protégé Relationship Presentation Title l Date l 20
21 ECMO: Complications Ischemia and Thrombosis Low perfusion Mentoring Check pulses and capillary refill Monitor Optimizing oxygen The saturation Mentor-Protégé on the affected Relationship limb ACT and coagulation profile Doppler study Presentation Title l Date l 21
22 ECMO: Complications Bleeding Be aware of current ACT and coagulation profile Mentoring Be aware about heparin level adjustment by ECMO specialist NEVER Optimizing do IM, SQ, The or Mentor-Protégé ID injection Relationship Remove faulty IV access or mark DO NOT USE Only withdraw blood only from lines Avoid new lines insertion Prevent pressure ulcers Presentation Title l Date l 22
23 ECMO: Complications Bleeding Mucosal bleeding = Difficult to compress Mentoring Nasopharyngeal: Suction Oropharyngeal: Optimizing The Suction Mentor-Protégé Relationship Tracheobronchial: Suction Rectal: Rectal thermometer Urinary: Urinary catheter Conjunctival: Cleaning NO SUCTIONING = Try to use soft gauze, sponge or syringe No suction if ACT or aptt high If suction is REQUIRED Low suction level Do not suction routinely No deep suctioning, only shallow If blood appears, stop IMMEDIATELY Presentation Title l Date l 23
24 ECMO: Complications Air Embolism Prevention is EVERYONE S responsibility Avoid entry from any connections and infusions ECMO circuit IV tubing and infusion pumps ECMO Presentation & Nursing Title l Date l 24
25 ECMO: Complications Infection ECMO Presentation & Nursing Title l Date l 25
26 ECMO: Complications Infection Antibiotic administration during cannulation and decannulation Pan-cultures twice/week Standard precautions and frequent handwashing Maintain sterility for all procedures ECMO Presentation & Nursing Title l Date l 26
27 ECMO: Complications Emergencies: How to Improve Emergency Response Coordinate emergency roles at start of each shift Bedside nurse: Monitor and maintain patient ECMO specialist nurse: Monitor and maintain ECMO circuit Frequent training and practice: Mock codes and scenarios Availability of the team Emergency Equipment: Another console Manual pump Clamps at the bedside Emergency medications Ambu bag Return ventilator to normal setting ECMO Presentation & Nursing Title l Date l 27
28 ECMO: Complications Emergencies: Line Cracking Crack and Bleeding from the RETURN line Put on STERILE gloves and cover/hold the crack to block it Crack and Bleeding from the DRAINAGE line Clamp the return line De-air PREVENTION: Check line position in hourly checks Check length and sutures Loosen but secure dressing Support weight of all of the lines, ensure that they free of tension ECMO Presentation & Nursing Title l Date l 28
29 ECMO: Complications Emergencies: Air Bubbles Clamp the return line Placement in Trendelenburg and initiation of CPR Remove air from the nearest port Consider replacement of the circuit ECMO Presentation & Nursing Title l Date l 29
30 ECMO: Complications Emergencies: Accidental Decannulation Partial Decannulation Hemodynamics will be low or maintained Secure and wait for review Complete Decannulation Hemodynamics will fail/collapse Clamp the circuit and control bleeding Initiate CPR PREVENTION: Ensure lines are free of tension and off from the floor GOAL: Recannulation ECMO Presentation & Nursing Title l Date l 30
31 Mentoring Optimizing The Mentor-Protégé Relationship CONSIDERATION OF THE FAMILY AND CAREGIVERS OF THE PATIENT REQUIRING ECMO Presentation Title l Date l 31
32 Family and Caregivers ECMO Presentation & Nursing Title l Date l 32
33 Family and Caregivers Do not let care of the patient busyness outweigh the importance of family and caregiver support, GET HELP Provide Mentoring comfortable environment Begin Optimizing teaching ONLY The Mentor-Protégé when there Relationship is an indication of readiness to learn Explain ALL procedures in simple, concise, and reassuring manner. Repeat as many times as necessary. Provide constant updates, especially with any new changes Maximize opportunities for them to be with patient Maximize opportunities for parents to make choices for their child Provide opportunities for them to help in care of the patient Presentation Title l Date l 33
34 References Nitasha joyner. (2014), ECMO: the Ultimate support for the Cardiopulmonary system, AACN, webinar. Mentoring Nitasha joyner. (2014), ECMO: the Ultimate support for the Optimizing The Mentor-Protégé Relationship Cardiopulmonary system, AACN, webinar Presentation Title l Date l 34
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