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Medic to Practical Nursing
SKILLS REFERENCE
and COMPETENCIES
BOOK
2015-2016
THIS BOOK BELONGS TO: _________________________________________________
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Medic to PN Certificate
NURSING PROGRAM
I have received my copy of the “Nursing Skills Reference and Competencies Book” and will become
familiar with its contents. The requirements and guidelines as stated are acceptable to me and will
provide information for completing skills demonstrations while in this program. I understand that
failure to abide by the contents in this book may result in disciplinary action and/or my failing the Medic
to PN Certificate Program.
____________________________________
Print Name
____________________________________
Signature
____________________________________
Student ID
____________________________________
Date
3
PRACTICAL NURSING SKILLS
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Head-to-Toe Physical Assessment
Female Cath
Administering a Nasogastric Tube Feeding
Administering Meds via Nasogastric Tube
Colostomy Care
Non-sterile Dressing Change
Open Sterile Pack/Add Sterile Items
Hand Washing
Administering Oral Meds
Administering Intramuscular (IM) Injection
Administering Meds from Ampule
Administering Subcutaneous Injection
Administering Meds from Vial
Administer Medication by Suppository
Female Cath
Male Cath
Tracheostomy Care
Tracheostomy Suctioning
NG Tube Insertion
Sterile Dressing
Suture and Skin Staple Removal
Hand Washing
IV Equipment Set-Up
Care for and Monitor a Peripheral IV Site
Discontinue an IV
Z-Track Method of IM Injection
Mixing and Administering Insulin

Peripheral Venipuncture with
Over the Needle Cath Insertion
4
TABLE OF CONTENTS
Adult Head-to-Toe Physical Assessment .................................................................... 6-18
Blood Glucose Testing .............................................................................................. 19-20
Hand Washing ........................................................................................................... 21-28
Sterile Gloves ............................................................................................................ 29-30
Suture and Skin Staple Removal ............................................................................... 31-32
Opening Sterile Packages and Adding Sterile Items to the Sterile Field .................. 33-34
Non-Sterile Dressing Change .................................................................................... 35-36
Sterile Dressing Change ............................................................................................ 37-39
Pulse Oximeter ............................................................................................................... 40
Female Catheterization ............................................................................................ 41-44
Male Catheterization ................................................................................................. 45-48
Catheter Management................................................................................................ 49-51
Catheter Irrigation ..................................................................................................... 52-53
Catheter Removal ...................................................................................................... 54-57
Care for and Monitor a Peripheral IV Site ..................................................................... 58
IV Equipment Set-up ................................................................................................. 59-60
Discontinuing an IV ....................................................................................................... 61
Saline Lock Flush ...................................................................................................... 62-63
Administering IV Push Medication (Existing Line & Saline Lock) ......................... 64-66
Administering IV Meds by Secondary Set (IVPB) ................................................... 67-69
Giving Meds through a Central Venous Catheter ..................................................... 70-71
Central Line Site Care and Dressing Change ............................................................ 72-74
Peripheral Venipuncture with Over-the-Needle Catheter Insertion .......................... 75-80
Mixing and Administering Insulin ........................................................................ 81-82
Administering Subcutaneous Medications ................................................................ 82-86
Administering IM Injections to an Adult .................................................................. 87-91
Z-Track Method of IM Administration ..................................................................... 92-93
Administering Oral Medications ............................................................................... 94-96
Preparing an Injectable Medication from an Ampule ............................................... 97-98
Preparing an Injectable Medication from a Vial ..................................................... 99-100
Inserting a Nasogastric Tube ................................................................................. 101-103
Irrigating a Nasogastric Tube ................................................................................ 104-105
Removing a Nasogastric Tube .............................................................................. 106-107
Administering a Tube Feeding .............................................................................. 108-110
Administering Medications via a Nasogastric Tube ............................................. 111-112
Changing and Emptying an Ostomy Appliance .................................................... 113-115
Irrigating a Colostomy........................................................................................... 116-117
Administering Medication by Suppository……………………………………….118-119
Tracheostomy Care................................................................................................ 120-124
Tracheostomy Suctioning ...................................................................................... 125-127
5
GENERAL STEPS
With almost every demonstration, there are eight initial general steps and five closing general steps.
These are listed below. The student will be expected to include these when they are performing the skill
demonstration and to explain any specific information related to them in a particular demonstration.
INITIAL GENERAL STEPS
1. Check the physician’s order.
 When this is a new order.
 If it is not clearly stated on the worksheet.
 If you have any questions concerning a procedure for a particular client.
2. Wash hands.
3. Gather needed equipment.
4. Respect client’s privacy by knocking on door or requesting permission to enter.
5. Introduce self to client unless already done so. Address client in a respectful manner, using the
name the client prefers.
6. Identify client, preferably using identification band:
 Have client state name and birth date.
 Ask family or regular staff to identify client.
 Utilize picture ID used by facility.
7. Explain procedure to client. Take into consideration the previous experience of the client with this
procedure, the level of understanding and any communication deficits such as language barriers,
hearing loss, or confused state.
8. Provide for privacy by drawing curtains or closing the door of the room.
CLOSING GENERAL STEPS
1. Remove gloves, if used, and wash hands.
2. Make sure client is safe and comfortable by:
 Readjusting clothing and coverings to provide privacy and warmth.
 Positioning in chair or bed in a comfortable position.
 Returning bed to lowest position.
 Making sure side rails are up and wheels are locked.
 Placing call signal within reach of the client.
3. Straighten room and remove any soiled items to the appropriate place.
4. Record information regarding the specific procedure.
5. Demonstrate an ability to give appropriate rationale for any step in the demonstration when
requested to do so by the instructor.
6
Adult Head-to-Toe Physical Assessment
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 30 minutes
Supplies needed: Stethoscope and blood pressure cuff
Patient gown
Alcohol wipes
Penlight
Other:
Partner needed
1.
Wash hands.
2.
Bring equipment to room. Client in hospital
gown.
3.
Introduce self and identify client by asking them
to state their name and checking their wrist band.
4.
Explain procedures (going to be checking their
pulse, lungs, etc.) now and throughout the
assessment.
5.
Provide for privacy. Keep the client covered
during the procedure exposing only areas being
examined.
6.
Prior to the start of the return demonstration, the
student will be sure the client is dressed in a
patient gown and will collect the following vital
sign information:
7.
A.
client’s lying, sitting, and standing B/P
B.
temperature, radial pulse and respiration
Elevate bed to working height.
COGNITIVE AND SENSORY ASSESSMENT
8.
General Appearance and Behavior
A.
Are the client’s actions and responses to
questions as you would expect (appropriate)
or are they inappropriate?
B.
Identify the client’s predominant emotion or
feeling (i.e., examples of “mood” could be
7
Performance Comments
Satisfactory
Unsatisfactory
happy, sad, depressed, fearful, etc.).
C.
Assess typical dress and grooming.
NOTE: Is clothing clean? Body odor?
Grooming?
COGNITIVE FUNCTION AND
THOUGHT PROCESSES
9.
Cognitive Function and Thought Processes
A.
Is client Awake and Alert? Understands
questions and responds appropriately and
reasonably quickly?
B.
State if client does not respond to question.
Proceed with the following – noting both the
stimulus required to elicit a response from
the client and the specific type of response to
the stimulus. (If client responds to 1, you
would not need to proceed to 2, 3, 4, or 5).
1) Instruct client to do something (i.e.,
squeeze my hand or open your eyes.)
2) Does client respond to his name?
3) Does client respond to touching of an
extremity?
4) Does client respond to shaking of
shoulder?
5) Does client respond to nail bed pressure
(pain)?
C.
3 Spheres of Orientation: Ask:
1) Person: What is your name:
2) Place: Where are you?
3) Time: What is the date or day and what
time is it?
8
Performance Comments
Satisfactory
Unsatisfactory
D.
Memory
1) Long-term memory: (distant past)
Ex: Where did you go to school? Where
born?
2) Short-term memory: (last 24 hours)
Ex: What did you have for breakfast?
3) Immediate recall: Is client able to repeat
a series of 4 or 5 numbers or words
unrelated to each other?
E.
Cranial Nerves (Eyes and Ears)
1) Hearing
A)
Ask if he/she has hearing problems
or hearing aid.
B) Assess speech. Speaking loudly?
C) Assess hearing by occluding one
ear by pressing inward on the tragus
and speak. Have client repeat it.
Then, repeat with the other ear.
2) Vision
A) Check if wears glasses. If so, do
they correct vision? Have them
read small print, covering one eye
than the other.
B) If cannot read print, have them cover
one eye and hold up 2 fingers and
ask how many fingers are held up.
3) Pupil Response
Assess pupils by shining penlight into
one eye and then the other. Check for:
A) Size
B) Shape
C) Equality
9
Performance Comments
Satisfactory
Unsatisfactory
D) Reaction to light
E) Symmetry to reaction to light
(check one eye and then other to
see if same amount of reaction).
10.
11.
Neck Assessment: Carotid Pulses
A.
Use the pads of the index and 2 middle
fingers for palpation of pulses.
B.
Palpate the carotid arteries (one at a time).
Slide index and middle fingers around the
medial edge of the sternocleidomastoid
muscle to locate artery (toward the trachea).
Ask client to turn head toward side examined
Never vigorously palpate or massage a
carotid artery.
Chest Assessment: (Cardiac and Respiratory)
Ask client to sit on side of bed or raise bed to
sitting. Face client to assess the anterior chest.
Ask the client if he/she is having any difficulty
breathing, any cough, or any sputum production.
A.
Inspection: (expose upper chest and observe)
Inspect for shape:
1) Retraction/bulging of intercostals spaces
2) Presence of masses/deformities
3) Equal chest expansion
B.
Palpation
Feel all of anterior upper chest with fingers
flat against skin moving in circular motion.
Feel for:
1) Masses/deformities
2) Equal chest expansion
3)
Tenderness (ask if touching hurts)
10
Performance Comments
Satisfactory
Unsatisfactory
C.
Auscultation: (With stethoscope, listen for
heart and lung sounds.) Expose only as
needed.
1) Finding Anterior Land Marks
A) Locate the angel of Louis and 2nd
intercostals space to the left of the
sternum.
B) Count down the intercostals spaces
to locate the 5th intercostal space.
C) Slide finger along the 5th space to
the mid-clavicular line.
D) Identify that: the apex of the heart,
where the APICAL PULSE is
located, is at approximately the 5th
rib at the mid-clavicular line.
2)
Apical Pulse: Ask client to breathe
normally and to refrain from speaking
during listening period.
A) Auscultate the apical pulse for one
full minute. The instructor will
check the radial pulse at the same
time. Student’s reading must be
within 4 beats of the instructor’s
reading.
B) State: The S1 is the first heart
sound (lub) and the S2 is the second
heart sound (dub). Assess the beat
for strength and rhythm.
3)
Auscultate Anterior Lung Sounds
A) Auscultate and listen for one full
inspiration and expiration at each
lung location.
B) Compare breath sound
characteristics of both lungs.
11
Performance Comments
Satisfactory
Unsatisfactory
C) During auscultation, direct client to:
i.
turn and face opposite nurse
ii. breath normally with open
mouth
iii. if unable to hear breath sounds,
ask client to take deeper breaths
iv. refrain from talking during
assessment
v.
instruct to tell you if they get
dizzy or tired
D) Do not auscultate over bone or
clothing. Follow sequence as
shown in picture:
1. Above clavicle
2. @ 2nd intercostal
L-sternal boarder
3. @ 4th intercostal
L-sternal boarder
4. @ 6th intercostal
mid-clavicular line
E). Cover client anteriorly and positions
client facing away. (Or examiner
can go to other side of bed). Expose
the posterior chest.
4)
Find Posterior Land Marks
A) Locate 7th cervical spinous process
(ask client to flex neck so this is
easier to locate).
B) Palpate each spinous process down
to the 10th and 12th thoracic spinous
process.
12
Performance Comments
Satisfactory
Unsatisfactory
NOTE: The lower boarder of the lungs
is at the level of the 10th spinous process
on expiration and descends to the 12th
spinous process on inspiration.
5)
Auscultate Posterior Lung Sounds
A) Auscultate and listen for one full
inspiration and expiration at each
lung location.
B) Compare breath sound
characteristics of both lungs.
C) Follow sequence as shown in
picture:
6)
After auscultating lung bases, locate the
Lateral Lung Boarder. Follow the 10th
intercostals space around the side of the
(mid-axillary line) and count up to 2 ribs
to the 8th intercostals space. The inferior
boarder of the lungs laterally is
approximately at the level of the 8th rib
at the mid-axillary line.
12.
GU: Any hesitancy, frequency, burning, pain with
urination or change in urinary pattern?
13.
Abdominal Assessment: (GI Assessment)
(Have client lie supine and expose the abdomen
from the lower costal margin to the super-pubic
region).
13
Performance Comments
Satisfactory
Unsatisfactory
Ask the client when their last bowel movement
was. Any changes in bowel habits?
A.
Landmark Abdomen: (4 quadrants)
Visualize a vertical line and a horizontal line
crossing the umbilicus. Name the 4
quadrants:
ULQ – Upper Left Quadrants (on the client’s
side)
URQ – Upper Right Quadrant
LLQ – Lower Left Quadrant
LRQ – Lower Right Quadrant
B.
Inspection: Observe from both sides and
foot of the bed at eye level for:
i.
shape (rounded, conclave, or flat)
ii.
masses/deformities
iii. peristaltic movement
C.
Auscultation: (NOTE: Auscultation is done
prior to palpation to prevent increased bowel
sounds caused by palpation). Listen in all 4
quadrants until a bowel sound is heard in
each quadrant. *Must listen for a full 5
minutes before stating, “No bowel sounds.”
D.
Palpation: Light palpation of all areas of the
abdomen. Using pads of the fingers, palpate
no more than 1 inch deep, feeling for lumps
or masses. Ask if there is any tenderness.
NOTE: No palpation is done on any client
with undiagnosed abdominal pain.
14.
Peripheral Pulses & Circulation
Use the pads of the index and middle fingers for
palpation of pulses (total of 3 fingers).
A.
Upper Extremities
14
Performance Comments
Satisfactory
Unsatisfactory
1)
Radial Pulses: Locate radial artery on
the radial (thumb side) of the wrist. Feel
both right and left at the same time to
compare for symmetry.
NOTE: On actual client, if radial pulses
are present, you would not need to check
any more proximal pulses. For
demonstration purposes, you will need
to show location of all upper extremity
pulses on one arm.
B.
2)
Ulnar Pulse: Locate ulnar artery on the
opposite side of the wrist.
3)
Brachial Pulse: Locate the brachial
artery by finding the groove between the
biceps and triceps muscle above the
elbow at the anticubital fossa.
4)
Inspects and palpates for circulation
comparing for equality with the opposite
extremity:
a.
nail bed and skin color
b.
temperature
c.
capillary refill
d.
presence of edema
e.
characteristics of the most distal
pulse
Lower Extremities
1)
Dorsalis Pedis (PEDAL) Pulses:
Locate pedal pulse by placing fingertips
between the great and first toe and
slowly inching up the foot until the pulse
is palpable. Feel both right and left at
the same time to compare for symmetry.
NOTE: On actual client, if pedal pulses
are present, you would not need to check
any more proximal pulses. For
demonstration purposes, you will need
15
Performance Comments
Satisfactory
Unsatisfactory
to show location of all lower extremity
pulses on one leg.
2)
Posterior Tibial Pulse: Locate artery
by placing fingers behind and below the
medial malleolus on the inner aspect of
the ankle. (Cup fingers over ankle bone
pointing finger tips toward the heel.)
3)
Popliteal Pulse: Locate artery behind
the knee. Palpate with index and middle
fingers of both hands deeply into the
popliteal fossa just lateral to the mid
area of the knee. Ask client to keep leg
relaxed as you lift knee to slightly flex
it.
4)
Femoral Pulse: Expose inguinal area.
Locate artery midway between the
anterior superior iliac spine and the
symphysis pubis. (Student can
demonstrate the position to them self
during return demo).
5)
Inspect and palpate pulses and compare
the following for equality with the
opposite extremity for:
A) nail bed and skin color
B) temperature
C) capillary refill
D) presence of edema
E) characteristics of the most distal
pulse
15. Sensory Function Assessment
To assess sensory function (feeling), do the
following:
Ask the client if they have numbness, tingling, or
decreased ability to feel on any part of their body.
If so, identify the area and its boundaries.
16
Performance Comments
Satisfactory
Unsatisfactory
16.
Motor Function
A.
B.
Assess ROJM as follows:
1)
Ask the client to move each extremity
through the normal range of joint
motion. Model each movement for the
client. First arms, then legs.
2)
If client is unable to do this
independently, assess ROJM passively.
Assess Muscle Strength
Test by asking client to move actively
against your resistance or to resist your
movement. Compare symmetrical areas.
1)
Upper Extremities
A) At the elbow, test flexion and
extension by having the client pull
and push against your hand.
B) To test grip, ask the client to
squeeze 2 of your fingers. (Do both
hands simultaneously). Use the
index and middle fingers with the
middle fingers atop the index
fingers.
2)
Lower Extremities
A) While client is in sitting position,
test flexion and extension. Have
client push both legs forward
against examiner’s hands and pull
lower legs back as the examiner
tries to pull them forward.
B) At the ankle, test dorsiflexion, and
plantar flexion by asking the client
to pull up and push down against
your hand.
17
Performance Comments
Satisfactory
Unsatisfactory
C.
Posture
1)
Check current activity orders and if the
client is allowed out of bed, assist to the
standing position. Open gown and
visualize the client’s spine.
A) From the side, inspect the spinal
profile noting the cervical, thoracic,
and lumbar curves.
B) From behind, inspect for lateral
curves. Check for any differences
in the shoulder height, the iliac
crests, and the skin creases below
the buttocks.
D.
17.
Assess Gait
1)
Determine the client has an activity
order to ambulate. If so, determine if
client needs assistance (1 or 2 persons)
or any equipment (cane, crutches, or
walker). If needed, provide the
assistance/equipment needed.
2)
Have client walk and assess the gait
observing for balance, leg movement,
and arm movement.
Cover the client and assist them to a comfortable
position.
18. Make sure the bed is in low position, the side rails
are up, and the client has the call light.
19.
Document the findings accurately on the
appropriate section of the database tool which is
copied on this form. (See the following page.)
20.
Be able to explain the rationale for any step of the
procedure as requested by the instructor.
18
Adult Head-to-Toe Physical Assessment Worksheet
(This worksheet may be used during the Adult Head-to-Toe Physical Assessment Return Demo)
Objective: Distinguish between normal and abnormal.
Cognitive &
Sensory
Assessment
Cardiac
Assessment
(Chest
Assessment)
Respiratory
Assessment
GU
Abdominal
Assessment
Peripheral Pulses
& Circulation
Sensory
Function
Assessment
Motor
Function
General Appearance ______________
Behavior _______________________
Awake & Alert __________________
Orientation _____________________
Memory_______________________
Hearing________________________
Vision ________________________
Pupil Response__________________
Carotid Pulse____________________
Inspection ______________________
Palpation _______________________
Apical Pulse ____________________
Inspection ______________________ (If not completed with the Cardiac)
Palpation _______________________
Anterior Lung Sounds _____________
Posterior Lung Sounds _____________
Ask _____________________________
Ask ____________________________
Inspection ______________________
Auscultation ____________________
Palpation _______________________
Ask ____________________________
Radial __________________________
Nail bed_______________________
Ulnar __________________________
Temperature____________________
Pedal __________________________
Cap. Refill _____________________
Posterior Tibial __________________
Edema ________________________
Popliteal _______________________
Femoral _______________________
Characteristic of the most distal pulse ________________________________
Numbness/Tingling _______________
ROM _________________________
Posture ________________________
Gait ___________________________
(Revised 07/12)
19
Blood Glucose Testing
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 30 minutes
Supplies needed: Blood glucose monitor
Lancet
Test strips
Cotton balls
Alcohol wipe
Clean disposable gloves
Clean gauze (2x2) and Band-Aid
(if needed)
1.
Verify order, ID patient using two forms of
identification and provide for privacy.
2.
Turn on glucose monitor and press “continue.”
3.
Enter your operator ID.
4.
Select “Patient Test.”
5.
Enter the patient’s ID number or scan the patient’s
bar code on their identification bracelet.
6.
Select the test strip lot number or code on the
monitor screen to match the number/code on the
test strip bottle. You may need to scan the test strips.
7
Apply disposable gloves.
8.
Select a puncture site. For fingers, the lateral aspect
at the level of the nail bed is optimal. Avoid areas of
bruising, callouses, or multiple puncture sites.
9.
Cleanse the site with an alcohol wipe. Allow area
to dry or wipe with a cotton ball or 2x2 gauze.
10. Insert test strip into slot on glucose monitor. Read
results after monitor counts down.
11.
Use the lancet to puncture the chosen site. Apply a
large drop of blood to the test strip pad. Do not
add a second drop. Some meters may require for
you to insert test strip into slot on glucose monitor
first before using the lancet to puncture chosen
site. (See Blood Application picture on following
page.)
20
Performance Comments
Satisfactory
Unsatisfactory
12.
Dispose lancet device in sharps container. Discard
test strip and cotton ball or 2x2 gauze in trash
container.
13.
Assure puncture site is no longer bleeding.
14.
Document reading in patient’s chart, along with
any actions taken for abnormal readings.
21
Hand Washing
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 5 minutes
Supplies needed: Water
Soap
Paper towels
Hand Washing (with non-antiseptic soap) and
Antiseptic Hand Wash (soap contains antiseptic agent)
1.
Use technique when hands visibly soiled,
before eating, and after using the restroom.
2.
Stand away from sink so as not to touch sink.
3.
Turn on faucet to have warm (not hot) water.
4.
Wet hands and wrists with water.
5.
Keep fingers pointing down during hand
washing to prevent contaminating arms.
6.
Apply liquid soap. If you have to use bar soap,
rinse before applying.
7.
Rub hands together for at least 15 seconds
covering all surfaces of hands, fingers, and
wrists. May extend hand washing if indicated.
8.
Clean under your fingernails.
9.
Rinse hands and wrists under running water
keeping fingers pointed downward (water
should flow from wrists to hands).
10.
Dry hands and wrists thoroughly by using
single paper towels wiping in the direction
from finger tips to wrists. Dispose of each
paper towel after reaching the wrist. Do not
return to the fingers with a used paper towel.
(Will use multiple paper towels).
11.
Use a new clean and dry paper towel to turn off
faucets.
22
Performance Comments
Satisfactory
Unsatisfactory
12.
Repeat procedure at step 4 if your hands touch
the anytime between step 4 and 10.
Hand rubs: Use of a waterless antiseptic agent
containing alcohol to decontaminate hands.
1.
Use technique before and after direct patient
contact, after removing gloves, and after
contact with bodily fluids or excretions,
mucous membranes and would dressings,
provided hands are not visibly soiled.
2.
Apply agent to palm of one hand. (Use
volume of agent recommended by the
manufacturer.)
3.
Rub hands together covering all surfaces
including sides of hands and fingers.
4.
Continue rubbing until all surfaces are DRY.
5.
Do not use paper or cloth towels in conjunction
with waterless antiseptic agents.
23
24
25
26
27
28
29
Sterile Gloves
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 5 minutes
Supplies needed: Sterile Gloves
(in student nursing kit)
1.
Application of sterile gloves
A.
Wash hands thoroughly.
B.
Follow principles of surgical asepsis during
all movements.
C.
Place glove package on a clean, dry, firm
surface at waist length.
D.
Remove outer package wrapper by peeling
sides apart.
E.
Grasp inner package and lays it on a clean
flat surface.
F.
Open the package. Keep gloves on the
wrapper’s inside surface.
G.
Identify the right and left glove.
H.
Glove the dominant hand.
I.
With the thumb and first two fingers of the
non-dominant hand, grasp the edge of the
cuff of the glove for the dominant hand.
Touch only the inside surface of the glove
and keep finger pointed downward.
J.
Move back and away from the sterile field
and keep sterile glove above the waist and
in view at all times.
K
Pull the glove over the dominant hand.
L.
With gloved dominant hand, slip the finger
underneath the second glove’s cuff.
30
Performance Comments
Satisfactory
Unsatisfactory
2.
M.
Pull the second glove over the nondominant hand. Do not let any part of the
gloved hand touch the ungloved hand.
Keep thumb of dominant hand abducted
back.
N.
Keep both sterile gloves in front of you
above waist level.
Removal of contaminated gloves
A.
Grasp outside cuff of one gloved hand
without touching any bare skin.
B.
Peel glove off, turning it inside out and
discard glove in receptacle.
C.
Tuck 2 fingers of bare hand inside the
remaining glove’s cuff without touching
the contaminated portion of the glove.
D.
Peel glove off, turning it inside out and
discard glove in receptacle.
3.
Wash hands.
4.
Explain rationale for any step of the procedure as
requested by instructor.
31
Suture and Skin Staple Removal
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 10 minutes
Supplies needed: Suture removal kit
Skin staple remover
Clean gloves
Biohazard bag
Material to cleanse wound
4 x 4 with at least 5 interrupted
sutures
4 x 4 with a least 5 staples
1.
Check for doctor’s order to remove sutures or
skin staples.
2.
Gather equipment.
3.
Implement Initial General Steps.
4.
Put on gloves, remove and discard any
dressing. Remove and discard gloves.
5.
Wash hands.
6.
Observe wound characteristics.
7.
Suture Removal
A.
Open disposable suture removal kit.
B.
Put on clean gloves.
C.
Pick up suture scissors with dominant
hand.
D.
Place curved tip of suture scissors
under suture, next to the knot.
E.
Cut suture and with forceps pull suture
through skin with one movement.
(Refer to figure on next page.)
32
Performance Comments
Satisfactory
Unsatisfactory
NOTE: Remove every other interrupted
suture. Check incision line for gaping. If the
edges remain approximated, remove the rest of
the sutures.
8.
Discard suture material in biohazard bag.
Dispose of forceps and scissors in sharps
container.
9.
Skin Staple Removal
A.
Put on clean gloves.
B.
Obtain disposable staple remover.
C.
Place staple remover under the staple
and pinch down to exert pressure on its
center. (This motion raised the ends of
the staple, allowing it to be easily
removed.)
NOTE: Remove every other staple. Check
incision line for gaping. If the edges remain
approximated, remove the rest of the sutures.
10.
Discard staples and disposable staple remover
in sharps container.
11.
Observe the appearance of the wound;
approximation of the edges, presence of
inflammation and edema, and appearance of
any drainage.
12.
Clean wound, redress as ordered. Remove and
discard gloves.
13.
Document the procedure, observations of the
wound, and patient tolerance.
33
Opening Sterile Packages and Adding Sterile Items to the Sterile Field
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 5 minutes
Supplies needed: Sterile package with four flaps for
sterile field
Sterile item enclosed in package
with 1 flap
Sterile item enclosed in package
with 2 peel back (i.e., 2 x 2
dressing)
1.
Gather equipment.
2.
Demonstrate principles of surgical asepsis
during all movements.
3.
Establish sterile field. To open items
packaged in linen and commercially packaged
items with four flaps, the nurse:
A.
Removes any type or seal indicating
sterilization date.
B.
Grasps the outer surface of the tip of the
outermost flap.
C.
Opens the flap away from the body.
D.
Keeps the arm outstretched and away and
away from the sterile field.
E.
Grasps the outside surface of the first
side flap.
F.
Opens the side flap, allowing it to lie flat
on the table surface. Keeps arm to side
and not over sterile field.
G.
Repeats steps E and F for remaining
flaps.
4.
Sterile items are now added to the sterile
field.
5.
To open commercially packaged sterile items
enclosed in a wrapper with one flap and add
this item to the sterile field, the nurse:
34
Performance Comments
Satisfactory
Unsatisfactory
A. grasps the flap by the unsealed corner and
pulls flap away from self.
B. positions the pack so the open end faces the
sterile field.
C. holds open pack to the side of the sterile
field and about 6 inches above it.
D. allows contents to drop within sterile field.
6.
7.
To open commercially packaged sterile items
enclosed in a wrapper with two peel back flaps
and add this item to the sterile field, the nurse:
A.
Grasps both flaps and gently pulls them
apart.
B.
Holds package so open end is facing
sterile field.
C.
Folds flaps back so the outside of the
flaps cover hands.
D.
Holds package to the side of the sterile
field and about 6 inches above it.
E.
Allows contents to drop within the sterile
field.
Explain rationale for any step of the procedure
as requested by instructor.
35
Non-Sterile Dressing Change
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Clean, non-sterile dressing
Non-sterile gloves
Biohazard bag
Appropriate screening to provide
for privacy
Sterile saline
Materials to cleanse site of wound
1.
Assemble equipment, knock on client’s door,
introduce self and identify the client by
checking the arm bracelet or using facilityapproved and accepted method of
identification.
2.
Provide for privacy for the client. Explain
procedure to client.
3.
Wash hands. Put on non-sterile gloves. Grasp
old dressing with covered hand and pull off
dressing. Turn covering inside-out over the
old dressing.
4.
Ensure proper disposal of old dressing
following agency protocol. Arrange supplies.
5.
Cleanse the wound. Sterile saline is the
cleansing agent of choice. Topical antiseptics
(i.e., povidone-iodine, hexachlorophene,
alcohol or boric acid) may be used on intact
skin surrounding the wound but should never
be used within the wound or if allergy is noted
to any of these products.
6.
Allow skin to dry; prepare clean dressing.
7.
Apply clean dressing to wound.
8.
Remove any materials used to apply the nonsterile dressing, cleansing any items prior to
storage. Discard non-sterile gloves according
to facility policy and procedure.
36
Performance Comments
Satisfactory
Unsatisfactory
9.
Ensure that client is in a comfortable and safe
position. Leave call light, telephone and
fresh water close at hand; return bed to lowest
position; remove any screening used for
privacy, wash hands.
10.
Report and record any significant observations
(i.e., wound size, color, drainage).
37
Sterile Dressing Change
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Sterile materials for dressing
change
Tape
Sterile gloves
Disposable gloves
Biohazard bag
Appropriate screening
Sterile saline to loosen the dressing
Sterile cleansing materials for the
wound
1.
Assemble equipment, knock on client’s door,
introduce self and identify the client by
checking the arm bracelet or using facilityapproved and accepted method of
identification.
2.
Provide for privacy for the client. Explain
procedure to client.
3.
Wash hands.
4.
Use sterile technique and observe universal
precautions during dressing change.
5.
Remove the old/soiled dressing:
A. Put on disposable gloves.
B. Loosen dressing by removing tape from
skin. Use care not to disturb wound
closures or any newly formed tissue.
C. Remove old/soiled dressing. Use
sterile water or sterile saline to loosen
the dressing, if needed. Do not moisten
“wet to dry” dressings.
D. Place old/soiled dressings in waterproof
bag for disposal.
38
Performance Comments
Satisfactory
Unsatisfactory
6.
Assess condition/characteristics of the wound:
color, skin characteristics, presence of
drainage, characteristics or any drainage,
and security of wound closure.
7.
Remove gloves. Establish safe, clean site for
sterile dressing supplies.
8.
Open sterile supplies and cleansing materials.
9.
Put on gloves using sterile technique.
10.
Cleanse the wound using supplies provided
and observing the following principles:
A. Cleanse from top to bottom of wound.
B. Cleanse from center of wound to periphery
of wound.
C. Use cleansing items for one pass over the
wound.
D. Discard used cleansing items.
E. Place materials used for cleansing in a
moisture-proof bag.
11.
Redress wound; apply smaller non-adhering
dressing to wound followed by primary
dressing designed to collect drainage.
12.
Cover entire wound with secondary, larger
dressing.
13.
Remove gloves. Secure dressing with tape.
14.
Remove any materials used to change the
sterile dressing. Dispose of soiled/old
dressings and materials following facility
guidelines.
15.
Ensure that client is in a safe and comfortable
position. Leave call light, telephone and fresh
water close at hand. Return bed to lowest
position. Remove any screening used for
privacy.
39
Performance Comments
Satisfactory
Unsatisfactory
16.
Wash hands.
17.
Report and record characteristics of the wound,
amount and type of drainage and
characteristics of skin surrounding the wound.
40
Pulse Oximeter
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Pulse Oximeter
1.
Evaluate for presence of any factors which
could interfere with accuracy of reading of
arterial oxygen saturation levels including
degree of light, client movement, temperature,
blood pressure level and vasoconstriction and
nail polish. (Remove dark nail polish.)
2.
Read the monitor recording of oxygen
saturation levels.
3.
Protect the transducer from strong light. Check
the skin with monitor placement for abrasion
and vascular insufficiency. Compare pulse
reading and client’s actual pulse and report any
discrepancies.
4.
Assess for adequacy of placement. Rotate the
transducer every four hours to discourage skin
impairment.
5.
Ensure that client is in a comfortable and safe
position. Leave call light, telephone and fresh
water close at hand; return bed to lowest
position; remove any screening used for
privacy; remove soiled linens; wash hands.
6.
Invite visitors to return to bedside.
7.
Report readings as required by agency
protocol.
8.
Chart the following:
A. Initial assessment findings that warrant use
of oximeter.
B. Subsequent respiratory assessments.
C. Actual pulse oximeter readings.
41
Female Cath
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Catheter tray and drainage bag
Velcro catheter strap
Disposable gloves
Wash cloth
Soap & water
Bath towel
Bath blanket
Source of extra light
Two plastic bags
Waste receptacle
1.
Check for iodine allergy. Ask client about
iodine allergy prior to procedure.
2.
Provide for privacy and explain purpose of
procedure. Explain steps of procedure as you do
them.
3.
Don clean gloves and wash perineum with soap
and water, if necessary.
4.
Remove gloves and wash hands.
5.
Raise bed to working height. Place over bed
table with equipment on it perpendicular to bed
on dominant side.
6.
Position client in dorsal recumbent position.
Drape bath blanket in diamond fashion over
client. Wrap one corner of blanket around
each foot. Leave perineum covered.
7.
Open sterile catheterization tray according to
directions on package. Open package with
four flaps, making sure not to reach over the
sterile field and do not allow wrapper to hang
over the sides of the over bed table.
8.
Follow principles of surgical asepsis during all
movements. Instruct client to keep hands
folded on chest during procedure and to refrain
from moving, if possible.
42
Performance Comments
Satisfactory
Unsatisfactory
9.
Expose perineal area. If a second person is
available, he or she may expose the perineal area.
10.
Don sterile gloves.
11.
Prepare items in catheter kit on overbed table
before transferring the tray to the bed.
A. Move sterile container close to your side
of the field to avoid reaching over the
field when preparing the items.
B. Open antiseptic solution & simulate pouring
contents over sterile cotton balls. Discard
antiseptic solution package. When discarding
items allow them to drop into a receptacle;
remembering to keep sterile hand above the
waist.
C. Connect syringe to port.
D. Simulate lubricating catheter tip (2-3 inches)
without plugging drainage port and
discard this package.
12. Pick up solid sterile drape, allow it to unfold,
and allow top edge of drape to form a cuff over
both hands. Ask the client to raise hips off
of the bed and slip the cuffed edge just under
the client's buttocks. Avoid contaminating
gloves.
13. Place sterile catheter tray and tray with cotton
balls on sterile drape between client's thighs.
NOTE: If client is unable to remain still, keep
sterile trays on over bed table and position within
reach.
14.
With non-dominant hand, retract labia outward
and upward to fully expose the meatus.
Maintain this position during the procedure.
15.
With dominant hand, pick up a cotton ball with
forceps and cleanse perineal area. Wipe
from front to back, clitoris towards anus, in
over meatus. Use a new sterile cotton ball for
each wipe. Do not cross over the sterile tray
discarding them.
43
Performance Comments
Satisfactory
Unsatisfactory
16.
With dominant hand, pick up catheter about 2
inches from the tip. Make sure the catheter end is
over the collection basin or attached to drainage
bag.
17.
Ask the client to take a deep breath and slowly
insert catheter until urine appears (about 3
inches). If the catheter is inserted into the
vagina, leave it in the vagina and insert another
sterile catheter into the urinary meatus. Then,
remove the first catheter from the vagina.
18. When urine appears, advance catheter another
2 to 3 inches. Do not force catheter against
resistance.
19.
Release labia and holds catheter with
non-dominant hand about 1" from meatus.
20.
Inject total amount of solution into port. If the
client experiences pain, aspirate back solution
and advance catheter farther. (Actually insert
water into catheter with demonstration
manikin). Maintain pressure on plunger
of syringe until syringe is disconnected.
21.
Pull gently on catheter to feel resistance.
Move non-dominant hand to syringe part and
disconnect syringe from catheter.
22.
Obtain sterile urine specimen if ordered.
23.
Utilize Velcro foley catheter strap to secure the
catheter tubing to the client’s upper leg. If the
catheter is secured to the right thigh, hang the
bag on the right side of the bed frame.
24.
Place excess coil of tubing on bed and fasten
it to the bottom sheet with a clip.
25.
Discard equipment. Cover the client, lower
bed height, put the side rails up, and give the
call light to the client.
26.
Moisten wash cloth with warm water. Return
to bedside. Cleanse and dry the perineum,
remove gloves properly, and cover the client.
44
Performance Comments
Satisfactory
Unsatisfactory
27.
Assist the client to a comfortable position.
28.
Teach client as appropriate:
A.
the importance of fluids
B.
to keep the bag off of the floor and below
the level of the bladder
C.
how to hold the catheter when walking
D.
the importance of keeping the tubing
taped to the thigh
E.
not to lie on the tubing
F.
not to pull on the catheter
G.
to cleanse around the catheter site with
soap and water daily
29.
Tie knot in plastic bag and remove it from
the waste receptacle. Place clean plastic bag
in the receptacle.
30.
Wash hands.
31.
Discard plastic bag in dirty utility room.
32.
Wash hands.
33.
Chart – Utilizing Nursing Notes at end of booklet:
A.
Catheter size and balloon volume
B.
Amount and characteristics of urine obtained
C.
Catheter secured to leg with tap
D.
Connected to closed drainage system
E.
Client teaching done
F.
Client's response to the procedure
45
Male Catherization
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Catheter tray and drainage bag
Wash cloth, soap, water, bath towel
Bath blanket
Source of extra light (flashlight,
gooseneck lamp)
Velcro catheter-strap
Disposable gloves
Sterile gloves
Two plastic bags
Waste receptacle
1.
Check for iodine allergy. Ask client about
iodine allergy prior to procedure.
2.
Provide for privacy and explain purpose of
procedure. Explain steps of procedure as you do
them.
3.
Don clean gloves and wash perineum with soap
and water, if necessary.
4.
Remove gloves and wash hands.
5.
Follow sterile asepsis during procedure.
6.
Put on clean gloves and wash penis with soap and
water if necessary. If uncircumcised, retract
foreskin to cleanse the urethral meatus.
7.
Remove gloves and wash hands.
8.
Raise bed to working height.
9.
Place overbed table perpendicular to bed on
dominant side and place equipment on table.
10.
Position client in supine position.
11.
Cover client’s upper trunk with bath blanket and
covers lower extremities with the bed sheets.
Places clean towel over perineum.
46
Performance Comments
Satisfactory
Unsatisfactory
12.
Open sterile catheterization tray according to
directions on package. Open package with
four flaps, making sure not to reach over the
sterile field and do not allow wrapper to hang
over the sides of the over bed table.
13.
Instruct client to keep his hands away from
sterile field and to refrain from moving during
procedure.
14.
Expose perineal area.
15.
Put on sterile gloves.
16.
Lift sterile drapes out of catheterization tray
and lay on sterile field (wrapper of tray).
17.
Open antiseptic solution and simulate pouring
contents over sterile cotton balls.
18.
Connect syringe to port, and leave syringe
connected to port.
19.
Simulate lubricating catheter liberally for about
3-5 inches.
20.
Position sterile drapes.
A. Pick up solid drape by corner and allow it
to unfold. Place over client’s thighs just
below perineal area.
B. Pick up fenestrated drape and allow it to
unfold. Place hole over penis.
21.
With non-dominant hand, retract the foreskin of
the uncircumcised male. Firmly grasp the
penis shaft just below the glans.
22.
With dominant hand, pick up cotton ball with
forceps and clean the glans. Move in a
circular motion from the meatus around the
glans down to the base of the glans. Repeat
cleaning motion three to four more times using
a new cotton ball each time.
47
Performance Comments
Satisfactory
Unsatisfactory
23.
With dominant hand, pick up catheter 3-5
inches from tip, and avoid getting lubricant on
gloves. (Lubricant is very slippery and may
cause nurse to lose grip.)
24.
Lift penis to a position perpendicular to client’s
body and apply light traction. Instruct client to
bear down as if to void and slowly insert
catheter into meatus.
25.
Make sure catheter end is over collection basin
or attached to drainage bag.
26.
Advance the catheter up to the “Y” at the port or
until urine returns (at least 7-8 inches for an
adult or 2-3 inches for a young child).
27.
Advance catheter (1-2 inches, if possible) to
allow for balloon to expand in bladder. Hold the
catheter about 1” away from the meatus, with the
non-dominant hand.
28.
Inject solution into balloon through port. If
client complains of discomfort, deflate balloon,
advance catheter and then reinflate balloon.
29.
Gently pull on catheter to feel resistance. (This
determines that balloon has inflated
sufficiently.) Maintain pressure on the plunger
of syringe until the syringe is disconnected.
30. If urine is being collected in basin or drainage
bag, note amount that has been obtained. Obtain
urine specimen if ordered.
31.
Attach bag to the side of the bed frame.
32.
Utilize Velcro leg strap to secure the catheter
tubing to the client’s upper leg.
33.
Coils excess tubing on bed and fastens to
bottom sheet with clip.
34.
Teach client the following as appropriate:
A. Why increasing fluid intake is
important.
48
Performance Comments
Satisfactory
Unsatisfactory
B. Keeping bag off the floor and below
bladder level.
C. How to hold catheter when walking.
D. Importance of keeping catheter secured to
body.
35.
E.
Avoid tugging on catheter.
F.
How to cleanse around catheter with
soap and water when bathing.
Chart – Utilize Nursing Notes at end of booklet:
A. Catheter size and balloon volume.
B.
Amount and characteristics of urine
obtained.
C.
Closed drainage system connected.
D. Catheter taped in place.
E.
Client teaching given.
F.
Client’s response to procedure and
teaching.
49
Indwelling Catheter Management: From Habit-based to
Evidence-based Practice
Author(s):
JoAnn Mercer Smith, BSN, RN, CWOCN
Pretesting silicone balloons is not recommended; the silicone can form a cuff or crease at the balloon
area that can cause trauma to the urethra during catheter insertion.10,13
Inflation
Much confusion exists about the proper volume to be used for balloon inflation. The guiding
principle is to follow the manufacturer’s instructions. Catheter manufacturers test their balloons to
determine the amount of fluid required to obtain a symmetrical balloon. Under- or overinflation can
result in an asymmetrical balloon, which can deflect the catheter tip to one side. This deflection can
cause occlusion of the drainage eyes, irritate the bladder wall, and lead to bladder spasms (see Figure 1
and Figure 2). In general, a 5-cc balloon requires about 10 cc of fluid for symmetrical inflation.
Manufacturers recommend that sterile water be used to fill catheter balloons; normal saline can lead to
crystal formation in the inflation lumen (and difficulty deflating the balloon), and
inflation with air will cause the balloon to float in the bladder.24 Silicone catheter
balloons can lose fluid over time as fluid diffuses out into the urine; therefore, fluid
levels should be checked at least every 2 weeks and fluid added as needed.25
Catheter Securement
All urinary catheters should be secured, yet securement is not routinely performed in practice.
Unsecured urinary catheters can lead to bleeding, trauma, pressure sores around the meatus, and bladder
spasms from pressure and traction.26 It is recommended that the catheter be secured to the thigh for
women and to the upper thigh or lower abdomen for men. The lower abdominal position in men
decreases the potential for pressure necrosis and urethral erosion at the penile-scrotal junction.24
Ambulatory men may find abdominal securement difficult; these patients can be instructed to secure the
catheter to the upper thigh in the daytime and to change the position to the lower abdomen for sleep.
Many securement devices are available, including adhesive, non-adhesive straps and catheter-specific
anchors. A new catheter specific anchor (StatLock Foley™, Venetec International®, Inc. San Deigo,
Calif. ) offers advantages that include a reclosable locking mechanism that swivels as the patient moves
and an adhesive comfort pad that can be left in place for up to 1 week without altering skin integrity.26
Whatever product is selected, nurses should instruct patients in the proper use and removal of the
securement device.
Urine Collection
Drainage bags now come with a special “safe sampling” port designed to obtain urine specimens
while maintaining a closed system. The CDC recommends that urine specimens be obtained directly
through these ports using an aseptic technique.8 The drainage tubing is occluded below the port
temporarily, allowing the urine to collect in the tubing. The port is swabbed with alcohol, and the urine
is withdrawn following manufacturer’s instructions using a needle, blunt cannula, or luer lock syringe.
50
Urine for a culture and sensitivity should be obtained from a newly inserted catheter and drainage bag to
avoid culturing the system (catheter and drainage bag) rather than the urine.
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Nursing. 1996;16:140–144.
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3. Maki DG, Tambyah PA. Engineering out the risk of infection with urinary catheters. Emerg Infect Dis.
2001;7(2)342–347.
4. Wilde M. Meanings and practical knowledge of people with long-term urinary catheters. Journal of Wound
Ostomy Continence Nursing. 2003;30(1):33–39.
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catheters in preventing urinary tract infection. Arch Intern Med. 2000;160(17):2670–2675.
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in Adults. Acute and Chronic Management. Rockville, Md. US Department of Health and Human Services.
Public Services Agency for Health Care Policy and Research; March 1996. AHCPR Publication No.96-0682.
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Disease Control and Prevention. 1981;Feb. [serial online]. Available at:
http://www.cdc.gov/ncidod/hip/GUIDE/uritract.htmnece. Accessed September 8, 2003.
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quadriplegics? A comparative study of suprapubic cystostomy and clean intermittent catheterization. Eur Urol.
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Allergol Clin Immunol. 1999;9(6):356–360.
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Devices; User Labeling, Federal Register 1997;62(189):51021–51030.
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a prospective clinical trial. British Journal of Urology. 1985;57(3):325–328.
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19. Salgado CD, Karchmer TB, Farr BM. Prevention of catheter-associated urinary tract infections. In: Wenzel
RP, ed. Prevention and Control of Nosocomial Infections, 4th ed. Philadelphia, Pa.: Lippincott Williams &
Wilkins; 2003;297–311.
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21. Newman DK. Managing indwelling urethral catheters. Ostomy/Wound Management. 1998;44(12):26–35.
22. Chinnes L, Dillion A, Fauerbach L. Home Care Handbook of Infection Control 2002. Washington, DC:
Association of Professionals in Infection Control and Epidemiology (APIC);2002.
23. Gerard L, Sueppel C. Lubrication technique for male catheterization. Urology Nursing. 1997;17(4):156–158.
24. Cancio LC, Sabanegh ES JR, Thompson IM. Managing the foley catheter. Am Fam Physician.
1993;48(5):829–836.
25. Wilde M. Long-term indwelling urinary catheter care:conceptualizing the research base. J Adv Nurs.
1997;25(6):1252–1261.
26. Hanchett M. Techniques for stabilizing urinary catheters. Am J Nurs. 2002;102(3):44–48.
27. Getliffe K. Managing recurrent urinary catheter blockage: problems, promises and practicalities. Wound
Ostomy Continence. 2003;30(3):146–151.
51
28. Dille C, Kirchhoff K. Increasing the wearing time of vinyl urinary drainage bags with bleach. Rehabilitation
Nursing. 1993;18(5):292–295.
29. Rutala WA, Barbee SL, Aquiar NC, et al. Antimicrobial activity of home disinfectants and natural products
against potential human pathogens. Infect Control Hosp Epidemiol. 2000;21(1):33–38.
30. Daifuku R. Stann WE. Association of rectal urethral colonization with urinary tract infection in patients with
indwelling catheters. JAMA. 1984;252(15)2028–20230.
31. Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents. 2001;17(4):299–303.
32. Maki DG, Knasinski V, Halvorson K, Tambyah PA. Risk factors for catheter-associated urinary tract
infection: a prospective study showing the minimal effect of catheter care violations on the risk of CAUTI
(abstract). Infect Control Hosp Epidemiol. 2000;21:165.
33. Stickler DJ. Bacterial biofilms and encrustations of urethral catheters. Biofouling. 1996;94:293–305.
34. Donlan RM. Biofilms and device-associated infections. Emerg Infect Dis CDC. 2001;(7)2:277–281.
35. Kunin CM, Chin QF, Chambers S. Formation of encrustations on indwelling urinary catheters in the elderly: a
comparison of different types of catheter materials in “blocker” and “nonblocker”. J Urol. 1987;138(4):899–902.
36. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic; a prospective study
of 1,497 catheterized patients. Arch Intern Med. 2000;160(5):678–682.
37. Gammack JK. Use and management of chronic urinary catheters in long-term care: much controversy, little
consensus. Journal of the American Medical Directors Association. 2002;3(3):162–168.
38. McGeer A, Campbell B, Emori TG, et al. Definitions of infection for surveillance in long-term care facilities.
Am J Infect Control. 1991;19(1):1–7.
39. Switters DM. Assessing leakage from around the urethral catheter. Urological Nursing. 1989;9(3):8–10.
40. Bhatia NN, Bergman A. Cystometry: unstable bladder and urinary tract infection. Brit J Urol.
1986;58(2):134–137.
41. Ziemann LK, Lastauskas NM, Ambrosini G. Incidence of leakage from indwelling urinary catheters in homebound patient. Home Healthcare Nurse. 1984;2(5):22–26.
42. Stickler DJ. Hewitt P. Activity of antiseptics against biofilms of mixed bacterial species growing on silicone
surfaces. Eur J Clin Microbiol Infect Dis. 1991;10:416–421.
43. Morris NS, Stickler DJ. Does drinking cranberry juice produce urine inhibitory to the development of
crystalline, catheter-blocking Proteus mirabilis biofilms? BJU Int. 2001;88(3):192–197.
52
Catheter Irrigation
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 10 minutes
Supplies needed: Catheter irrigation set
Sterile irrigating solution
Disposable gloves
Alcohol wipes
Towel
1.
Follow asepsis during procedure.
2.
Put on clean gloves.
3.
Pour solution into basin properly, then recap
bottle.
4.
Aspirate 30 ml of solution into syringe.
5.
Expose catheter-drainage tubing junction and
place a clean towel under this area. Place
basin within reach of working area.
6.
Open one edge of alcohol wipe packet.
7.
Remove protective covering and separate tubing
from catheter. Insert end of tubing into wrapper
from the alcohol wipe. Hold end of catheter in
non-dominant hand while tucking tubing under
draw sheet or towel in a manner to prevent it
sliding off of the bed.
8.
Wipe end of catheter with alcohol wipe. Insert
tip of irrigating syringe into distal end of
catheter. Hold catheter and irrigating syringe
perpendicular to the floor. Slowly inject the
30cc. of solution.
9.
Pinch catheter with finger of non-dominant hand
and remove syringe.
10.
Hold end of catheter over basin and allow
urine to drain until flow stops.
11.
Repeat steps 9 through 11 as necessary until
urine flows freely.
53
Performance Comments
Satisfactory
Unsatisfactory
12. Retrieve drainage tubing. Wipe across opening
of drainage tubing and catheter with a new
alcohol wipe.
13.
Reconnect catheter to drainage tubing while
maintaining sterility of system.
14.
Implement Closing General steps.
15.
Chart the following:
A.
Amount and type of sterile solution used
B.
Number of irrigations needed
C.
Color and character of return
D.
Amount of urine returned (subtract amount
of solution used from total return)
E.
How client tolerated procedure
54
Catheter Removal
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 10 minutes
Supplies needed: Sterile syringe (no needle) larger
than the balloon size of the
catheter you are removing
Disposable gloves
Bath towels and washcloth
Paper towels
Plastic bags
Waste receptacle
Appropriate urine collection device
1.
Check physician’s most current order.
2.
Wash your hands.
3.
Introduce self to the client, unless you already
have done this.
4.
Identify client by asking them to state their
name and checking their wrist band.
5.
Explain the procedure and provide for privacy.
6.
Elevate bed to working height and assist the
client to a supine position. Ask the female
client to abduct her leg.
7.
Remove Velcro strap anchoring catheter to
client’s leg.
8.
Don clean gloves.
9.
Place bath towel between the female client’s
thighs with one edge under the buttocks. If the
client is a male, place a towel over his thighs
and under his penis.
10.
Keep client draped with top covers.
11.
Assess the balloon size, as indicated on the
balloon injection port of the catheter, to
determine the approximate amount of fluid in
the balloon. Insert the syringe into the balloon
injection port. Turn the syringe clockwise so it
fits well into the port & withdraw all fluid.
55
Performance Comments
Satisfactory
Unsatisfactory
12.
Tell client they may feel a burning sensation as
the catheter is withdrawn.
13.
Hold a paper towel under the catheter tubing
close to the insertion site. Pull the catheter out
smoothly and slowly; collecting it in the paper
towel.
14.
Cover the client with the top sheets.
15.
Tell the client they may experience some
burning when urinating for the first time. Ask
the client to urinate in a collection device so
the amount can be measured and to call the
nurse each time they urinate.
16.
Disconnect catheter from tubing and discard
paper towel and catheter in waste receptacle.
17.
Cleanse perineal area with soap and water and
dry. Remove towel beneath them. Cover
client.
18.
Assist client to a comfortable position.
19.
Lower bed height. Make sure side rails are up
and give the client the call light.
20.
Empty catheter drainage bag into graduated
container. Place spigot over container.
Unclamp spigot and drain urine from the bag.
Place container on a flat surface and assess the
amount of urine present at eye level.
21.
Discard drainage bag.
22.
Remove gloves.
23.
Tie knot in plastic bag and remove it from
waste receptacle. Place clean plastic bag in the
receptacle.
24.
Wash hands.
25.
Document amount of urine drained from bag
on the client’s I & O sheet.
26.
Discard plastic bag in dirty utility room.
56
Performance Comments
Satisfactory
Unsatisfactory
27.
Wash hands.
28.
Chart:
29.
A.
Time catheter removed.
B.
Characteristics of urine and amount of
drainage bag.
C.
Client’s response to the procedure.
Provide a collection device, as directed below,
and write the client’s name and room number
on it. The urine collection device may be
taken to the room before or after the procedure.
A.
B.
Ambulatory Client
1)
Man - provide urinal
2)
Woman - provide specimen hat
3)
Explain procedure for use
4)
Store device in the bathroom
Bedridden Client
1)
Man - provide urinal, explain
procedure for use and place within
reach.
2)
Woman - provide bedpan and store
in a drawer of the bedside
nightstand.
3).
Follow-up care includes:
A ) Maintaining I & O.
B) Encouraging 2-3L of fluid per
day unless contraindicated.
C) Assessing for signs of urinary
retention and notifying the
physician if these occur.
57
Performance Comments
Satisfactory
Unsatisfactory
D) Notifying the physician if the
client is unable to void within 8
hours of removal or if the client
has signs of urinary retention or
discomfort.
After the catheter has been
removed, this time frame may
be less than 8 hours depending
on the client’s condition,
treatment regimen, or
physician’s order. A bladder
scan may also be
utilized/ordered to assist with
determining urinary retention.
E) Reporting to the nurse working
the next shift the time the
catheter was removed and
whether or not the client voided.
58
Care for and Monitor a Peripheral IV Site
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 5 minutes
Supplies needed: Clean Gloves
1.
Wash hands and don clean gloves.
2.
Identify the patient.
3.
Introduce yourself.
4.
Explain the procedure.
5.
Provide for privacy.
6.
Observe the IV site, noting any redness,
swelling, or drainage.
7.
Assess the dressing, reinforcing if necessary.
8.
Remove gloves and wash hands.
9.
Document date, time, any observations about
the IV site, name and title.
59
IV Equipment Set-Up
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Correct solution
IV tubing & label
IV pole
Disposable gloves
Needleless adaptor
Saline flush
1.
Open sterile packages using aseptic technique.
2.
Check solution, using 8 “Rights” of drug
administration (drug, dose, client, route,
time, allergies, expiration date,
documentation), comparing with order, label
bag with patient name, ID information, room
number, date, time, solution, expiration date,
and any additives. Initial the label.
3.
Open tubing set, maintaining sterility of both
ends.
4.
Place roller clamp about 2-4 cm (1-2 in) below
drip chamber, and move roller to off position.
5.
Hang bag on IV pole.
6.
Insert tubing set spike into IV fluid bag
A. Remove protective cover from IV bag
without touching opening & maintaining
sterility.
B. Remove protector cap form tubing
insertion spike, not touching spike, and
insert spike into opening of IV bag.
7.
Prime tubing
A. Compress drip chamber, release & fill to
line.
B. Remove protective cap at end of tubing and
attach needleless adaptor. Release roller
clamp, slowly allowing fluid to travel from
60
Performance Comments
Satisfactory
Unsatisfactory
drip chamber through tubing. Be sure to
invert filter & y-site & tap as fluid flows
through. Return roller clamp to off
position after tube is filled.
C. Be certain tubing is clear of air bubbles.
D. Replace cap protector.
E. Attach label to tubing indicating
date/time/initials.
8.
Put on gloves and inspect site of IV infusion
for complications (redness, swelling,
tenderness, induration, etc.) If complications
are present, discontinue the site.
9.
Set up IV pump – set rate according to
physicians order with ml per hour.
10.
Remove gloves and dispose of equipment
properly.
11.
Record in nurses’ notes type of fluid, flow rate,
and time infusion was begun as well as site
condition, patient’s response and teaching
performed.
12.
Observe client at least every hour or as needed
to determine response to fluid therapy:
A. Correct amount of solution infused as
prescribed
B. Proper flow rate ml/hour
C. Patency of IV catheter or needle
D. Absence of infiltration, phlebitis, or
inflammation
61
Discontinuing an IV
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Disposable gloves
Bandaid
Sterile gauze dressing (2x2)
Tape
Adhesive remover (if needed)
1.
Identify the patient.
2.
Wash hands and put on gloves.
3.
Close the flow clamp and disconnect tubing
from needleless adapter.
4.
Inspect site for complications (redness,
swelling, tenderness, induration, etc).
5.
Remove all the tape except the last piece
holding the cannula.
6.
While holding the hub, remove the last piece of
tape.
7.
Remove the cannula by pulling it out in a
direct line opposite to insertion.
8.
Gently press a sterile 2 x 2 over the entry site
as the cannula is being removed until bleeding
stops. Check cannula for visual intactness.
9.
Apply band-aid to site.
10.
Dispose of equipment properly. Dispose of
tubing, bag in soiled waste container.
11.
Remove gloves and cleanse hands.
12.
Chart the procedure: Time and date, reason for
discontinuing, condition of the site, nursing
interventions, amount of IV infused, visual
intactness of cannula, and client response, and
any teaching done.
62
Saline Lock Flush
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Clean gloves
Alcohol swabs
Syringes (needleless)
0.9 Sodium Chloride (normal
saline)
1.
Review agency policy regarding amount of
saline & frequency of saline flush.
2.
Peripheral venous access devices (VADs) shall
be flushed with a minimum of 3 ml of normal
saline (0.9 sodium chloride).
3.
Routine flushing shall be performed every shift
if not in use, or with the following:
A. Administering of blood and blood
components
B. Blood sampling
C. Administration of incompatible
medications or solutions
D. Administration of medication
E. Intermittent therapy
F. When converting between intermittent and
continuous therapies
4.
Prior to beginning procedure:
A. Use aseptic technique and observe
standard precautions throughout
procedure.
Saline Lock Flush
With saline (0.9% sodium chloride,
injection) only: Flush with saline to
maintain patency of intermittent VADs.
63
Performance Comments
Satisfactory
Unsatisfactory
B. Cleanse access port with antiseptic
solution.
C. Connect saline-filled syringe to catheter
via insertion into prepared injection/access
port.
D. Slowly aspirate until positive blood flow is
obtained to confirm catheter patency.
E. Slowly inject flush, maintaining positive
pressure.
F. Disconnect syringe from injection/access
port.
64
Administering IV Push Medication (Existing Line and Saline Lock)
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: IV push (existing line) or IV push
(IV lock)
Medication in vial or ampule
Syringe (3 to 5 ml)
Syringe (3 ml)
Sterile needles (21 and 25 gauge)
or needleless device
Antiseptic swab
Vial of heparin flush solution (1 ml
+ 100 units or 1 ml + 10 units)
or vial of normal saline
(depending on agency policy)
Disposable gloves
Watch with second hand or digital
read out
1.
Check physician’s order for type of medication
to be administered, dosage and route. Assess 8
“Rights” (drug, dose, client, route, time,
allergies, expiration date, documentation).
Bring medication book. A drug will be
selected for you to look up and explain. Be
able to indicate over what period of time the
medication is to be administered.
2.
Prepare equipment and assemble three 3 cc
syringes and label 2 as NS and 1 as the
medication; alcohol wipes, gloves. Keep end of
syringe sterile.
Note: Facility policy will dictate how much
saline to use.
3.
Prepare ordered medication from vial or
ampule. Read package directions carefully for
proper IV dilution of medication, if needed.
Determine if IV incompatibilities exist with IV
fluid/IV medication concurrently administered
and time period over which it is to be given.
4.
Wash hands.
65
Performance Comments
Satisfactory
Unsatisfactory
5.
Administer medication by IV push (existing
line):
A. Check client’s identification by looking at
armband and asking name. Compare with
patient’s MAR.
B. Observe site.
C. Select injection port of IV tubing closest to
client and prior to the filter.
D. Clean off injection port with antiseptic
swab. Allow to dry.
E. Connect tip of syringe to injection port.
F. Inject medication slowly over time period
indicated. (Read direction on drug
package. Check for compatibility of drug
and existing IV fluid/medication added.)
Use watch to time administrations.
G. After injecting medication, release tubing,
withdraw syringe, and recheck fluid
infusion rate. (Be sure to maintain positive
pressure on syringe plunger whenever
using a syringe.)
6.
IV Push Medication (Saline lock)
Using SAS (Saline-Administration-Saline)
method.
A. Cleanse access port with antiseptic
solution.
B. Connect first saline-filled syringe to
injection/access port.
C. Slowly aspirate until positive blood return
to confirm catheter patency.
D. Flush with saline.
E. Cleanse port with appropriate antiseptic
solution.
66
Performance Comments
Satisfactory
Unsatisfactory
F. Connect medication to injection/access
port.
G. Administer medication as stated in drug
book.
H. Disconnect medication from injection/
access port.
I. Cleanse injection/access port with
appropriate antiseptic solution.
J.
Connect second saline-filled syringe to
injection/access port.
K. Flush with saline.
L. Disinfect injection/access port with
appropriate antiseptic solution.
7.
Post-Flush
A. Monitor patient’s response.
B. Discard used supplies in appropriate
receptacles.
C. Remove gloves.
D. Wash hands.
E. Document in patient’s medical record:
1) Amount of saline used.
2) Condition of the site.
3) Any problems encountered in flushing
and action taken.
4) Response of client and teaching done.
5) Any adverse reactions to medication
67
Administering IV Medication by Secondary Set (IVPB)
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Drug book
Disposable gloves
Alcohol swabs
Correct medication
Syringes (10 ml needeless)
Metal hook (optional)
For this demo, you need to go review pump operation
instructions (printed on pump and enclosed in your IV
Therapy objectives booklet). A pump problem will be
provided for you to solve. Practice using the pump
before your demo time.
1.
Check physician’s order to determine type of
medication and dosage and type of solution to
be used. Assess 8 “Rights” (drug, dose, client,
route, time, allergies, expiration date,
documentation).
A drug will be selected for you to look up and
explain. Be able to calculate the rate which the
medication is to be administered. Assess
compatibility of drug and primary infusion
components.
2.
Assess patency of existing IV infusion line and
note infusion rate of main IV line.
3.
Assess IV site for signs of infiltration or
phlebitis and other problems.
4.
Prepare equipment & supplies:
Secondary set
A. Medication prepared in a labeled infusion
bag with IV line, microdrip or macrodrip
infusion tubing set with needleless
connector.
B. Alcohol swab
C. Plastic hook (optional)
D. Disposable gloves
68
Performance Comments
Satisfactory
Unsatisfactory
5.
Check client’s identification by looking at
identification bracelet and asking name.
6.
Wash hands and apply gloves.
7.
Administer medications by piggyback/
secondary set.
A. Hang medication bag at or above level of
main fluid bag. Hook may be used to
lower main bag.
B. Clean injection port of main line with
antiseptic swab.
C. Administer medication by pump via
secondary set. To set secondary:
1)
Press Secondary.
2)
Press Drug List.
3)
Select medication from drug list.
4)
Press correct medication dosage listed
on pump.
5)
Press Next to confirm.
6)
Press Start.
D. After medication has infused, check flow
of primary infusion. Primary infusion
should automatically begin to flow after
piggyback is empty.
E. Leave secondary bag and tubing in place
for future drug administration or discard in
appropriate containers. (Based on facility
policy.)
8.
Remove and dispose of gloves. Wash hands.
9.
During infusion, periodically check infusion
rate, pump function and condition of IV site.
Assess for side effects and therapeutic effects
of medication.
69
Performance Comments
Satisfactory
Unsatisfactory
10.
Record drug, dose, route and time administered
on medication form. Record volume of
syringe on intake and output form. Document
any side effects and therapeutic effects of
medication.
11.
Demonstrate ability to give appropriate
rationale for any step when requested to do so
by instructor.
70
Giving Medication through a Central Venous Catheter
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Disposable gloves
Alcohol swabs
Syringes (10 ml needleless)
Saline (0.9 sodium chloride)
Correct medication
Drug book
1.
Check physician’s orders regarding the
medication. Check 8 “Rights” (drug, dose,
client, route, time, allergies, expiration date,
documentation).
A medication will be selected for you to look
up and explain. Be sure to be able to indicate
over what period of time the medication is to
be administered and its compatibility with
existing concurrent infusion.)
2.
Wash your hands.
3.
Draw up medication in a 10 ml syringe.
Assemble and fill two 10 ml syringes with 10 ml
normal saline.
Label all syringes: Medication and normal
saline (x2).
4.
Identify patient, introduce self and explain
procedure.
5.
Put on gloves.
6.
Check CVC catheter site for complications. (See
Site Inspection from CVC Dressing procedure.)
7.
Cleanse port of CVC catheter tubing with
alcohol.
8.
Using the needleless system at your facility,
insert needleless syringe containing 10 ml of
NS into end of CVC tubing port.
9.
Open CVC tubing clamp and aspirate to check
for blood return. If blood doesn’t return,
71
Performance Comments
Satisfactory
Unsatisfactory
reposition patient. If it still doesn’t return,
inject slowly. DO NOT USE FORCE. If
saline doesn’t flush easily, stop and report
situation. Flush tubing. Note any problems
around CVC insertion site.
10.
Clamp CVC catheter and remove syringe from
port.
11.
Insert syringe containing medication into end
of CVC catheter after cleansing its port with
alcohol.
12.
Open clamp and give medication over correct
period of time, watching for any adverse
reactions.
13.
Clamp CVC catheter and remove medication
syringe.
14.
Insert syringe containing normal saline into
CVC tubing port after cleansing with alcohol.
15.
Open clamp and flush catheter tubing with 10
ml normal saline.
16.
Close clamp and remove the syringe.
17.
Dispose of equipment. (Syringes into sharps
container.)
18.
Assist patient as necessary and answer
questions. Do teaching as needed.
19.
Remove gloves, wash hands.
20.
Chart procedure, medication, condition of
site, patient toleration, and teaching.
21.
Assess patient for response to medication
(therapeutic and side effects).
22.
Demonstrates ability to give appropriate
rationale for any step when requested to do so
by instructor.
72
Central Line Site Care and Dressing Change
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Mask for you and patient
Clean gloves
Sterile gloves
Central line dressing kit
Alcohol sticks, if allergic to
tincture of chlorhexidine
1.
Put following equipment in “sterile” package
(use your catheter package): Sterile gloves,
2% tincture of chlorhexidine (if allergic to
chlorhexidine, use packages of alcohol sticks),
transparent dressing.
2.
Identify patient and introduce yourself.
3.
Position patient. Turn his/her head away from
the dressing to make the insertion site more
accessible and to minimize risk of
contamination (put make on patient).
4.
Prior to Beginning Procedure
A. Check for allergies.
B. Wash hands.
C. Don clean gloves.
D. Open dressing change kit.
E. Use aseptic technique and observe
standard precautions throughout
procedure.
5.
Equipment Inspection
Inspect and monitor the following vascular
access equipment:
A. Connections
B.
Fluids being infused
C.
Pump function including flow rate
73
Performance Comments
Satisfactory
Unsatisfactory
6.
Site Selection
A.
Don mask. Don patient with mask.
B.
Remove dressing from CAD
insertion/exit site with clean gloves.
C.
Inspect site for signs of infusion-related
complications to include but not limited
to:
1) Discoloration (i.e., blaching,
erythema)
2) Disruption of sensation (i.e., pain,
tenderness, numbness)
3) Edema (i.e., pitting, non-pitting)
4) Localized swelling – Exudate (i.e.
drainage)
7.
D.
If there is indication of complication
development, notify the physician.
E.
Discard gloves.
Dressing Change
A.
Don sterile gloves.
B.
Disinfect catheter-skin junction using
septic solution:
1) Using friction, apply 2% tincture of
chlorhexidine in a sweeping motion.
2) If sensitivity to chlorhexidine exists,
use friction to apply 70% alcohol
three times in a sweeping motion and
allowing air dry between
applications.
3) Cover an area approximately the size
of the dressing.
4) Allow solution to air dry.
74
Performance Comments
Satisfactory
Unsatisfactory
5) Repeat if necessary.
C.
8.
Apply transparent dressing over site,
leaving the catheter hub and tubing
exposed. Do not apply gauze.
Post-Dressing Change
A.
Discard used supplies.
B.
Remove gloves.
C.
Wash hands.
D.
Label new dressing with date, time and
nurse initials.
E.
Document in patient’s medical record
assessment of site, what was used to
cleanse area and new dressing applied.
75
Peripheral Venipuncture with Over-the-Needle Catheter Insertion
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Correct solution
Catheter (18-24 gauge depending
on vein size)
IV tubing and IV pump
2% tincture of chlorhexidine
Tourniquet
Transparent dressing
Tape
Towel
Disposable gloves
Sharps container
1.
Observe for signs and symptoms indicating
fluid or electrolyte imbalances.
A.
Sunken eyes
B.
Edema
C.
Greater than 2% increase or decrease in
body weight
D.
Dry mucous membranes
E.
Flattened or distended neck veins
F.
Hypotension, tachycardia
G.
IV Regular pulse
H.
Crackles in lungs
I.
Inelastic skin turgor
J.
Increased or decreased bowel sounds
K.
Decreased urine output
L.
Behavioral changes
M.
Confusion
76
Performance Comments
Satisfactory
Unsatisfactory
2.
Review orders for solution to be administered,
dose of medication, rate of administration,
frequency of administration, and route of
administration.
3.
Assemble necessary equipment for initiating
IV line.
4.
Identify client and explain procedure. Change
client’s gown to IV gown.
5.
Wash hands (15-20 seconds).
6.
Organize equipment on clutter-free over-bed
table.
7.
Assemble equipment/maintaining sterility of
connecting parts, attach syringe of normal
saline to needles connector and flush.
8.
Site selection
A.
Assess patient’s upper extremities.
NOTE: Do not use lower extremities in
patients of walking age without a
specific order from a physician.
B.
Assess veins on both the ventral and
dorsal surfaces:
1) Metacarpal
2) Cephalic
3) Basilic
4) Median cubital
C.
Select the most distal site for peripheralshort catheter placement:
1) Select sites that are proximal to
previous cannulation sites.
2) When possible, avoid areas of
flexion; existing phlebitis; bruises; or
previous areas of infiltration.
77
Performance Comments
Satisfactory
Unsatisfactory
3) Avoid arms with comprised
circulation, post-mastectomy or postaxillary node dissection, and
fistualated extremities.
NOTE: If these areas must be used,
obtain a specific order from the
physician.
4) In pediatric/neonatal patients, a site in
the scalp, hand or foot is preferred
over sites in the leg, arm, or
antecubital fossa.
D.
Assess availability of acceptable veins by
applying tourniquet 4 to 8 inches
proximal to intended vein puncture site:
1) Place patient in comfortable position.
2) Palpate extremity distal to tourniquet
to assess vein condition and visually
inspect skin integrity.
3) Palpate to differentiate arteries from
veins.
4) If unable to palpate vein, instruct
patient to open and close fist several
times: apply warm heat to the
extremity for approximately 15
minutes to promote vein relaxation
and dilation if necessary.
E.
Select insertion site.
F.
Select the smallest gauge, shortest length
device to achieve the required therapy.
(See figure on the following page for
suggested gauge application).
78
Performance Comments
Satisfactory
Unsatisfactory
Gauge and Suggested Application
Catheter Gauge Size
Use this size gauge for:
Trauma patients
14 to 18
Surgery patients
Blood transfusions
General infusions
20
Intermittent infusions
Blood transfusions
General infusions:
Child and adult, elderly
22
Intermittent infusions
Blood transfusions
General infusions:
24
Children and elderly
Intermittent infusions
9.
Site preparation
A.
Don gloves.
B.
Wash intended cannulation site with
antiseptic soap if visible dirt and
contaminated insertion site.
C.
Remove excess hair from intended
cannulation site with clippers or scissors
if necessary. Do not shave area as this
may cause micro abrasions.
D.
Cleanse site, using friction with 2%
tincture of chlorhexidine in a sweeping
motion for 30 seconds. Allow to air dry
for 30 seconds.
NOTE: For infants under 2 months or if
there is a sensitivity to chlorhexidine, the
site will be cleansed using friction with
alcohol in a sweeping motion three times,
allowing drying between applications.
10.
Cannula insertion
A.
Insert cannula for product integrity.
B.
Stabilize vein below intended access site
with non-dominant hand.
C.
Insert cannula bevel up through skin at a
15-30 degree angle and observe for blood
return with flashback chamber.
79
Performance Comments
Satisfactory
Unsatisfactory
D.
Lower angle of cannula inserting to about
15 degrees and continue to advance
cannula into vein.
E.
Holding stylet steady, push cannula off
stylet and into the vein until cannula hub
is situated against the skin.
F.
Occlude tip of cannula by pressing
fingers on non-dominant hand over
approximate vein pathway to prevent
retrograde bleeding.
G.
Release tourniquet. Remove stylet.
H.
Optional: Blood may be drawn at this
point using a tube-holder with a male
leur adapter.
I.
Use a new device for each cannulation
attempt.
J.
If unsuccessful at cannulation after two
(2) attempts, have another person
competent in peripheral cannulation
assess the patient.
K.
Stabilize site with sterile transparent
dressing. For neonates/pediatrics, place
dressing so that it does not extend beyond
the back edge of the catheter hub.
L.
Label site with date, time, and initials of
the inserter.
M.
Flush site as per protocol and/or initiate
prescribed therapy.
N.
If restarting a site, discontinue previous
site at this time.
O.
Discard equipment in appropriate
receptacles.
P.
Document procedure, site, catheter size
and number of attempts made to
cannulate in patient’s medical record.
80
Performance Comments
Satisfactory
Unsatisfactory
Q.
Remove gloves.
R.
Cleanse hands.
11.
Teach client about the purpose of IV therapy,
complications and to notify RN in event of
complications. Indicate complications that
might occur.
12.
Observe client every hour or as needed to
determine response to fluid therapy.
A.
Correct amount of solution is prescribed
B.
Proper flow rate
C.
Patency of IV
D.
Absence of infiltration, phlebitis, or
inflammation
13.
Record in nurses’ notes cleansing procedure,
number of attempts, type of fluid, location of
insertion site, solution flow rate, size and type
of IV catheter or needle, time infusion was
begun, teaching done, client’s response and
any problems encountered in inserting the
catheter.
14.
Demonstrate ability to give appropriate
rationale for any step when requested to do so
by instructor.
81
Mixing and Administering Insulin
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Insulin syringe
Vial of “regular” insulin
Vial of “NPH” insulin
Clean gloves
Alcohol wipes
1.
Check doctor’s orders for correct dosage. (If
patient is to undergo surgery or diagnostic
procedures, check with the physician regarding
insulin amount adjustment.)
2.
Check 8 “Rights” (drug, dose, client, route,
time, allergies, expiration date, documentation) of
giving medications.
3.
Check compatibility of insulin and time period.
Regular insulin needs to be given within 5
minutes of preparation.
4.
Gather equipment.
5.
Roll the cloudy insulin between palms to
distribute solution. (Know that shaking vial will
cause insulin to foam and form bubbles.)
6.
Clean the top of each insulin vial with an alcohol
wipe.
7.
Pull back plunger on syringe and fill with the
amount of air that corresponds to the correct
number of units of NPH insulin. Inject air into
NPH vial without withdrawing insulin.
8.
Remove needle and syringe from NPH insulin vial.
9.
Pull back plunger on syringe and fill with the
amount of air that corresponds to the correct
number of units of regular insulin. Inject air into
regular insulin and withdraw correct number of
units of insulin.
82
Performance Comments
Satisfactory
Unsatisfactory
10.
Withdraw needle and syringe and check syringe
for air bubbles before next step. If bubbles are
present, push plunger to expel them. Recheck
number of units in syringe. If more is needed,
withdraw correct amount or expel excess. No
airlock is needed. Have another nurse verify the
order, the regular insulin vial, and the dose drawn
up in the syringe.
11.
Return to NPH insulin vial, insert needle and
carefully withdraw correct number of units of NPH
insulin into syringe so that the exact amount is in
syringe. (Know that it cannot be pushed back into
vial, as syringe now contains a mixture of regular
and NPH insulin.)
12.
Have another nurse verify the order, the NPH
insulin vial, and the total dose drawn up in the
syringe.
13.
Administer insulin correctly using subcutaneous
technique.
14.
Put away/dispose of equipment correctly.
15.
Correctly record medication administered.
16.
Check client for side effects and therapeutic
response.
17.
Demonstrate an ability to give appropriate
rationale for any step in the demonstration when
requested to do so by the instructor.
83
Administering Subcutaneous Medications
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Ampule
Clean gloves
2 alcohol swabs
Needle and syringe
Bandaid
1.
Verify medication order with original doctor’s
order in the chart if:
A. You are the first nurse giving the client the
medication.
B. There is no nurse verification signature on
MAR.
C. There is any discrepancy or lack of clarity
with the order or the transcription.
2.
If the above criteria are met, do not need to
verify the MAR transcription with the original
chart order.
3.
Wash hands.
4.
Maintain medical or surgical asepsis as
appropriate throughout the procedure.
5.
Prepare the medication at the medication cart
using the MAR as point of reference.
6.
Read the medication order and check the 8
“Rights” (drug, dose, client, route, time,
allergies, expiration date, documentation) for
each medication.
7.
Choose the correct equipment:
- Needle length: 3/5 – 5/8
- Needle gauge:
8.
25 to 27 gauge
Give only small doses (no more than 1 ml)
of water soluble medication per subcutaneous
route.
84
Performance Comments
Satisfactory
Unsatisfactory
9.
Correctly draw up the medication from an
ampule or vial (Follow steps outlined in these
separate procedures). For this demonstration
draw up the medication from an ampule.
Follow written procedure.
10.
Subcutaneous Medication Administration
A. Provide for client privacy by closing
curtains around bed and exposing only
chosen injection site.
B. Raise bed to working height.
C. Don clean gloves.
D. Select appropriate injection site on actual
person by:
1) Assess for tenderness, hardness,
bruising, infection, or edema and
avoiding those areas.
2) Consult MAR for previous injection
sites and rotating sites.
a)
outer aspects of upper arms
b) anterior aspects of thigh
c)
abdomen from below costal
margins to iliac crest and at least 2
inches away from umbilicus
d)
scapular areas of upper back
e)
upper gluteal areas site
E. Position client comfortably in relation to
site.
F. Cleanse the site with alcohol swab starting
at center of site and rotate outward in a
circular direction for about 2 inches.
G. Hold swab between fingers of nondominant hand.
85
Performance Comments
Satisfactory
Unsatisfactory
H. Remove needle cap from syringe by
pulling cap straight off.
I. Hold syringe between thumb and
forefinger of dominant hand as if grasping
a dart or pencil.
J. For an average sized or an obese client,
inject at a 90 degree angle. For a child or
very thin adult, inject at a 45 degree angle
(with needle bevel up).
K. With non-dominant hand, lift and pull up
to separate subcutaneous tissue from
muscle and form a cushion of
subcutaneous tissue.
L. With non-dominant hand, pinch the
subcutaneous cushion with injection of
needle (To minimize pain of needle
penetration of skin). Inject needle through
skin using a smooth darting motion.
M. Release tight pinch before injections and
maintain the lifted subcutaneous cushion
during injection.
N. Withdraw the needle quickly while
placing the alcohol swab just above the
injection site. Keep non-dominant hand
away from needle when withdrawing from
site.
O. Activate needle safety device.
P. Massage site lightly unless
contraindicated.
Q. Apply band-aid only if necessary
9.
Assist client to comfortable position.
10.
Lower bed height, put up side rails, and give
client the call light.
86
Performance Comments
Satisfactory
Unsatisfactory
11.
Dispose of syringe unit and cap in identified
receptacle in client’s room. If no receptacle in
room, recap needle without sticking self by
placing needle cap on flat surface and sliding
syringe unit into cap. Do not hold needle cap
with hand. Keep hand away from dirty needle
until needle in cap. Secure cap on needle.
Dispose of paper/plastic cups in waste
receptacle.
12.
Wash hands.
13.
Correctly chart medication according to
agency policy.
14.
Return medication cart to secure area.
15.
Explain rationale for any step of procedure as
requested by instructor.
87
Administering IM Injections to an Adult
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Clean gloves
Alcohol swabs
Vial
Syringe & needle
Injection pad
Band-aid
1.
Verify medication order with original doctor’s
order in the chart if:
A. You are the first nurse giving the client the
medication.
B. There is no nurse verification signature on
MAR.
C. Or, there is any discrepancy or lack of clarity
with the order or the transcription.
2.
If the above criteria are met, do not need to verify
the MAR transcription with the original chart
order.
3.
Wash hands.
4.
Maintain both medical & surgical asepsis
throughout the procedure.
5.
Prepare the medication at the medication cart
using the medication record point of reference.
6.
Correctly calculate volume of drug as necessary.
7.
Choose the correct equipment:
A. Needle length (weight influences needle
length): 5/8 – 1½”
B. Needle gauge (selection based on viscosity of
medication): - 20-25 gauge for aqueous
- 18-25 gauge for oral based or
viscous
88
Performance Comments
Satisfactory
Unsatisfactory
Children:
Adult:
Elderly:
5/8 – 1”
1 – 1½”
May need 5/8”
8.
Validate the medication order against the 8
“Rights” (drug, dose, client, route, time, allergies
expiration date, documentation).
9.
Correctly draw up the medication from an ampule
or vial. (Follow steps outlined in these separate
procedures.)
10.
Change the needle if the medication is irritating
to the tissues and/or for Z-track method.
11.
Take the following to the client’s bedside:
A. Prepared medication
B. Medication record
C. Alcohol swab
D. Band-aid
E. Clean gloves
12.
Introduce self to client unless have already met
client. Identify client by asking client to state
name and verifying name on client’s wrist band.
Use second client identification method according
to agency policy.
13.
Explain procedure to client.
14.
Explain the purpose of the medication and its
action to the client.
15.
Again verify the 8 “Rights” (drug, dose, client
route, time, allergies, expiration date,
documentation).
16.
Provide for client privacy by closing curtains
around bed and exposing only chosen injection
site.
17.
Raise bed to working height.
89
Performance Comments
Satisfactory
Unsatisfactory
18.
Don clean gloves.
19.
Select appropriate injections site on actual person
by:
A. Volume of fluid to be given (No more than
1 ml. in deltoid or no more than 3 ml. in
other sites).
B. Assessing for tenderness, hardness, bruising
infection, or edema and avoiding these areas.
C. Consulting MAR for previous injection sites
and rotating sites.
20.
Describes rationale for choice of injection site to
instructor (For purpose of return demo, instructor
will select injection site to be used from the
following: deltoid, vastus lateralis, or
ventrogluteal).
21.
Position client comfortably and correctly in
relation to injection site.
Deltoid – Sitting or lying flat with lower arm
flexed and resting across abdomen or lap.
Vastus Lateralis – Supine with knee slightly
flexed.
Ventrogluteal – Side or back with knee and hip
flexed on the side to be injected.
22.
Locate and palpate site on actual person (not
lab simulators) using correct anatomical
landmarks. State anatomical landmarks using
correct terms.
Deltoid
Acromion process
Mid-point of lateral aspect of upper arm
1 to 2 inches below acromion process
Vastus Lateralis
Handbreadth above knee
Handbreadth below groin & greater trochanter
Middle third of muscle which is lateral to top
of thigh
90
Performance Comments
Satisfactory
Unsatisfactory
Ventrogluteal
Use opposite hand and opposite hip
Heel of hand on greater trochanter
Thumb toward groin
Fingers toward head
Index finger over anterior superior iliac spine
Middle finger extended along iliac crest
toward buttock
Give in center of “V” formed by index and
middle finger
23.
Cleanse the site with alcohol swab starting at
center of site and rotating outward in a circular
direction for about 2 inches.
24.
Hold alcohol swab between fingers of nondominant hand.
25.
Remove needle cap from syringe by pulling cap
straight off.
26.
Hold the syringe between thumb and first 2 fingers
(with a dart or pencil hold). (If irritating
preparation, use Z-track method of administration
described at end of procedure).
27.
Spread skin over site with non-dominant hand
(If client’s muscle mass is small, grasp the body of
the muscle with non-dominant hand).
28.
Tell client that he/she will feel a stick now.
29.
Inject needle quickly and smoothly at a 90 degree
angle.
30.
Maintain pencil hold on syringe with dominant
hand and avoid any syringe movement.
31.
Once the needle enters the site, move nondominant hand to top of plunger.
32.
With non-dominant hand, slowly pull back
slightly on the syringe to aspirate. Should blood
appear, withdraw the needle, dispose of the syringe
and start medication preparation again.
33.
If no blood appears, inject medication slowly.
91
Performance Comments
Satisfactory
Unsatisfactory
34.
Withdraw the needle quickly while placing the
alcohol swab just above the injection site.
Engage the needle safety device (keep nondominant hand away from needle being pulled
out of skin).
35.
Massage site lightly unless contraindicated.
36.
Apply bandaid only if necessary.
37.
Assist client to comfortable position.
38.
Lower bed height, put up side rails, and give client
the call light.
39.
Dispose of syringe unit and cap in identified
receptacle in client’s room. If no receptacle in
room, recap needle without sticking self by placing
needle cap on flat surface and sliding syringe unit
into cap. Secure cap on needle.
40.
Wash hands.
41.
Correctly chart medication and site according to
agency policy.
42.
Explain rationale for any step of procedure as
requested by instructor.
92
Z-Track Method of IM Administration
Performance Comments
Satisfactory
Unsatisfactory
Time needed: To Be Completed with IM Injection
Supplies needed: Clean gloves
Alcohol swabs
Vial
Syringe & needle
Injection pad
Bandaid
Med tray
May use for any IM injection. Must use when
medication to be given is irritating to tissue, may stain
tissue, or if to be given deep IM.
1.
Check 8 “Rights” (drug, dose, client, route,
time, allergies, expiration date, documentation)
of giving medications.
2.
Use at least a 1½ inch needle. Add 0.2 - 0.3 ml
of air after accurate dose measurement. Change
needle after drawing up med.
3.
Give injection only in ventrogluteal site.
4.
Locate appropriate landmarks using previously
describe guidelines.
5.
Cleanse a 3-inch area with alcohol swab using
previously described guidelines.
6.
Pull overlying skin and subcutaneous tissue
approximately 1 to 1 ½ inches to the side and
hold it over with the little finger side of the
non-dominant hand. Do not contaminate
prepared area when displacing skin. Maintain
this position until withdrawing needle.
7.
Aspirate with thumb & first finger of dominant
hand.
8.
Inject medication into original site and
subcutaneous tissue displaced.
9.
Maintain position with both hands for 10
seconds after medication injected.
93
Performance Comments
Satisfactory
Unsatisfactory
10.
Withdraw needle quickly while simultaneously
releasing displaced skin.
11.
Do not massage site.
12.
Explain rationale for any step of procedure as
requested by instructor.
94
Administering Oral Medications
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Medication (Pill or Liquid)
Clean gloves
Medicine cup
1.
Verify medication order with original doctor’s
order in the chart if:
A. You are the first nurse giving the client
the medication.
B. There is no nurse verification signature
on MAR.
C. There is any discrepancy of lack of
clarity with the order or the transcription.
2.
If the above criteria are met, do not need to
verify the MAR transcription with the original
chart order.
3.
Wash hands.
4.
Maintain medical asepsis throughout the
procedure.
5.
Prepare the medication at the medication cart
using the medication record as point of
reference.
6.
Read the medication order and check the 8
“Rights” (drug, dose, client, route, time,
allergies, expiration date, documentation).
7.
Pill Form
A. Compare label on unit dose package
with the order on the MAR for exact
accuracy.
B. Leave pill in original wrapper and place
entire package in medicine cup.
95
Performance Comments
Satisfactory
Unsatisfactory
C. Take the medicine cup and the medication
record to the client’s bedside.
8.
Liquid Form
A. Compare drug label on bottle with the
order on the medication record for exact
accuracy.
B. Remove bottle cap and place it upside
down. Hold bottle with label against palm
of hand while pouring. Pour liquid into
plastic graduated medicine cup if exact
amount is so marked on the cup. Verify
correct amount with cup on a flat surface
and read amount poured at eye level. Wipe
lip of bottle with paper towel if necessary.
C. If dosage amount is not marked on
graduated cup, draw up dosage in a syringe
and then squirt correct dosage amount into
medicine cup.
9.
Take prepared medication and medication
record to client’s bedside. Leave medication
cart in med room or take to door of client’s
room within easy view.
10.
Introduce self to client unless have already met
client.
11.
Identify client using 2 methods:
A. Asking client to state name and by
verifying name on client’s wrist band.
B. Using second method according to agency,
policy, i.e., birthday.
12.
Again, check the 8 “Rights” (drug, dose, client,
route, time, allergies, expiration date,
documentation) against the order on the
medex.
13.
Explain the purpose of the medication and its
action to the client.
96
Performance Comments
Satisfactory
Unsatisfactory
14.
Assist client to a sitting position in chair or
elevate head of bed unless contraindicated. If
sitting contraindicated, assist to side-lying
position.
15.
Open pre-packaged pill form and drop
medication into medication cup.
16.
Do not touch pill with your hands.
17.
Give client pill cup or liquid medication if
he/she is able to hold it. Assist client if
necessary.
18.
Give client full glass of fresh water unless
contraindicated. (Some meds need to be given
with juice or other drinks. Consult drug
resource for this information.)
19.
Stay with client until he/she has completely
swallowed each medication. If uncertain, ask
client to open mouth. Never leave medications
for client to take independently unless
specifically ordered that way.
20.
Assist client to comfortable position.
21.
Discard used medication cup, wrappers, etc.
22.
Lower bed height, put up side rails, and give
client the call light.
23.
Wash hands.
24.
Correctly chart medication according to agency
policy.
25.
Return medication cart to secure area.
97
Preparing an Injectable Medication from an Ampule
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Clean gloves
Alcohol swabs
Ampule
Syringe & needle
Injection pad
Band-aid
1.
Wash hands
2.
Read the medication order and check the 8
“Rights” (drug, dose, client, route, time,
allergies, expiration date, documentation).
3.
Sign out medication in narcotic/record book if
appropriate.
4.
Tap the top of the ampule lightly and quickly
with a finger to dislodge any medication from
the top into the ampule.
5.
Place a small, dry gauze pad or alcohol wipe
still in opened wrapper around the neck of the
ampule.
6.
Snap the neck of the ampule in a direction
away from your hands and face.
7.
Insert the needle (use a filter needle when
available) into the center of the ampule taking
care not to allow the tip or shaft of the needle
to touch the outer rim of the ampule.
8.
Invert (turn upside down) the ampule with
needle inserted. Hold ampule & syringe with
non-dominant hand.
9.
Aspirate the medication into the syringe by
pulling back on the plunger with the dominant
hand.
10.
Keep the needle tip below the surface of the
liquid. Tilt ampule to bring all the fluid within
reach of the needle if all the volume of
medication is to be withdrawn.
98
Performance Comments
Satisfactory
Unsatisfactory
11.
If air bubbles are aspirated, do not expel the air
into the ampule.
12.
To expel excess air bubbles, remove the needle
from the ampule. Hold the syringe with the
needle pointing up. Draw back slightly on the
plunger, and then push the plunger upward to
eject the air. Do not eject fluid.
13.
Hold the syringe and needle upright and tap the
syringe barrel to dislodge air bubbles. Eject
the air as described in step 12.
14.
Verify accurate and exact amount of drug and
correct if necessary by adding or deleting fluid.
15.
Cover the needle with its sheath or cap
maintaining surgical asepsis.
16.
Explain rationale for any step of the procedure
as requested by instructor.
99
Preparing an Injectable Medication from a Vial
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Clean gloves
Alcohol swabs
Vial
Syringe & needle
Injection pad
Band-aid
1.
Wash hands.
2.
Read the medication order and check the 8
“Rights” (drug, dose, client, route, time,
allergies, expiration date, documentation).
3.
Sign out medication in narcotic/record book if
appropriate.
4.
Remove the metal cap to expose the rubber
seal.
5.
With an alcohol swab wipe off the surface of
the rubber seal.
6.
Remove needle cap. Pull back on the plunger
to draw air into the syringe equivalent to the
volume of mediation to be aspirated from the
vial into the syringe.
7.
Insert the tip of the needle, with bevel pointing
up, through the center of the rubber seal.
Apply pressure to the needle point during
insertion.
8.
Inject the air into the vial and hold onto the
plunger after injecting the air.
9.
Invert the vial while keeping a firm hold on the
syringe and plunger.
10.
Hold the vial and the syringe with the nondominant hand.
11.
Grasp the end of the barrel and plunger with
thumb and forefinger of the dominant hand.
100
Performance Comments
Satisfactory
Unsatisfactory
12.
Keep tip of the needle below fluid level.
13.
Allow air pressure to gradually fill the syringe
with medication. Pull back slightly on the
plunger if necessary.
14.
Tap the side of the barrel carefully to dislodge
any air bubbles.
15.
Eject any air remaining at the top of the
syringe into the vial.
16.
Once the correct volume is obtained, remove
the needle from the vial by pulling back on the
barrel.
17.
Remove any remaining air from the syringe
and again verify that there is correct amount of
medication in the syringe.
18.
Recover needle with cap maintaining surgical
asepsis.
19.
Explain rationale for any step of the procedure
as requested by instructor.
101
Inserting a Nasogastric Tube
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: NG tube - appropriate size
(8 to 18 French)
Stethoscope
Glass of H2O with straw
Water soluble lubricant
Flashlight/Penlight
Disposable gloves
Tape, 1” wide
Tissues
Bath towel
Emesis basin
Safety pin & rubber band
1.
Check physician’s order for insertion of
nasogastric tube.
2.
Explain procedure to patient, discussing with
patient the need for the nasogastric tube;
answer any questions patient may have.
3.
Gather equipment.
A. Set up suction, intermittent – set to high
(120 mmHg), continuous – set to low 0-80
mmHg, or to ordered suction.
B. Cut a 4-inch piece of tape and split bottom
2 inches, or use packaged nose tape for
nasogastric tubes.
4.
Perform hand hygiene. Don disposable gloves.
5.
Assist patient to high Fowler’s position, or to
45 degrees if unable to maintain upright
position, and determine which nostril will be
easier access by using a penlight to inspect for
a deviated septum or other abnormality; or ask
the patient to occlude one nostril and breathe
normally through the other, selecting the
nostril through which air passes more easily.
6.
Drape chest with bath towel or disposable pad.
and have emesis basin and tissues handy.
102
Performance Comments
Satisfactory
Unsatisfactory
7.
Measure distance to insert the tube by placing
tip of tube at patient’s nostril and extending to
tip of earlobe and then to tip of xiphoid
process. Mark tube with a piece of tape.
8.
Lubricate tip of tube (at least 1 to 2 inches)
with water-soluble lubricant.
9.
After having the patient lift his or her head,
insert tube into nostril while directing tube
upward and backward. Patient may gag when
tube reaches the pharynx. Provide tissues for
tearing or watering eyes.
10.
Instruct patient to touch his or her chin to
chest. Encourage him or her to sip water
through a straw, or to swallow if no fluids
are permitted. Advance tube in a downwardand-backward direction when patient
swallows. Stop when patient breathes. If
gagging and coughing persist, check placement
of tube with a tongue blade and flashlight.
Keep advancing tube until tape marking is
reached. Do not use force. Rotate tube if it
meets resistance.
11.
Discontinue the procedure and remove the tube
if there are signs of distress, such as gasping,
coughing, cyanosis, or the inability to speak or
hum.
12.
Cleanse nose with alcohol pad and allow to
dry. Secure tube with tape to patient’s nose.
Be careful not to pull tube too tightly against
nose.
A. Place unsplit end over bridge of patient’s
nose.
B. Wrap split ends under tubing and up and
over onto nose.
13.
While keeping one hand on tube, determine
that the tube is in the patient’ stomach using
one of the following methods:
103
Performance Comments
Satisfactory
Unsatisfactory
A. Insert 10-20ml air. Place stethoscope over
epigastric area inject air while listening for
air rush.
B. Attach syringe to end of tube, aspirate for
stomach contents.
C. Obtain radiograph of placement of tube (as
ordered by physician.
14.
Attach tube to suction or clamp tube and cap it
according to physician’s orders.
15.
Secure tube to patient’s gown by using a
rubber band or tape and a safety pin. If
double-lumen tube is used, secure vent above
stomach level. Attach at shoulder level.
16.
Assist or provide patient with oral hygiene at
regular intervals.
17.
Remove disposable gloves and perform hand
hygiene. Remove all equipment and make
patient comfortable.
18.
Record the insertion procedure, type and size
of tube. Also document description of
gastric contents, which naris used, patient’s
response, and method used to verify placement.
104
Irrigating a Nasogastric Tube
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 10 minutes
Supplies needed: Irrigation set, or
50 cc catheter tip syringe
Clean basin
Container of normal saline
Towel or waterproof pad
Clean gloves
Stethoscope
NOTE: It is suggested that you plan to carry out this
procedure with the insertion of the nasogastric tube
procedure.
1.
Raise level of bed to working height.
2.
Put on gloves.
3.
Place towel or waterproof pad across client’s
chest.
4.
Turn off suction or feeding and disconnect
tubing.
5.
If possible, check for tube placement as
described in tube insertion. (Know that this
may not be possible if tube is occluded.)
6.
Fill syringe with 30-50 cc of normal saline and
insert tip into end of tubing. (Saline is preferred
over water because it reduces electrolyte
depletion.)
7.
Gently instill fluid into tubing. If fluid will not
enter, loosen tape and move tube slightly, then
retape. (Know that tip of tubing may be
against mucosa.)
8.
Aspirate fluid and discard basin. (If not
returned, instill another 30-50 cc. If still not
returned, do not instill more as it may cause
distention.)
105
Performance Comments
Satisfactory
Unsatisfactory
9.
Repeat instillation and aspiration with normal
saline until tubing is cleared of clotted material
or thick mucus.
10.
During procedure, keep track of amount of
saline instilled. If all of this amount is not
returned, make sure the amount remaining in
the stomach is included in intake for client.
11.
Reconnect tubing to suction or feeding.
12.
Inject 10 cc of air into air vent lumen and insert
anti-reflux valve.
13.
Chart:
A.
Signs and symptoms that prompted
irrigation.
B.
Position of tube if determined.
C.
Amount of normal saline used and amount
of return.
D.
Characteristics of returned fluids.
E.
Any difficulties encountered.
F.
Outcome of procedure (i.e., was patency
reestablished?)
G.
How client tolerated procedure.
106
Removing a Nasogastric Tube
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 10 minutes
Supplies needed: Disposable gloves
Towel
Adhesive remover
Tissues
Emesis basin
1.
Check physician’s order for removal of
nasogastric tube.
2.
Explain procedure to patient and assist to semiFowler’s position.
3.
Gather equipment.
4.
Perform hand hygiene. Don clean disposable
gloves.
5.
Place towel or disposable pad across patient’s
chest. Give tissues and emesis basin to patient.
6.
Discontinue suction and separate tube from
suction. Unpin tube from patient’s gown and
carefully remove adhesive tape from patient’s
nose.
7.
Instruct patient to take a deep breath and hold
it.
8.
Clamp tube with fingers by doubling tube on
itself. Quickly and carefully remove tube
while patient holds breath.
9.
Dispose of tube per agency policy. Remove
gloves and place in bag.
10.
Offer mouth care to patient and facial tissues to
blow nose.
11.
Measure nasogastric drainage in suction
device. Remove all equipment and dispose
according to agency policy. Perform hand
hygiene.
107
Performance Comments
Satisfactory
Unsatisfactory
12.
Record removal of tube, patient’s response,
and measure of drainage. Continue to monitor
patient for 2 to 4 hours after tube removal for
gastric distention, nausea, or vomiting.
108
Administering a Tube Feeding
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Disposable gloves
Tube feeding at room temperature
Stethoscope
Syringe (60 ml)
Towel
Tap water
1.
Explain procedure to patient. Use a
stethoscope to assess bowel sounds.
2.
Assemble equipment. Check amount,
concentration, type, and frequency of tube
feeding on patient’s chart. Check expiration
date of formula.
3.
Perform hand hygiene. Don disposable gloves.
4.
Position patient with head of bed elevated at
least 45 degrees or as near normal position for
eating possible.
5.
Unpin tube from patient’s gown and check to
see that nasogastric tube is properly located in
stomach, as described in step 12 of the
“Inserting a Nasogastric Tube” demo.
6.
Check residual by using a syringe to aspirate
all gastric contents and measure. Return
immediately through tube. Proceed with
feeding if amount of residual does not exceed
policy of agency or physician’s guideline.
Disconnect syringe from tubing.
7.
When using a feeding bag (open system):
A. Hang bag on intravenous pole and adjust to
about 12 inches above stomach. Clamp
tubing.
B. Cleanse top of feeding container with
alcohol before opening it. Pour formula
into feeding bag and allow solution to run
through tubing. Close clamp.
109
Performance Comments
Satisfactory
Unsatisfactory
C. Attach feeding setup to feeding tube,
open clamp, and regulate drip rate
according to physician’s order or allow
feeding to run in over 30 minutes.
D. Add 30 to 60 ml (1 to 2 ounces) of
water for irrigation to feeding bag when
feeding is almost completed and allow it to
run through tube.
E. Clamp tubing immediately after water has
been instilled. Disconnect from feeding
tube. Clamp tube and cover end with
sterile gauze secured with rubber band and
apply cap.
8.
When using a large syringe (open system):
A. Remove plunger from 30 or 60 ml syringe
and irrigate with 30 ml of water.
B. Attach syringe to feeding tube, pour
premeasured amount of tube feeding into
syringe, open clamp, and allow feeding to
enter tube. Regulate the rate by raising or
lowering the height of the syringe. Do not
push formula with syringe plunger.
C. Add 30 to 60 ml of water for irrigation to
syringe when feeding is almost completed
and allow it to run through the tube.
D. When syringe has emptied, disconnect
from the tube. Clamp the tube.
9.
When using prefilled tube feeding setup
(closed system):
A. Remove screw-on cap and attach
administration setup with drip chamber and
tubing. Hang set on intravenous pole and
adjust to about 12 inches above the
stomach.
Clamp tubing and squeeze drip chamber to
fill to one-third to one-half of capacity.
Release clamp and run formula through
tubing. Close clamp.
110
Performance Comments
Satisfactory
Unsatisfactory
B. Follow Actions 7c, 7d, and 7e. Feeding
pump may be used with tube feeding setup
to regulate drip.
For Continuous Feedings
10.
When using a feeding pump (continuous
feeding):
A. Close flow regulator clamp on tubing and
fill feeding bag with prescribed formula.
Amount depends on agency policy. Place
label on container.
B. Hang feeding container on intravenous pole
and allow solution to flow through tubing.
C. Connect to feeding pump following
manufacturer’s directions. Set rate.
11.
Observe patient’s response during and after
tube feeding.
12.
Have patient remain in upright position for at
least 30 to 60 minutes after feeding.
13.
Wash and clean equipment or replace
according to agency policy. Remove gloves
and perform hand hygiene.
14.
Record type and amount of feeding, residual
amount, verification of placement, and
patient’s response. Monitor blood glucose, if
ordered by physician.
111
Administering Medications via a Nasogastric Tube
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Disposable gloves
60 ml syringe
Medications (crushed or in liquid
form)
Water for flush
1.
Check to see whether medications to be
administered come in a liquid form. If pills or
capsules are to be given, check with pharmacy
about crushing or opening capsules. Ensure
that the tube is patent and irrigate as necessary
(see Skill 11-4).
2.
Using medicine cups, prepare all medications
to be given. Also prepare 15-20 ml of water
for each medication that is to be given.
3.
Perform hand hygiene and don gloves. If
patient has continuous tube feedings, pause
tube feeding pump.
4.
Verify placement of tube with instillation of
10-20 ml air. While inserting air bolus,
auscultate for air rush.
5.
Fold tube over and clamp with fingers.
Insert tip of 60 ml syringe into gastric tube.
Release NG tube. Pull plunger back using a
constant gentle pressure to check for residue.
6.
After noting amount, replace residual feeding
back into stomach.
7.
Fold NG tube over and clamp with fingers.
Remove 60 ml syringe. Remove plunger from
syringe. Flush with 10 ml of water, administer
each medication, flushing between each
medication with 5-10 ml of water.
8.
Flush with 30 ml of water after last medication
is administered.
112
Performance Comments
Satisfactory
Unsatisfactory
9.
Fold tubing back over and clamp with fingers.
If more medications are to be given, repeat
Actions 7 and 8. If no more medications are to
be given, reconnect tube feeding or clamp NG
tube. Do not return to suction for at least 45
minutes.
10.
Remove gloves and perform hand hygiene.
11.
Record amount of water uses to flush tube and
document on the medication administration
record.
113
Changing and Emptying an Ostomy Appliance
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Disposable gloves
Basis with water, soap & towel
Ostomy wafer and measuring
device
Skin protectant or barrier
Ostomy bag (correct size)
Graduated container
Scissors
Adhesive
1.
Gather the necessary equipment.
2.
Perform hand hygiene and apply non-sterile
gloves.
3.
Explain procedure to the patient.
4.
Provide for patient’s privacy. Assist to a
comfortable sitting or lying position in bed or a
standing or sitting position in the bathroom.
To empty a pouch, proceed to Action 11. To
change a pouch, continue to Action 5.
5.
Empty the partially filled appliance or pouch
into a bedpan if it is drainable.
6.
Slowly remove the appliance, beginning at the
top while keeping the abdominal skin taut. If
any resistance is felt, use warmth or the
adhesive solvent to facilitate removal. Discard
the disposable appliance or pouch in a plastic
bag.
7.
Use toilet tissue to remove any excess stool
from the stoma. Cover stoma with a gauze
pad. Gently wash and pat dry the peristomal
skin. Mild soap may be used to cleanse the
peristomal skin, taking care to ensure that all
soap is rinses before reapplying pouch. Do not
apply any lotion to the peristormal area.
114
Performance Comments
Satisfactory
Unsatisfactory
8.
Assess the appearance of the peristomal skin
and stoma. A moist reddish-pink stoma is
considered normal.
9.
Apply one-piece or two-piece system:
A. Select size for stoma opening by using the
measurement guide (template).
B. Trace same size circle on the back and
center the skin barrier.
C. Use scissors to cut an opening 1/4 to 1/8
inch larger than stoma.
D. Remove the backing of protective skin
barrier. Apply additional skin protection
necessary.
E. Remove gauze pad covering stoma.
F. Ease barrier appliance or pouch onto the
abdomen and over the stoma, and gently
press onto skin while smoothing out
creases or wrinkles. Hold in place for 3
minutes.
10.
Close the bottom of appliance or pouch by
folding the end upward and using a clamp or
clip that comes with product. Continue to
Action 15.
To Empty Appliance or Pouch
11.
Plan to drain the appliance or pouch when it is
one-third to one-half full. Remove clamp and
fold the end of the pouch upward like a cuff.
12.
Empty contents into bedpan, toilet, or
measuring device. Rinse appliance or pouch
with tepid water or water mixed with a drop of
mouthwash administered with a squeeze bottle.
13.
Wipe the lower 2 inches of the appliance or
pouch with toilet tissue.
14.
Uncuff the edge of the appliance or pouch and
apply the clip or clamp.
115
Performance Comments
Satisfactory
Unsatisfactory
15.
Dispose of used equipment according to
agency policy. Remove non-sterile gloves
from inside out and discard.
16.
Perform hand hygiene.
17.
Document the following: appearance of stoma,
condition of peristomal skin, characteristics of
drainage (amount, color, consistency, unusual
odor), and patient’s reaction to procedure.
116
Irrigating a Colostomy
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Disposable gloves
Irrigation container with cone
tubing
Water soluble lubricant
Warm solution as ordered (tap
water)
1.
Assemble the necessary equipment. If tap
water is used, adjust temperature as it flows
from the faucet to a warm temperature.
2.
Explain procedure to the patient and plan
where he or she will receive irrigation. Assist
patient onto bedside commode or into nearby
bathroom.
3.
Perform hand hygiene.
4.
Add irrigation solution to container. Release
the clamp and allow fluid to progress through
the tube before reclamping to prime tubing.
5.
Hang container so that the bottom of bag will
be at the patient’s shoulder level when seated.
6.
Put on disposable gloves.
7.
Remove appliance and attach irrigation
sleeve. Place the drainage end into the toilet
blow or bedpan.
8.
Lubricate the end of the cone with watersoluble lubricant.
9.
Insert the cone into the stoma. Introduce the
solution slowly over a period of 5 minutes.
Hold tubing (or if patient is able allow patient
to hold tubing) all the time that solution is
being instilled. Control the rate of flow by
closing or opening the clamp.
10.
Hold the cone in place for an additional 10
seconds after the fluid is infused.
117
Performance Comments
Satisfactory
Unsatisfactory
11.
Remove the cone. Assist patient to remain
seated on toilet or bedside commode.
12.
After most of the solution has returned, allow
patient to clip (close) the bottom of the
irrigating sleeve and continue with daily
activities.
13.
After solution has stopped flowing from stoma,
remove irrigating sleeve and cleanse skin
around stoma opening with mild soap and
water. Gently pat peristomal skin dry.
14.
Attach new appliance to stoma (see Changing
and Emptying an Ostomy Appliance demo) if
needed.
15.
Document the procedure, including the amount
of irrigating solution used; color, amount, and
consistency of stool returned; condition of the
patient’s stoma; degree of patient participation;
and patient’s reaction to the irrigation.
118
Administering Medication by Suppository
Performance Comments
Satisfactory
Unsatisfactory
Time needed:
15 Minutes
Supplies needed: Medication in suppository
form
Disposable gloves
Lubricant
Medication order
Tissues
Disposable bag
1.
Assemble equipment (medication in
suppository form, glove, lubricant), go to
client’s room, knock, introduce self and
identify the client by checking the arm
bracelet or using facility approved and
accepted method of identification.
2.
Provide for privacy of the client. Arrange
appropriate screening. Explain the
procedure to the client, family member, or
caregiver.
3.
Wash hands.
4.
Help the client assume a left sidelying/lateral position with the top knee in
acute flexion.
5.
Unwrap the suppository and place it on the
work surface on the wrapper or a clean,
protected surface. Put on the glove. Place a
small amount of lubricant on the tip of the
suppository.
6.
Ask the client to breathe deeply to help
relax the anal sphincter to ease insertion of
the suppository. The suppository is
inserted in a smooth motion up to 10 cm.
(4”) into the rectal passage with the finger
of the gloved hand directing the
suppository into the anus. Attempt to place
the suppository along the rectal wall.
7.
Observe anal area for hemorrhoids.
119
Performance Comments
Satisfactory
Unsatisfactory
8.
Remove finger (the glove is removed by
drawing the inside over the outside). Wipe
lubricant off anus.
9.
Encourage the client to hold the buttocks
together to prevent expulsion of the
suppository in response to an urge to
defecate.
10.
Return after 15 minutes to ensure client is
comfortable.
11.
Chart medication and results obtained.
120
Tracheostomy Care
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed:
Tracheostomy care kit
Sterile normal saline
Hydrogen peroxide
Sterile gloves
Disposable gloves
Waste receptacle lined with
plastic bag
Bath towel
Cleaned and cleared overbed table
1.
Wash hands for 3 minutes and applies face
shield or goggles if splashing is likely.
2.
Introduce self to the client.
3.
Identify the client.
4.
Explain reason for procedure & tell client the
steps of the procedure prior to doing them.
Provide for privacy.
5.
Raise bed to working height.
6.
Place cleaned & cleared over-bed table
perpendicular to the head of the client’s bed
within reach of working area.
7.
Suction the client through the tracheostomy
prior to performing tracheostomy care.
(Separate demo for students) Replace the
client’s oxygen source.
8.
Using same gloves previously donned for the
suctioning, remove soiled dressing & discard in
receptacle. Remove gloves & discard.
9.
Open tracheostomy care kit and establish
sterile field.
10.
Fill one fluid receptacle of the tray (one on
your left) with about 2 inches of peroxide.
121
Performance Comments
Satisfactory
Unsatisfactory
11.
Uncap bottle of normal saline & fill the other
receptacle with about 2 inches of normal saline.
12.
Set up sterile field with all cleaning equipment
and dressings.
13.
Don sterile gloves.
14.
Maintain surgical asepsis throughout procedure
with dominant hand.
15.
Remove oxygen source from tracheostomy
with non-dominant hand.
16.
While holding the outer cannula with the non
dominant hand, unlock the inner cannula with
the dominant hand (sterile hand) by turning it to
the left 90 degrees.
17.
Remove the inner cannula & place it in the tray
of peroxide with dominant hand. (Or replace
inner cannula with a new disposable inner
cannula. If the patient has disposable inner
cannula, do not clean the old inner cannula;
simply discard it.)
NOTE: If the client is on a ventilator, a spare
sterile inner cannula should be inserted at this
time so the client can be quickly reattached to
the ventilator.
18.
Replace oxygen source (non-dominant hand).
19.
Cleanse the lumen & the outside surface of the
inner cannula with the brush. Hold end of brush
with non-dominant hand.
20.
Rinse inner cannula with normal saline & shake
off excess moisture.
21. Remove oxygen source with non-dominant hand.
22.
Replace inner cannula with dominant hand.
Hold onto outer cannula with non-dominant
hand during this procedure.
23.
Lock inner cannula by turning it to the right
(should feel it lock) with the dominant hand.
122
Performance Comments
Satisfactory
Unsatisfactory
24.
Replace oxygen source with non-dominant
hand.
25.
Using the dominant hand, moisten a sterile
cotton tipped applicator with peroxide &
cleanse sides of stoma.
26.
Cleanse far side of the stoma using one
applicator & use another applicator for the near
side.
27.
Repeat procedure using cotton tipped applicators
moistened with normal saline to rinse.
28.
Hold a 4 x 4 in the dominant hand, moisten it with
normal saline & cleanse the tube’s flange.
29.
Dry areas with 4 x 4’s following the same
sequence.
30.
Second nurse washes hands and dons clean
gloves.
31.
Second nurse removes oxygen source.
32.
Second nurse stands at the side of the bed
opposite the first nurse. Second nurse gently
holds sides of tracheostomy flange to prevent tube
from being coughed out.
33.
First nurse cuts old tracheostomy strings at
both
sides of the client’s neck or unhooks Velcro
straps from each side. Takes extra caution to
avoid cutting cuff tubing.
34.
Remove old tracheostomy string. First nurse
picks ups trach string. Inserts one trach string into
the flange opening nearest to him/her. Passes the
string behind the client’s neck and through the
back side of the opposite flange opening. Next,
pass the string behind the client’s neck again and
tie the two ends together in a knot on the side of
the client’s neck or fasten Velcro straps.
(See picture on next page.)
123
Performance Comments
Satisfactory
Unsatisfactory
35.
Second nurse’s role in now over. Removes
gloves & washes hands.
36.
First nurse applies trach dressing. Holds trach
dressing with hand on outside edges only.
Uses forceps to pull dressing beneath strings &
flange.
37.
Recheck tightness of ties.
38.
Replace oxygen source.
39.
Discard equipment and remove gloves.
40.
Assist the client to a comfortable position.
41.
Lower bed height, raise side rails, and give call
light to client.
42.
Wash hands.
43.
Chart procedure: Characteristics of drainage on
soiled dressing, condition of stoma, client’s
response to procedure, what area was cleansed
with, and type of dressing applied.
44.
Explain rationale for any step of procedure as
requested by instructor.
124
Tracheostomy Suctioning
Performance Comments
Satisfactory
Unsatisfactory
Time needed: 15 minutes
Supplies needed: Suction catheter (diameter not
more than ½ the size of the
tracheostomy opening)
Sterile normal saline irrigating
solution
Sterile container for normal saline
1 pair sterile gloves
Yankeur suction
Oxygen source, flow meter, wing
tip connector, oxygen
connecting tubing, ambu bag
with trach adaptor
Waste receptacle lined with plastic
bag
Bath towel
Cleaned and cleared overbed table
Note: If the client has an artificial airway, a suction
apparatus, connecting tubing & sterile normal
saline should always be kept at the bedside. In
addition, an ample supply of suction catheters
& sterile gloves should always be kept at the
bedside.
1.
Wash hands for 3 minutes and applies face
shield or goggles if splashing is likely.
2.
Introduce self and identify the client.
3.
Explain reason for procedure & tell client
the steps of the procedure to doing them.
Provide for privacy.
4.
Raise bed to working height. Elevate the
head of the bed to at least 45 degrees unless
contraindicated.
5.
Place cleaned & cleared overbed table
perpendicular to the head of the client’s bed
within reach of working area. Place equipment
on table.
125
Performance Comments
Satisfactory
Unsatisfactory
6.
Assess breath sounds for quality & rate of
respirations. Assess apical pulse rate &
rhythm & color of lips & nailbeds. Do not
suction client routinely. Suction only when
needed.
7.
Attach suction connecting tubing to suction
apparatus. Turn on suction, occlude tubing &
test suction amount. Regulate suction
between 80 and 120. Make sure end of
connecting tubing is within close reach.
8.
Attach ambu bag to oxygen source & turn
flow meter to 12-15 liters/min. Place ambu
bag on opposite side of the bed.
9.
Follow principles of surgical asepsis during all
movements. Ask the client to refrain from
touching the suction catheter.
10.
Pour normal saline into sterile container.
Open sterile gloves & suction catheter
packages.
11.
Don sterile gloves. To lessen risk of
contamination, wrap catheter around the
fingers of dominant gloved hand. Grasp
suction connection tubing with non-dominant
hand. Insert connection part of catheter into
suction tubing.
NOTE: During this procedure, the gloved
dominant hand should remain sterile. The nondominant hand is gloved for the nurse’s
protection from the client’s secretion.
Remember to refrain from contaminating the
dominant gloved hand.
12.
Lubricate the catheter with the normal
saline by applying suction & drawing up
normal saline through the catheter.
13.
The second nurse now assists after washing
hands & donning clean gloves.
126
Performance Comments
Satisfactory
Unsatisfactory
14.
The second nurse stands on the opposite side
of the bed from the first nurse, removes the
oxygen source & connects the ambu bag to
the tracheostomy.
15.
Using two hands to deflate the bag, the second
nurse oxygenates the client with 3 to 5 deep
lung inflations to help compensate for the
oxygen removed during the suctioning process.
16.
The second nurse removes the ambu bag. The
first nurse inserts the catheter into the trach
opening as far as it will go, withdraws the
catheter 1-2 cm to prevent damaging the area.
17.
Rotate catheter between dominant thumb &
forefinger, gradually withdraw the catheter
while applying intermittent suction (move
non-dominent thumb up & down on suction
port to apply intermittent suction).
18.
Minimize hypoxemia by not suctioning for
longer than 10-15 seconds during each suction
attempt. After each suction pass, the first nurse
rinses the catheter by suctioning up normal
saline and clearing the tubing of secretions.
19.
Immediately after the first nurse removes the
catheter, the second nurse gives the client 3 to
5 deep ventilations with the ambu bag.
20.
Repeat the procedure as necessary -- usually
only one to two suction passes at one given
time are needed.
21.
After the last suction pass, the second nurse
oxygenates the client with the ambu bag and
replaces the oxygen source. The second
nurse’s role is completed.
22.
The first nurse discards the catheter.
23.
Suction the client’s mouth with the Yankeur
suction (clean), rinse the catheter & provide
oral hygiene.
24.
Assess the client’s breath sounds, heart rate,
and skin color.
127
Performance Comments
Satisfactory
Unsatisfactory
25.
Turn off the suction machine and the
secondary oxygen source.
26.
Discard the equipment & removes gloves
properly.
27.
Assist the client to a comfortable position.
28.
Lower bed height, raise side rails, and give
call light to client.
29.
Document procedure. Include: Size of
catheter, oxygenation with manual resuscitator
before & after each suction pass,
characteristics of secretions, quality of cough,
lung sounds, respiratory rate, & that oral
hygiene was given.
30.
Explain rationale for any step of procedure as
requested by instructor.