ALL Clinical Practice Q&A

Question: What is the suggested nurse/patient ratio and the suggested CNA/patient ratio for a medical-surgical floor?

There is no nationally suggested nurse to patient ratio or CNA to patient ratio for medical-surgical units. California is the only state that has passed a law mandating specific...

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

Answer: Per Infusion Nurses Society (INS) guidelines, 10 ml syringes can be used to evaluate line paten-cy and for flushing of the line...

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 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: Warming blankets should generally be used only in areas where body temperature and clinical condition can be monitored continuously. This is particularly important in patients who...

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 metoprolol has a cardiac monitor in place...

Question: What are the standards and frequency recommendations for taking “routine” and “post-operative” vital signs?

Vital signs are generally considered to include temperature, heart rate, respiratory rate, and blood pressure...

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 different levels of care...

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: There is very little in the literature that specifies where certain medications can be administered, only hospital specific guidelines. Our recommendation is that your hospital use an interprofessional team to develop a guideline for the administration of these medications.

Question: Can you provide examples of SBAR for shift hand-off that are approved by the association?

Answer: AMSN recommends utilizing an SBAR format that is developed by your nursing department and interprofessional team that meets the needs of your organization and conforms to your culture of safety...

Question: Is it evidence based practice to keep patient in flat position in bed for 45-60 minutes after PICC line removal?

Answer: The Infusion Nurses Society in their Policies and Procedures (2016) state to position the patient supine flat or Trendelenburg, unless contraindicated for any type of CVAD during removal...

Question: What is the best practice to remove sutures/staples from a surgical site?

Answer: Generally, removal of sutures or staples by a nurse requires an order from a provider...

Question: ...regarding infection control and IV solutions... we have IV tubings changed q96hrs and plain IV solutions q96hr but questioning if it should be q24hr?

Answer: The Center for Disease Control and Prevention (CDC) has no recommendations for the hang time of intravenous fluids....

Question: Questions About TPN Compatibility

Answer: Upon investigation we found that the A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations (Ayers et al., 2014) discourages co-infusion of medications through TPN lines...

Question: Practice has been if a PEG tube is pulled out that temporarily a foley of the same size should be placed in it to keep it opened...?

Answer: In searching the literature, we found no evidence to support replacing the dislodged PEG tube with a urinary catheter, except for a short-term solution...

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

Answer: The Centers for Disease Control and Prevention (CDC) does 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 (CDC, 2011)...

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

Answer: Aspiration is the process of pulling back on the syringe plunger by applying negative pressure for 5-10 seconds after the needle has been inserted into tissue, but before administration of the medication (CDC, 2017; Sepah et al, 2017)...

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 guide recommends the following best practices:..

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

Answer: Upon investigation of your clinical question, members of the committee have provided their expertise in regards to the care and maintenance of the small bore feeding tube...

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)...

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...

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: 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: 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: 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: 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...

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.)...