NCMA219 – Skills Laboratory
1.2 The Nature of Pain
DAY 1: PAIN ASSESSMENT
L E C T U R E
B Y
E D Q U I B A L
/
M A T E R N A L
&
C H I L D
H E A L T H
N U R S I N G
C A R E
O F
T H E
C H I L D B E A R I N G
&
C H I L D R E A R I N G
F A M I L Y
B Y
A D E L E
P I L L I T T E R I
9 T H
E D
LEARNING OUTCOMES
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1. Location
♦ Recognized in certain parts of the body (Example:
head, back, and chest)
− Pain Radiates (spread or extend) to other arias
♦ Referred – appear to arise in different areas
Identify the purpose of pain assessment and techniques
Recognize the form of pain
List factor affecting pain sensitivity
Discuss behavioral of response to pain
Follow and Use pain assessment tool/chart
(Example: cardiac pain may be felt in the shoulder or left
arm, with or without chest pain)
♦ Visceral Pain – pain arising from organs or hollow
viscera
2. Duration
1.1 Definition of Pain
Pain
{Subjective, 5th vital sign}
⎯
2011, (Pasero & McCaffery) – “pain is whatever the
person says it is, and exists whenever he says it
does”
⎯
2016, (American Pain Society) – “an unpleasant
sensory and emotional experience associated with
actual or potential tissue damage, or described in
terms of such damage”
⎯
Pain is unpleasant, sensory experience, emotional
experience, can be a warning signal, can be
deliberating, and frustrating
⎯
It interferes with sleep, work, activities, and quality
time
PAIN MANAGEMENT
♦ Is the alleviation of pain or a reduction in pain to a
level of comfort that is acceptable to the client.
♦ Persistent pain also contributes to insomnia, weight
gain
or
loss,
constipation,
hypertension,
deconditioning, chronic stress, and depression
a. Acute Pain – less than 6 months or has expected
recovery period
o Results from acute injury, disease or surgery
usually temporary, sudden onset and easily
localized
o Acts as warning signal (fight or flight
reaction) Example: laryngoscopy, hepatitis a,
appendicitis, labor pains, burn injury
b. Chronic Pain (persistent pain) – 6 months to even
years
o Chronic cancer pain – occupies space
(larger size cancer) and compress the nerve
and veins
▪ Does spread through blood stream
▪ It can be from chemo or radio therapy
o Chronic noncancer pain
▪ Common type: arthritis and lower back
pain Ex: hepa C & B, osteoarthritis
c. Cancer-related pain – result from the direct effect
of the disease and it’s treatment (such as radiation
or chemotherapy)
♦ Effective pain management is an important aspect
of nursing care to promote healing, prevent
complications, reduce suffering, and prevent the
development of incurable pain states
Acute Pain
Mild to severe
Mild to severe
SNS responses:
• Increased pulse rate
• Increased respiratory rate
• Elevated blood pressure
• Diaphoresis
• Dilated pupils
PNS responses:
• Vital signs normal
• Dry, warm skin
• Pupils normal or dilated
Related
to
tissue
resolves with healing
T R A N S C R I B E D
Chronic Pain
injury;
Continues beyond healing
Client may be restless and
anxious
Client is usually depressed and
withdrawn
Client reports pain
Client often does not mention
pain unless asked
Client may exhibit behavior
indicative of pain: crying,
rubbing area, holding area
Pain behavior often absent
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
a.
Numeric Scale: 0 (no pain) to 10 (worst pain
imaginable)
o
1-3 mild pain (use non-pharmacological
4-6 moderate pain (Continue medication
o
or plus add a mild opioid)
7-10 severe pain (medication + more
potent opioid)
C O U N S E L L I N G
post-herpetic
neuralgia,
diabetic
neuropathy, herpes zoster, stroke)
strategies)
o
A N D
Neuropathic pain - (Neuro; nerves/ phatic; pain)
associated with damaged or malfunctioning
nerves due to illness (electric-shock, tingling,
painful numbness, dull, and aching). (Example:
b.
3. Intensity
A S S E S S M E N T
c.
peripheral
Radicular pain – pain that radiates from your
back and hip into your legs through the spine
(pinched or inflamed)
♦ Spinal cord gets compressed
1.3 Non-Pharmacological Treatment
b.
Non-Pharmacological Treatments – is a strategies that is
effective in alleviating pain when used either alone or
in with other non-pharmacological or pharmacological
measures.
Wong – Baker faces pain scale
Non-pharmacological interventions may include:
•
•
•
•
4. Etiology
a.
Nociceptive pain – (Nocere; to harm/receptive;
responsive to) experienced when an intact,
properly functioning nervous system sends
signals that tissues are damaged
♦
Somatic Pain – ( skin, muscle, bone )
originates in skin, muscles, bone, or
connective tissue
(e.g. sound, lighting,
temperature)
•
•
•
•
Range of motion or
physical therapy
Repositioning
Relaxation techniques
and imagery
Immobilization
•
•
•
•
•
•
•
Distraction
Psychotherapy or
cognitive behavioral
therapy
Biofeedback
Music therapy
Aromatherapy
Acupressure or
acupuncture
Transcutaneous
electrical stimulus
(TENS)
1.4 Pharmacological Treatment
Types of Somatic Pain:
1. Superficial “Cutaneous” Pain - affects
the skin and subcutaneous.
∘ Sharp sensation
∘ Burning discomfort
Pharmacological Treatments – Use of medication to
treat pain.
1.
2. Deep Somatic Pain/Muscle pain –
affects muscles and bone
∘ Localized sharp
∘ Throbbing
∘ Intense sensation
Ex: trauma (fractures)
ANALGESIC - Acetaminophen (Tylenol®)
♦ Acetaminophen is a common analgesic used
for mild pain, or in a combination with opioids
for moderate pain.
♦ Caution:
exceeding
amount
of
acetaminophen used per day can result in
hepatic toxicity.
Ex: insect bite, paper cut
♦
Heat or cold (as
appropriate)
Massage
Therapeutic touch
Decreasing
environmental stimuli
2.
Visceral Pain – ( organs ) results from
activation of pain in organs or hollow
viscera
→ Cramping, throbbing, pressing, or
aching
→ Sweating, nausea, or vomiting
→ Labor pain, angina pectoris, or
irritable bowel
T R A N S C R I B E D
NON-STEROIDAL ANTI-INFLAMMATORY
(NSAIDs)
– salicylates, ibuprofen (Advil®), naproxen (Aleve®), and
ketorolac (Toradol®).
♦ These are used to reduce inflammation which
can decrease pain. NSAIDs can be used for
mild pain, or in combination with opioids for
moderate pain.
♦ Caution: Dosages for pediatric and elderly
patients, and patients with hepatic or renal
impairment,
bleeding
disorders,
or
gastrointestinal ulcers.
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
TRICYCLIC ANTIDEPRESSANTS
3.
(Elavil®), nortriptyline
(Norpramin®).
(Aventyl®),
G E N E T I C
(SSRIs) –
fluoxetine (Prozac®), paroxetine (Paxil®),
serotonin, and sertraline (Zoloft®).
♦ SSRIs can be used as adjunct therapy for
depression and neuropathic pain.
♦ Caution is required with pediatric and elderly
patients, as there is a risk of suicidal thoughts.
ANTICONVULSANTS –
carbamazepine (Tegretol®),
gabapentin (Neurontin®), and pregabalin (Lyrica®).
♦ Anticonvulsants can provide sedation and a
graded analgesic effect.
TOPICAL AGENTS – creams that have analgesic
6.
or local anesthetic agents.
♦ Topical
agents
may
neuropathies or arthritis.
7.
be
used
Q
Quality
• Ideally, this will elicit descriptions of
the patient’s pain’ whether it is sharp,
dull, crushing, burning, tearing, or
some other feeling, along with the
pattern,
such
as
intermittent,
constant, or throbbing.
♦ Anesthetics can be used for epidurals or
nerve blocks to assist with acute or chronic
pain.
♦ These are temporary and may be effective
up to three or four months.
♦ Risks and benefits must be evaluated prior to
performing a block.
OPIOIDS
♦ Mild:
codeine,
oxycodone,
and
hydrocodone.
♦ More potent opioids: morphine, fentanyl, and
hydromorphone, used for moderate to severe
pain.
♦ Opioids can be used with both acute and
chronic pain.
• Ask the patient to describe the quality
of pain, is it:
→ Throbbing?
→ Dull?
→ Aching?
→ Buring?
→ Sharp?
→ Crushing?
→ Shooting?
→ Etc..?
• Questions can be open ended “Can
you describe it for me?” or leading
with
ANESTHETICS
8.
C O U N S E L L I N G
→ Does any movement, pressure (such
as palpation) or other external
factor make the problem better or
worse? This can also include
whether the symptoms relieve with
rest
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
5.
A N D
→ Adjuvant: Which type of medication
relieves the pain (Tylenol, Ibuprofen,
etc..?)
∘
Does the use of heat or
icepacks alleviate pain?
∘
What type of alternative
therapy
(massage,
acupuncture) have you used
before?
(TCAs) – amitriptyline
and desipramine
♦ TCAs can be effective in treating neuropathic
pain and can provide a mild analgesic
effect.
♦ Caution: caution should be taken for
pediatric and elderlypatients.
4.
A S S E S S M E N T
R
Region &
Radiation
• Where pain is on the body & whether
it radiates (extends) or moves to any
other area? Referred pain can
provide clues to underlying medical
causes
• Location: body diagrams may help
patients illustrate the distribution of
their pain
• Dermatome map – may help
determine the relationship between
sensory location of pain & spinal
nerve segment
Referred Pain
→
1.5 Pain Assessment Tools
{reflective pain}
Is feeling pain in a location
other than original site of the
painful stimulus
Localized pain
O
Onset of
Event
• What was the patient doing when it
started? Were they active
• Did that specific activity prompt or
start the onset of pain?
• Was onset of pain sudden? Gradual?
Or part of an ongoing chronic
problem?
→
Is the pain better or worse with:
P
Provocation
& Palliation
of
Symptoms
→ Activity: Does walking, standing,
lifting, twisting, reading, etc… have
any effect of the pain?
S
Severity
→ Position: Which position causes or
relieves pain? Provide examples to
the patient (sitting, standing, supine,
lateral, etc)
T R A N S C R I B E D
B Y :
Is when pain typically stays in
one location and does not
spread
• Ask the patient to describe the
intensity of pain at baseline and
during acute exacerbations
• The pain score (usually on a scale of 0
to 10) where 0 is no pain and 10 is the
worst possible pain. This can be:
→ comparative (such as “…..
compared to the worst pain
you have ever experienced”)
→ imaginative (“….compare to
having your arm ripped off by
a bear”). If the pain is
compared to a prior event, the
nature of that event may be a
follow – up question
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
• Identify when the pain started, under
what circumstances, duration, onset
(sudden/gradual),
frequency,
whether acute/chronic
T
Timing
A S S E S S M E N T
A N D
C O U N S E L L I N G
Defense and Veterans Pain Rating Scale 2.0 (DVPRS)
• How long the condition has been
going on and how it has changed
since onset (better, worse, different
symptoms)?
• Whether it has ever happened
before, and how it may have change
since onset, and when the pain
stopped if it is no longer currently
being felt?
C
Character
Description of pain Ex: Sharp, Burning
O
Onset
When was the pain started (Acute or
Chronic)
L
Location
Specific region/parts of body
D
Duration
When is usually pain occur or subsides
S
Severity
Describe the intensity of the pain (Ex:
bearable or unbearable)
P
Patterns
How often does the pain attack or
when it is usually occurs (Ex: Night time)
A
Associating
Factors
Factors that might contribute to the
pain (Ex: Post-op)
1.6 Pain Assessment Scale: Adult
Visual Analogue Scale (VAS)
The numeric Pain Rating Scale Instructions
1.
General Information:
•
•
The patient is asked to make three pain ratings,
corresponding to current, best and worst pain
experienced over the past 24 hours
The average of the 3 ratings was used to
represent the patient’s level of pain over the
previous 24 hours
Patient Instructions (adopted from McCaffery, Beebe
et.al 1989): “Please indicate the intensity of current, best, and
worst pain levels over the past 24 hours on a scale of 0 (no
pain) to 10 (worst pain imaginable)”
Numeric Rating Scale (NRS)
Is a measurement instrument that tries to
measure a characteristic or attitude that is
believed to range across a continuum of
values and cannot easily be directly measured.
How severe is your pain today? Place a vertical mark on the
line below to indicate how bad you feel your pain is today.
No Pain
Very
1.7 Pain Assessment Scale: Pedia
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
A S S E S S M E N T
A N D
C O U N S E L L I N G
5
Administer pain-relieving medications per health
care provider’s orders.
6
Removed or reduced painful stimuli by assisting
patient to comfortable position and repositioning
linens, bandage, tube, and equipment as needed
Taught patient how to splint over painful site using
pillow or hand:
a) Explained purpose of splinting
b) Placed pillow or blanket over site, assisted
patient to place hands firmly over area of
discomfort.
c) Hand patient hold area firmly while
coughing, deep breathing, and turning .
7
1.8 Performance Skills: Pain assessment and
basic comfort measures
Reduced or eliminated emotional factors that
increase pain experience:
Purpose of Pain Assessment
•
To provide guideline for the appropriate
identification and assessment of patients who
may experience pain.
8
9
Assessment
a) Offered information that reduces anxiety.
b) Offered patient opportunity to pray
c) Spent time to allow patient to talk about
pain
If used, removed and
performed hand hygiene.
1
Identify patient using 2-3 identifiers
2
Assess patient’s risk for pain
Evaluation
Ask patient if he or she is in pain, used appropriate
language for patient’s values, obtained an
interpreter if necessary
1
3
3
4
Perform hand hygiene. Examine site of patient’s
pain, inspect ROM of joints involved, conduct
percussion and auscultation to help identify
abnormalities,
determine
cause
of
pain,
auscultate abdomen before palpation.
5
Assess physical, behavioral, and emotional signs
and symptoms of pain.
6
Assess characteristics of pain, followed agency
policy regarding frequency of assessment, use
OPQRST or COLDSPA
7
Assessed patient’s medical history for successful
pain relief therapies
8
Assessed
patient’s
response
pharmacological interventions,
analgesic side effect are likely.
9
Assessed for allergies to medications
to
previous
determined if
2
disposed
of
gloves,
Asked patient to describe level of relief within 1
hour of intervention
Compared patient’s current pain with personally
set pain-intensity goal.
Compared patient’s ability to function and
preform ADL’s before and after pain interventions.
4
Observed patient’s nonverbal behaviors.
5
Evaluated for analgesic side effect
6
Asked patient to explain when to use previous
techniques for pain relief
7
Identified unexpected outcomes
Recording and Reporting
1
Recorded and reported character of pain before
intervention, therapies used, and patient response
in appropriate log.
2
Documented evaluation of patient learning.
3
Recorded inadequate pain relief, reduction in
patient function, adverse side effect from pain
intervention, and any patient or family education.
Planning
1
Identified expected outcomes.
Implementation
1
Performed hand hygiene, applied clean gloves if
indicated
2
Prepared patient’s environment. And sound to
allow rest
3
Taught patient how to use pain-rating scale.
4
Set pain-intensity goal with patient when able.
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
NCMA219 – Skills Laboratory
1.11
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The nurse should conduct the following
interventions:
◻
◻
◻
◻
Collecting a urine specimen for culture and sensitivity
by clean catch
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◻ Diagnostic tests are tools that provide information
about clients.
1.12
⎯
⎯
Diagnostic Test Phases
The nurse contributes to the assessment of a
client’s health status by collecting specimens of
body fluids.
Nurses often assume the responsibility for specimen
collection
Nursing responsibilities associated with
specimen collection include the following:
1. Pretest Phases
♦
The major focus of the pretest phase is client
preparation.
A thorough assessment and data collection
assist the nurse in determining communication
and teaching strategies
o
♦
Inform the client and family of the time
frame for when the results will be
available.
Instruct the client and family to ask any
questions so that the healthcare provider
can clarify information and allay any fears
Specimen Collection and Testing
Diagnostic testing involves three phases:
♦
Instruct the client and family on the
reaction the diagnostic test may produce
(e.g., flushing if a dye is injected).
Demonstrate appropriate documentation and
reporting of diagnostic testing information.
◻ Tests may be used for basic screening as part of a
wellness check.
◻ Frequently tests are used to help confirm a
diagnosis, monitor an illness, and provide valuable
information about the client’s response to
treatment.
Explain the purpose and procedure of the
test.
Instruct the client and family about
activity restrictions related to testing, if
applicable (e.g., remain supine for 1 hour
after testing is completed)
◻
1.9 Overview of Diagnostic Test
1.10
Instruct the client and family about the
procedure for the diagnostic test ordered
(e.g., whether food is allowed prior to or after
testing, and the length of time of the test).
Describe the nurse’s role for each of the phases
involved in diagnostic testing.
Discuss the nursing responsibilities for specimen
collection.
Explain the rationale for the collection of each type
of specimen.
Verbalize the steps used in:
→
Example: biologic, psychologic, sociologic,
cultural, and spiritual
The nurse also needs to know what equipment
and supplies are needed for the specific test
◻
Provide client comfort, privacy, and safety
◻
Explain the purpose of the specimen
collection and the procedure for obtaining
the specimen.
◻
Use the correct procedure for obtaining a
specimen or ensure that the client or staff
follow the correct procedure.
o
2. Intratest
♦
Focuses
on
specimen
collection
and
performing or assisting with certain diagnostic
testing
♦
This phase is on nursing care of the client and
follow-up activities and observations.
The nurse also reports the results to appropriate
health team members.
T R A N S C R I B E D
Rationale:
The
use
of
aseptic
techniques in specimen collection
should be explained to the client/staff
to avoid cross contamination
◻
Note relevant information on the laboratory
requisition slip, for example, medications
the client is taking that may affect the
results.
◻
Transport the specimen to the laboratory
promptly. Fresh specimens provide more
accurate results.
◻
Report abnormal laboratory findings to the
healthcare provider in a timely manner
consistent with the severity of the abnormal
result
3. Posttest
♦
C O U N S E L L I N G
Client Teaching
LEARNING OUTCOMES
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A N D
Client Teaching: Preparing for Diagnostic Testing
DAY 1: DIAGNOSTIC TEST ⎯
SPECIMEN COLLECTION &
TESTING
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A S S E S S M E N T
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
1.13
G E N E T I C
Sputum Specimens
A S S E S S M E N T
A N D
C O U N S E L L I N G
To Collect a sputum specimen, the nurse must follow
these steps:
Sputum Specimen
{also known as Phlegm}
♦ Sputum is the mucous secretion from the lungs,
bronchi, and trachea.
1
♦ Important to differentiate it from saliva. ⎯Clear liquid
secreted by the salivary glands in the mouth are referred
to as “spit”
♦ Healthy individuals do not produce sputum.
♦ If a client is coughing or spitting up blood, or sputum
that contains blood, that’s called hemoptysis
2
3
Greet the client. Identify them using two
identifiers: usually their full name and birth date
Offer mouth care so that the specimen will not
be contaminated with microorganisms from the
mouth.
→ Provide the client with a small cup of
water to rinse their mouth to clear away
any microbes that may be present in
their mouth;
→ Ask them to spit into an emesis basin
after rinsing.
Best to collect the sputum in the morning upon
awakening.
•
Rationale: the client can cough up the
secretions that have accumulated during
nighttime
Wear gloves and personal protective equipment
♦ A nurse should obtain a sputum specimen by use of
pharyngeal suctioning ⎯Clients have to cough to bring
4
sputum up from the lungs, bronchi, & trachea
PURPOSE: Sputum specimens are usually collected for
one or more of the following reasons:
5
a) For culture and sensitivity to identify a specific
microorganism and its drug sensitivities.
b) For cytology to identify the origin, structure,
function, and pathology of cells. ⎯cytology often
6
!
If client is suspected of tuberculosis infection
then follow special specimen collection
protocol according to agency policy and
wear specialized PPE
Ask the client to expectorate (cough up) the
sputum into the specimen container.
! Make sure the sputum does not contact the
outside of the container. If became
contaminated, wash it with disinfectant
7
Following sputum collection, offer mouthwash to
remove any unpleasant taste
! don’t offer mouthwash before sputum
collection as it may kill the microbes in the
sputum
and,
consequently,
lead
to
inaccurate test results
d) To assess the effectiveness of therapy
Sputum Specimens are often collected
in the morning
Rationale: to avoid direct contact with the
sputum.
Ask the client to breathe deeply and then cough
up 1 to 2 teaspoons (4 to 10 mL) of sputum.
require collection of three consecutive early-morning
specimens & tested to identify cancer in lungs
c) For acid-fast bacillus (AFB), which also requires
collection, often for 3 consecutive days, to identify
the presence of tuberculosis (TB).
•
8
Label and
laboratory
9
Document the collection of
specimen on the client’s chart
T R A N S C R I B E D
B Y :
transport
the
E R E N / K H I A / A B I T R I A
specimen
the
to
the
sputum
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
1.14
G E N E T I C
Throat Culture
1.15
Throat Culture
{sample collected from mucosa of oropharynx and tonsillar
region}
♦ The sample is then cultured and examined for the
presence of disease-producing microorganisms.
♦ To obtain a throat culture specimen, the nurse
applies clean gloves, then inserts the swab into the
oropharynx and runs the swab along the tonsils and
areas on the pharynx that are reddened or contain
exudate
A S S E S S M E N T
A N D
C O U N S E L L I N G
Collecting Stool Specimens
Stool Specimens
{sample of the client’s feces}
♦ Analysis of stool specimens can provide information
about a client’s health condition
Purpose
To obtain a throat culture specimen
1
1
To analyze for dietary products and digestive
secretions.
→ Like Steatorrhea an excessive amount of
fat in the stool
→  amount of bile can indicate obstruction
of bile flow from the liver and gallbladder
into the intestine.
2
To detect the presence of ova and parasites
→ When collecting specimen for parasites,
it’s important that it is transported to lab
while it’s still warm.
→ Usually 3 stool specimens, over a period of
days, to confirm the presence & to identify
the organism
3
To detect the presence of bacteria or viruses
→ Only a small amount of feces is required
because the specimen will be cultured
4
To determine the presence of occult (hidden)
blood.
→ Bleeding can occur as a result of
gastrointestinal
ulcers,
inflammatory
disease, or tumors.
→ Guaiac Test – fecal occult blood test
(FOBT). Two types:
1. the
traditional
guaiac
test
(Hemoccult)
2. Fecal immunochemical test (FIT) aka
immunochemical fecal occult blood
test or iFOBT).
The nurse applies clean gloves. Greet the client.
Identify them using two identifiers: usually their full
name and birth date
Then inserts the swab into the oropharynx and runs
the swab along the tonsils and areas on the
pharynx that are reddened or contain exudate.
2
3
The gag reflex, active in some clients, may be
decreased by having the client sit upright (high
fowlers) if health permits
•
Rationale: The sitting position and extension of
the tongue help expose the pharynx;
4
Open the mouth, extend the tongue, and say
“ah,” and by taking the specimen quickly
•
Rationale: saying “ah” relaxes the throat
muscles and helps minimize contraction of the
constrictor muscle of the pharynx
Place the swab inside then break the swab shaft
at the score line, place the cap tightly, label and
transport to the lab
5
Before obtaining stool specimen, Inform client to:
1
Defecate in
commode.
2
If possible, do not contaminate the specimen with
urine or menstrual discharge. Void before the
specimen collection.
3
Do not place toilet tissue in the bedpan after
defecation. Contents of the paper can affect the
laboratory analysis.
4
Notify the nurse as soon as possible after
defecation, particularly for specimens that need
to be sent to the laboratory
immediately
T R A N S C R I B E D
B Y :
a
clean
bedpan
E R E N / K H I A / A B I T R I A
or
bedside
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
Planning
1
Identified expected outcomes.
2
Materials:
A S S E S S M E N T
A N D
C O U N S E L L I N G
Ensure that the specimen container is properly
labeled with necessary information
9
10
Do handwashing and send the collected
specimen to the laboratory promptly as fresh
specimen provides more accurate results
11
Document and record the procedure
Implementation
1
Before obtaining the specimen, determine the
reason for collection
2
Greet the client. Identify them using two identifiers:
usually their full name and birth date
3
Wear necessary
specimen
PPE
prior
to
collection
of
1.16
Instruct client to defecate in a clean bedpan or
bedside commode
4
5
If possible, do not contaminate the specimen with
urine or menstrual discharge. Instruct client to void
prior to defecation
6
Do not place toilet tissue in the bedpan after
defecation. Contents of the paper can affect the
results
7
Let the client notify the nurse as soon as possible
after defecation particularly for specimens that
need to be sent in the laboratory.
Scoop 1 inch or 2.5cm for firm stool, 15-30mL if
stool is liquid. Observe aseptic technique
collection
Urine Specimens
Urine Specimens
{Specimen for urinalysis or urine culture}
♦ The nurse is responsible for collecting urine
specimens for a number of tests:
1. Clean Voided Urine Specimens for routine
urinalysis,
2. Clean-Catch or Midstream Urine specimens for
urine culture,
3. Timed Urine Specimens for a variety of tests
that depend on the client’s specific health
problem.
◻ Clean Voided Urine Specimen
♦ Male clients generally are able to void (urinate)
directly into the specimen container
♦ Female clients usually sit/squat over the toilet,
holding the container between their legs during
voiding
Routine urine Examination:
8
◻
◻
◻
T R A N S C R I B E D
B Y :
The first voided specimen in the morning
10 mL of urine is generally sufficient for a routine
urinalysis.
Clients who are seriously ill, physically
incapacitated, or disoriented may need to use
a bedpan or urinal in bed; others may require
supervision or assistance in the bathroom
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
A S S E S S M E N T
A N D
C O U N S E L L I N G
Planning
Whatever the situation, clear and specific
directions are required:
◻
◻
◻
◻
The specimen must be free of fecal
contamination, so urine must be kept
separate from feces.
Female clients should discard the toilet
tissue in the toilet or in a waste bag
rather than in the bedpan because
tissue in the specimen makes laboratory
analysis more difficult.
Put the lid tightly on the container to
prevent spillage of the urine and
contamination of other objects
If the outside of the container has been
contaminated by urine, clean it with a
disinfectant
1
Equipment used varies from agency to agency.
◻ Clean gloves
◻ Antiseptic towelettes
◻ Sterile specimen container
◻ Specimen identification label.
2
In addition, the nurse needs to obtain the
following:
! The nurse must make sure that the specimen label
and the laboratory requisition carry the correct
information.
! Attach
them
securely
to
the
specimen.
Inappropriate identification of the specimen can
lead to errors of diagnosis or therapy for the client
Assignment AP may perform the collection of a
clean-catch or midstream urine specimen.
◻
◻
3
◻
Completed laboratory requisition form
Urine receptacle if the client is not
ambulatory
Basin of warm water, soap, washcloth,
and towel for the non-ambulatory client.
Indication of Specimen Collection
1
Aid to diagnosis to disease
2
To monitor effective treatment
3
To identify pathogenic
determine drug sensitivity
Implementation
microorganism
Preparation
Gather the necessary equipment needed for the
collection of the specimen. Use visual aids, if
available, to assist the client to understand the
midstream collection technique.
and
Contraindication of specimen collection
1
Bleeding on the site of collection
2
Bladder not fully enough
3
Recent abdominal surgery or trauma
4
Patient resists restrain and palpitation
Performance
1
Prior to performing the procedure,
introduce self and verify the client’s
identity using agency protocol. Explain
to the client that a urine specimen is
required, give the reason, and explain
the method to be used to collect it.
Discuss how the results will be used in
planning further care or treatments.
2
Perform hand hygiene and observe
other appropriate infection prevention
procedures
3
Provide for client privacy
◻ Clean Catch or Midstream Urine Specimen
♦ Clean-catch specimens are collected in a sterile
specimen container with a lid.
♦ Disposable clean-catch kits are available.
PURPOSE
•
To determine the presence of microorganisms,
the type of organism(s), and the antibiotics to
which the organisms are sensitive.
For an Ambulatory client who is able to follow
directions, instruct the client on how to collect the
specimen.
Assessment
1
2
Determine the ability of the client to provide the
specimen.
Assess the color, odor, and consistency of the urine
and the presence of clinical signs of urinary tract
infection (e.g., frequency, urgency, dysuria,
hematuria, flank pain, cloudy urine with foul odor).
•
•
4
T R A N S C R I B E D
•
•
B Y :
Direct or assist the client to the bathroom.
Ask the client to wash and dry the genitals
and perineal area with soap and water.
Ask the client if he or she is sensitive to any
antiseptic or cleansing agent.
Instruct the client on how to clean the
urinary meatus with antiseptic towelettes
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
FEMALE CLIENTS
❖ Spread the labia minora with one hand and
with the other hand, use one towelette to
cleanse one side of the labia minora.
❖ Use another towelette for cleaning the other
side of the labia minora.
❖ Use the third towelette to clean over the
urethra.
❖ Always cleanse the perineal area from front to
back and discard the towelette
A S S E S S M E N T
A N D
C O U N S E L L I N G
5
Collect the specimen from a non-ambulatory
client or instruct an ambulatory client on how to
collect it.
•
Instruct the client to start voiding.
•
Place the specimen container into the
midstream of urine and collect the
specimen, taking care not to touch the
container to the perineum or penis.
•
Collect urine in the container.
•
Cap the container tightly, touching only
the outside of the container and the cap
•
If necessary, clean the outside of the
specimen container with disinfectant
•
Remove and discard gloves.
•
Perform hand hygiene
6
Label the specimen and transport it to the
laboratory
•
Ensure that the specimen label is
attached to the specimen cup, not the lid,
and that the laboratory requisition
provides the correct information.
•
Arrange for the specimen to be sent to the
laboratory immediately.
7
Document pertinent data.
•
Record collection of the specimen, any
pertinent observations of the urine such as
color, odor, or consistency, and any
difficulty in voiding that the client
experienced.
•
Indicate on the laboratory slip if the client
is taking any current antibiotic therapy or if
the client is menstruating
MALE CLIENTS
❖ If uncircumcised, retract the foreskin slightly to
expose the urinary meatus.
❖ Using a circular motion, clean the urinary
meatus and the distal portion of the penis
For a client who requires assistance NonAmbulatory, prepare the client and equipment.
•
•
•
•
•
•
5
•
Apply clean gloves.
Wash the perineal area with soap and
water, rinse, and dry.
Assist the client onto a clean commode or
bedpan.
Remove and discard gloves.
Perform hand hygiene.
Open the clean-catch kit, taking care not
to contaminate the inside of the specimen
container or lid.
Apply clean gloves. and Clean the
urinary meatus and perineal area
Evaluation
1
Report laboratory results to the primary care
provider.
2
Discuss findings of the laboratory test with primary
care provider.
Conduct
appropriate
follow-up
nursing
interventions as needed, such as administering
ordered medications and client teaching
3
Possible Nursing Diagnosis
Impaired Urinary elimination, Risk for infection, Pain, &
Anxiety
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
1.17
Collection of Urine Sample in Urinary
Catheter
A S S E S S M E N T
A N D
C O U N S E L L I N G
IF Using Specimen container: Pour some on the
basin first before collecting the midstream in the
specimen container
Urine Specimen from Urinary Catheter:
◻ Check scope of practice & Facility
Policy
◻ Cannot be obtained from drainage
bag
Planning
6
Materials are:
➢ Gloves
➢ Clamp or Rubber band
➢ Disinfectant Swab/Alcohol + Cotton
➢ Specimen Container
IF Using Needless Syringe: Draw 30 mL of urine if
the specimen is required for a routine urinalysis or
3mL for culture. Empty the urine from the syringe
into the specimen container
1
IF Using Specimen container: attach the urine bag
back to the port
7
IF Using Needless Syringe: Remove the needless
syringe
Implementation
1
Greet the client. Identify them using two identifiers:
usually their full name and birth date
2
Prepare the materials needed for the procedure
3
Do hand hygiene and wear gloves
8
Unclamp the catheter and make sure that the
urine flows normally.
9
Take the urine specimen to the laboratory within
20 minutes (make sure to label the container).
Finally, make sure to clean and return the
equipment to the right place.
If the Urine Specimen is needed immediately
Clamp the catheter drainage
tubing with a clamp or a
rubber band for approximately
15-30 minutes 3 inch below the
level of the urine drainage port.
4
24-hour urine collection order / until morning
Clamp the catheter drainage
tubing with a clamp or a
rubber band for 24 hours or
until morning
Then, use the disinfectant swab to clean the port
for 15 seconds and allow it to dry
5
•
•
IF Using Specimen container: Remove
urine bag after the alcohol dries
IF Using Needless Syringe: Wipe where the
Luer-Lok/needless syringe will be inserted
(needless port) and attach the syringe to
the port at 90° angle after the alcohol
dries
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
1.18
G E N E T I C
Collection Wound Drainage Specimen
•
C O U N S E L L I N G
{aerobic microorganisms usually found in the surface of the
wound (they require oxygen to thrive)}
Apply clean gloves
To identify the microorganisms potentially
causing an infection and the antibiotics to
which they are sensitive
Open the specimen tube and place the cap upside
down on a firm, dry surface so that the inside will not
contaminate or if the swab is attached to the lid, twist
the cap to loosen the swab. Hold the tube in one hand
and take out the swab in the other
To evaluate the effectiveness of antibiotic
therapy
Rotate the swab back and forth over clean areas of
granulation tissue from the side or base of the wound.
∘
Rationale:
Microorganisms
most
likely
responsible for a wound infection reside in
viable tissue
Assessment
1
A N D
OBTAINING AEROBIC CULTURE
PURPOSE
•
A S S E S S M E N T
Appearance of the wound and surrounding tissue.
Check the character and amount of wound
drainage
2
Signs of infection such as fever, chills, or elevated
WBC count
3
Client complaints of pain or discomfort at the
wound site
A
Avoid touching the swab to intact skin at the wound
edges.
∘
Rationale: This prevents the introduction of
superficial skin organisms into the culture
Implementation
1
Prior to performing introduce yourself, discuss the
procedure to the client and identify the client with
2 identifiers
2
Perform hand hygiene and observe appropriate
infection prevention procedure
3
Provide client privacy
DO NOT USE pus or exudates to culture.
∘
Rationale: These secretions are mixture of
substances and contaminants that are not the
same as those causing the infection
Return the swab to the culture tube, taking care not to
touch the top or the outside of the tube. Secure the
swab or lid firmly.
∘
Rationale: The outside of the container must
remain free of pathogenic microorganisms to
prevent spread of others
Crush the barrier to the inner compartment containing
the transport medium at the bottom of the tube.
∘
Rationale: This ensures that the swab with the
specimen is surrounded by medium, which
prevents the specimen from drying out or any
microorganisms to multiply.
Remove the dressing that cover the wound
− Apply clean gloves
− Remove the dressing and observe any
drainage. Hold the dressing so that the
client does not see the drainage.
If a specimen is required from another site, repeat the
steps. Specify the exact site
∘ Rationale: presence of drainage might
upset the client
−
4
−
Determine the amount, color, consistency
and odor of the drainage for example
“one 4x4 gauze saturated with pale
yellow thick malodorous drainage”
Discard the dressing carefully so that the
dressing does not touch the bag.
OBTAINING ANAEROBIC CULTURE
{anaerobic microorganisms usually found in deep tissue wounds
and cavities (they do not require oxygen to thrive)}
Apply clean gloves
Insert a sterile 10-mL syringe (without needle) into the
wound, and aspirate 1 to 5 m of drainage in the syringe
∘ Rationale: touching the drainage bag
will contaminate it
−
Remove the gloves and perform hand
hygiene
5
Open the sterile dressing set
6
Assess the wound
B
Cleanse the wound using aseptic technique
− Apply clean gloves
− If a topical antimicrobial ointment is
applied, wipe and irrigate to remove it.
∘
−
7
−
∘
−
Remove and discard gloves, perform hand hygiene
Send the tube or syringe of drainage to the laboratory
immediately. Do not refrigerate
8
Rationale: this absorbs excess cleansing
solution
Remove
hygiene
gloves
and
perform
Immediately inject the drainage into the anaerobic
culture tube and cap the tube tightly or use an
anaerobic culture swab system in which the swab is
immediately placed into a tube filled with an oxygen
free gas or gel environment
Label the tube or syringe appropriately
Rationale: Residual antiseptic must be
removed prior to the culture
Clean the wound with normal saline
solution until all exudate has been
removed
After cleansing apply a sterile gauze pad
to the wound.
Attach the needle to the syringe and expel all air from
the syringe and needle
hand
T R A N S C R I B E D
Dress the wound and document the procedure
done along with pertinent information.
∘
Apply any ordered medication to the
wound
∘
Cover the wound with sterile dressing
∘
Remove gloves and perform hand
hygiene
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
NCMA219 – Skills Laboratory
◻
◻
◻
◻
2
C O U N S E L L I N G
{Primary Union or First Intention Healing}
•
Occurs where the tissue surfaces have been
approximated (closed) and there is minimal or
no tissue loss; Characterized by the formation
of minimal granulation tissue and scarring.
→
LEARNING OUTCOMES
◻
A N D
A. Primary Intention Healing
DAY 2: SKIN INTEGRITY AND
WOUND CARE
◻
A S S E S S M E N T
Example: Closed Surgical Incision & Tissue
Adhesive or Incisions
Describe factors affecting skin integrity
Differentiate primary and secondary wound healing.
Describe the three phases of wound healing.
Identify three major types of wound exudate.
Verbalize the steps used in:
a. Cleaning a sutured wound, dressing a drain
and Obtaining wound specimens.
b. Irrigating a wound and Applying dressings.
c. Removing sutures and staples.
Doffing and Donning
Overview: Skin Integrity & Wound Care
Skin Integrity & Wound Care
{ process that restores function to the skin and tissue }
B. Secondary Intention Healing
{Secondary intention}
♦ SKIN is the largest organ in the body and serves a
variety of important functions in maintaining health
and protecting the individual from injury.
•
♦ Intact skin refers to the presence of normal skin and
skin layers uninterrupted by wounds.
•
♦ The appearance of the skin and skin integrity is
influenced by internal factors such as genetics, age,
and the individual's underlying health as well as
external factors such as activity.
A wound that is extensive and involves
considerable tissue loss, and in which the
edges cannot or should not be approximated.
Difference to primary intention healing:
(1) The repair time is longer
(2) The scarring is greater
(3) The susceptibility to infection is greater
→ Example: Pressure Injury
2.1 Type of Wounds
→
→
→
Intentional or Unintentional
If the tissues are traumatized without a break in the
skin, The wound is closed.
The wound is open when the skin or mucous
membrane surface is broken
C. Tertiary Intention Healing
{Delayed Primary Intention}
•
2.2 Wound Healing
Wounds that are left open for 3 to 5 days to
allow edema or infection to resolve or exudate
to drain and are then closed with sutures,
staples, or adhesive skin closures.
→
T R A N S C R I B E D
B Y :
Example: Wounds left open to resolve
infection, edema, or to drain.
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
2.3 Phases of Wound Healing
A S S E S S M E N T
A N D
C O U N S E L L I N G
2.4 Types of Wound Exudate
Exudate
Inflammatory Phase
{fluid or cells secreted by an open wound}
♦ Begins immediately after injury and lasts 3 to 6
days.
♦ Two major processes occur during this phase:
Hemostasis and Phagocytosis
→ Hemostasis (the cessation of bleeding)
results from vasoconstriction of the larger
blood vessels in the affected area,
retraction (drawing back) of injured blood
vessels.
→ The Deposition of fibrin (connective tissue),
& the formation of blood clots in the area.
♦ Material, such as fluid and cells, which has escaped
from blood vessels during the inflammatory process
and is deposited in tissue or on tissue surfaces.
♦ The nature and amount of exudate vary according
to the tissue involved, the intensity and duration of
the
inflammation,
and
the
presence
of
microorganisms.
Proliferative Phase
♦ The second phase in healing, extends from day 3
or 4 to about day 21 postinjury.
♦ Fibroblasts (connective tissue cells), which migrate
into the wound starting about 24 hours after injury,
begin to synthesize collagen.
♦ Fibroblast begin to synthesize collagen → increase
Collagen → increase strength of the wound →
wound will close
2.5 Complications
Healing
&
Indications
of
Wound
Complications
•
•
•
•
Hemorrhage
Infection
Dehiscence
Evisceration
Indications of Wound Healing
•
•
•
Maturation Phase
Contaminated Wound
Wound Cleaning
Suture Removal
♦ Begins on about day 21 and can extend 1 or 2
years after the injury.
♦ Fibroblast begin to synthesize collagen → Result in
a hypertrophic scar, or keloid.
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
A S S E S S M E N T
A N D
C O U N S E L L I N G
2.6 PPE
Implementation
Applying and Removing Personal Protective Equipment
Remove or secure all loose items such as name tags or
jewelry.
Purpose of PPE
•
To protect healthcare workers and clients from
transmission of potentially infective materials
Assessment
1
Prior to performing the procedure, introduce self
and verify the client’s identity using agency
protocol. Explain to the client what you are going
to do, why it is necessary, and how to participate.
2
Perform hand hygiene
Apply a clean gown.
Consider which activities will be required while the
nurse is in the client’s room at this time
Pick up a clean gown, and allow it to
unfold in front of you without allowing it
to touch any area soiled with body
substances
Planning
Application and removal of PPE can be time
consuming. Prioritize care and arrange for
personnel to care for your other clients if indicated.
3
Slide the arms and the hands through the sleeves.
Fasten the ties at the neck to keep the gown in
place.
Determine which supplies are present within the
client’s room and which must be brought to the
room.
Overlap the gown at the back as much as
possible, and fasten the waist ties or belt
Consider if special handling is indicated for
removal of any specimens or other materials from
the room
Apply the face mask
Assignment:
∘ Use of PPE is identical for all healthcare
providers. Clients whose care requires use of
PPE may be assigned to AP. Healthcare team
members are accountable for proper
implementation of these procedures by
themselves and others.
Locate the top edge of the mask.
The mask usually has a narrow metal
strip along the edge.
Hold the mask by the top two strings or loops
Equipment
∘ As indicated according to which activities will
be performed, ensure that extra supplies are
easily available.
➢ Gown
➢ Mask
➢ Eyewear
➢ Clean Gloves
4
Place the upper edge of the mask over the bridge
of the nose, and tie the upper ties at the back of
the head or secure the loops around the ears. If
glasses are worn, fit the upper edge of the mask
under the glasses.
Secure the lower edge of the mask under the chin,
and tie the lower ties at the nape of the neck
If the mask has a metal strip, adjust this firmly over
the bridge of the nose
Wear the mask only once, and do not wear any
mask longer than the manufacturer recommends
or once it becomes wet
Do not leave a used face mask hanging around
the neck.
The Practice Guidelines provide further instructions
on using a face mask.
Apply
protective
eyewear if it is not
combined with the face
mask
5
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
1
No special technique is required.
If wearing a gown, pull the gloves up to cover the
cuffs of the gown. If not wearing a gown, pull the
gloves up to cover the wrists
To remove soiled PPE, remove the gloves first since
they are the most soiled.
If wearing a gown that is tied at the waist in front,
undo the ties before removing gloves.
Remove the first glove by grasping it on its palmar
surface, taking care to touch only glove to glove.
7
A N D
C O U N S E L L I N G
Evaluation
Apply clean gloves
6
A S S E S S M E N T
Pull the first glove completely off by inverting or
rolling the glove inside out.
2
Conduct any follow-up indicated during your care
of the client. If there has been any failure of the
equipment and exposure to potentially infective
materials is suspected, follow the procedure in the
Practice Guidelines: Steps to Follow After
Occupational Exposure to Bloodborne Pathogens
later in this chapter.
Ensure that an adequate supply of equipment is
available for the next healthcare provider
2.7 Cleaning a Sutured Wound & Dressing a
Wound with a Drain
Purpose
Continue to hold the inverted removed glove by
the fingers of the remaining gloved hand. Place
the first two fingers of the bare hand inside the cuff
of the second glove
Pull the second glove off to the fingers by turning it
inside out. This pulls the first glove inside the second
glove
•
To promote
intention
wound
•
To prevent infection
•
To assess the healing process
•
To protect
trauma
the
healing
wound
from
by
primary
mechanical
Using the bare hand, continue to remove the
gloves, which are now inside out, and dispose of
them in the refuse container
Assessment
8
Perform hand hygiene.
1
Client allergies to wound cleaning agents
2
The appearance and size of the wound
9
Remove protective eyewear and dispose of
properly or place in the appropriate receptacle
for cleaning
3
The amount and character of exudates
4
Client complaints of discomfort
Remove the gown when preparing to leave the
room.
5
The time of the last pain medication
Avoid touching soiled parts on the outside of the
gown, if possible..
6
Signs of systemic infection (e.g., elevated body
temperature, diaphoresis, malaise, leukocytosis)
Grasp the gown along the inside of the neck and
pull down over the shoulders. Do not shake the
gown.
Planning
Roll up the gown with the soiled part inside, and
discard it in the appropriate container
Before changing a dressing, determine
specific orders about the wound or dressing.
any
Assignment:
10 Remove the mask
Remove the mask at the doorway to the client’s
room. If using a respirator mask, remove it after
leaving the room and closing the door.
If using a mask with strings, first untie the lower
strings of the mask.
Untie the top strings and, while holding the ties
securely, remove the mask from the face. If side
loops are present, lift the side loops up and away
from the ears and face. Do not touch the front of
the mask
Discard a disposable mask in the waste container.
Perform proper hand hygiene again
T R A N S C R I B E D
B Y :
•
Cleaning a wound, especially one with a
drain, requires application of knowledge,
problem-solving, and aseptic technique.
•
As a result, this procedure is not assigned
to assistive personnel AP.
•
Te nurse can ask the AP to report soiled
dressings that need to be changed or if a
dressing has become loose and needs to
be reinforced.
•
The nurse is responsible for the assessment
and evaluation of the wound
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
Equipment
➢ Bath blanket (if necessary)
➢ Moisture-proof bag
➢ Mask (optional)
➢ Acetone or another solution (if necessary
to loosen adhesive)
➢ Clean gloves
➢ Sterile gloves
➢ Sterile dressing set: Drape or towel ,Gauze
squares ,Container for cleaning solution
,Cleaning solution (e.g., normal saline)
,Two pairs of forceps ,Gauze dressings and
surgipads
➢ Additional supplies required for the
particular dressing (e.g., extra gauze
dressings and ointment, if ordered)
➢ Tape, tie tapes, or binder
A S S E S S M E N T
A N D
C O U N S E L L I N G
Place the soiled dressing in the moisture-proof bag
without touching the outside of the bag.
Remove the underdressing's, taking care not to
dislodge any drains. If the gauze sticks to the drain,
support the drain with one hand and remove the
gauze with the other.
4
Assess the location, type (color, consistency), and
odor of wound drainage, and the number of
gauzes saturated, or the diameter of drainage
collected on the dressings.
Discard the soiled dressings in the bag as before.
Remove and discard gloves in the moisture-proof
bag
Perform hand hygiene.
Set up the sterile supplies.
Implementation
Open the
technique.
Prepare the client and assemble the equipment.
Obtain assistance for changing a dressing on a
restless or confused client
5
Place the sterile drape beside the wound.
Open the sterile cleaning solution and pour it over
the gauze sponges in the plastic container
Assist the client to a comfortable position in which
the wound can be readily exposed.
Apply sterile gloves.
Make a cuff on the moisture-proof bag for disposal
of the soiled dressings, and place the bag within
reach.
Clean the wound, if indicated.
Clean the wound, using your gloved hands or
forceps and gauze swabs moistened with cleaning
solution.
Apply a face mask, if required
Prior to performing the procedure, introduce self
and verify the client's identity using agency
protocol. Explain to the client what you are going
to do, why it is necessary, and how to participate.
Discuss how the results will be used in planning
further care or treatments.
If using forceps, always keep the forceps tips lower
than the handles
1
Use the cleaning methods
6
2
Perform hand hygiene and observe other
appropriate prevention control procedures.
3
Provide for client privacy
Remove and
appropriately.
dispose
of
soiled
Apply clean gloves and remove
abdominal dressing or surgipad
4
sterile dressing set, using aseptic
Use a separate swab for each stroke and discard
each swab after use.
dressings
the
outer
If adhesive tape was used, remove it by holding
down the skin and pulling the tape gently but
firmly toward the wound.
Lift the outer dressing so that the underside is away
from the client’s face.
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
If a drain is present, clean it next, taking care to
avoid reaching across the cleaned incision. Clean
the skin around the drain site by swabbing in half
or full circles from around the drain site outward,
using separate swabs for each wipe
A S S E S S M E N T
A N D
C O U N S E L L I N G
2.8 Wound Irrigation & Packing
♦ A 30 - to 60-mL piston syringe with a 19-gauge
needle or catheter provides approximately 8 psi.
Using piston syringes instead of bulb syringes to
irrigate a wound also reduces the risk of aspirating
drainage.
♦ Commercially prepared normal saline irrigation is
available in pump spray, aerosol cans, and
prefilled, single-dose plastic vials called bullets.
6
Irrigating a Wound
Purpose of Irrigating a Wound
Support and hold the drain erect while cleaning
around it
Dry the surrounding skin with dry gauze swabs as
required.
To clean the area
•
To apply an antimicrobial solution
Assessment
Assess the client’s record to determine:
Apply dressings to the drain site and the incision.
Place a precut 4*4 gauze snugly around the drain,
or open a 4*4 gauze to 4*8 in., fold it lengthwise to
2*8 in., and place it around the drain so that the
ends overlap
•
1
•
Previous appearance and size of the wound
•
Character of the exudate
•
Presence of pain and the time of the last pain
medication
•
Clinical signs of systemic infection
•
Allergies to the wound irrigation agent or tape
Planning
7
Apply the sterile dressings one at a time over the
drain and the incision.
Apply the final surgipad. Remove and discard
gloves. Secure the dressing with tape or ties.
•
Before irrigating a wound, determine
(a) the type of irrigating solution to be used,
(b) the frequency of irrigations, and
(c) the temperature of the solution.
•
If possible, schedule the irrigation at a time
convenient for the client. Some irrigations
require only a few minutes and others can take
much longer.
•
Determine if the client requires premedication
for pain or other pain management techniques
prior to wound care
Perform hand hygiene
8
Document the
assessments
procedure
and
all
nursing
Evaluation
1
2
3
Conduct appropriate follow-up, such as amount
of granulation tissue or degree of healing; amount
of drainage and its color, consistency, and odor;
presence of inflammation; and degree of
discomfort associated with the incision or drain
site.
Assignment:
Due to the need for aseptic technique and
assessment skills, wound irrigations are not assigned
to AP. However, AP may observe the wound and
dressing during usual care and must report
abnormal findings to the nurse. Abnormal findings
must be validated and interpreted by the nurse
Compare to previous findings, if available.
Report significant deviations from normal to the
primary care provider
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
Equipment
➢ Sterile dressing equipment and dressing
materials
➢ Sterile irrigation set or individual supplies,
including:
∘ Sterile syringe (e.g., a 30- to 60-mL
syringe) with a catheter of an
appropriate size (e.g., #18 or #19) or an
irrigating (catheter) tip syringe
∘ Splash shield for syringe (optional)
∘ Sterile graduated container for irrigating
solution
∘ Basin for collecting the used irrigating
solution
∘ Moisture-proof drape
➢ Moisture-proof bag
➢ Irrigating solution, usually 200 mL (6.5 oz) of
solution room
➢ temperature
or
warmed
to
body
temperature, according to the
➢ agency’s or primary care provider’s choice
➢ Goggles, gown, and mask
➢ Clean gloves
A N D
C O U N S E L L I N G
Remove and discard clean gloves.
Perform hand hygiene
Prepare the equipment
Open the sterile dressing set and supplies.
5
Pour the ordered solution into the solution
container.
Position the basin below the wound to receive the
irrigating fluid.
Irrigate the wound.
Apply clean gloves.
Instill a steady stream of irrigating solution into the
wound. Make sure all areas of the wound are
irrigated.
Use either a syringe with a catheter attached or
with an irrigating tip to flush the wound.
6
Implementation
1
A S S E S S M E N T
Prior to performing the procedure, introduce self
and verify the client's identity using agency
protocol. Explain to the client what you are going
to do, why it is necessary, and how to participate.
Discuss how the results will be used in planning
further care or treatments.
2
Perform hand hygiene and observe other
appropriate prevention control procedures.
3
Provide for client privacy
If you are using a catheter to reach tracks or
crevices, insert the catheter into the wound until
resistance is met. Do not force the catheter.
Continue irrigating until the solution becomes clear
(no exudate is present).
Dry the area around the wound.
Remove and discard gloves.
Prepare the client.
Perform hand hygiene.
Assist the client to a position in which the irrigating
solution will flow by gravity from the upper end of
the wound to the lower end and then into the
basin.
Place the moisture-proof drape under the wound
and over the bed.
Assess and dress the wound
7
Assess the appearance of the wound again,
noting in particular the type and amount of
exudate still present and the presence and extent
of granulation tissue
Using aseptic technique, apply a dressing to the
wound based on the amount of drainage
expected
Perform hand hygiene
4
8
Apply clean gloves and remove and discard the
old dressing.
If indicated, clean the wound from the cleanest
area toward the least clean. If the wound is
circular, this would be from the center of the
wound outward. For a linear wound, cleanse from
top to bottom, beginning in the middle and
moving progressively laterally
Document the irrigation and the client’s response
in the client record using forms or checklists
supplemented
by
narrative
notes
when
appropriate. Electronic health records will use a
designated wound and skin documentation sheet.
Evaluation
1
2
Assess the wound and drainage.
T R A N S C R I B E D
Perform follow-up based on findings that deviate
from expected or normal for the client. Relate
findings to previous assessment data if available.
Report significant deviations from normal to the
primary care provider
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
2.9 Dressing Wounds
∘
∘
has been used to pack wounds that require
debridement.
Types of Dressing:
∘
∘
The type of dressing used depends on:
a) the location, size, and type of the wound;
b) the amount of exudate;
c) whether the wound requires debridement or is
infected; and
d) such considerations as frequency of dressing
change, ease or difficulty of dressing
application, and cost
∘
∘
∘
∘
∘
∘
∘
These dressings offer several advantages:
∘
C O U N S E L L I N G
They act as temporary skin.
They are nonporous, nonabsorbent, selfadhesive dressings that do not require
changing as other dressings do. Because they
are transparent, the wound can be assessed
through them. Furthermore, they are semi
occlusive,
Because they are elastic and They adhere only
to the skin area
They allow the client to shower or bathe
without removing the dressing.
∘
{special kind of wound dressing used for minor burns or bed
sores}
They are occlusive, are opaque, and obscure
wound visibility.
They have a limited absorption capacity.
They can facilitate anaerobic bacterial growth.
They can soften and wrinkle at the edges with
wear and movement.
They can be difficult to remove and may leave
a residue on the skin
Securing Dressings
The correct type of tape must be selected for the
purpose. The nurse follows these steps:
1
Place the tape so that the dressing cannot be
folded back to expose the wound. Place strips at
the ends of the dressing, and space tapes evenly
in the middle
2
Ensure that the tape is long enough and wide
enough to adhere to several inches of skin on
each side of the dressing, but not so long or wide
that the tape loosens with activity.
3
Place the tape in the opposite direction from the
body action, for example, across a body joint or
crease, not lengthwise
4
Montgomery straps (tie tapes) are used for wounds
requiring frequent dressing changes
Transparent Dressings
Hydrocolloid Dressings
They last 3 to 7 days.
They do not need a “cover” dressing and are
water resistant, so the client can shower or
bathe.
They can be molded to uneven body surfaces.
They act as temporary skin and provide an
effective bacterial barrier.
They decrease pain and thus reduce the need
for analgesics.
They absorb moderate drainage and therefore
can be used on slowly draining wounds.
They contain wound odor
These dressings have certain limitations, however:
Transparent dressings are often applied to wounds
including ulcerated or burned skin areas
∘
A N D
Are frequently used over pressure injuries. These
dressings offer several advantages:
♦ Gauze packing using the damp-todamp technique
∘
∘
A S S E S S M E N T
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
A S S E S S M E N T
A N D
C O U N S E L L I N G
NCMA219 – Skills Laboratory
DAY 3: NASOGASTRIC TUBE
INSERTION
LEARNING OUTCOMES
◻
◻
◻
◻
◻
Discuss nasogastric tube insertion and removal
procedure
Describe the type of NG tubes used in the
procedure
Demonstrate the correct procedure in performing
nasogastric tube insertion and removal procedure
Perform the procedure through return
demonstrations
3
3.1
3.2
3.3
3.4
3.5
Overview: NGT
Enteral Feeding
Enteric Device
Nasogastric Tube
Types of NG-Tube
Indication & Contraindication for NG-Tube
Insertion
3.6 Inserting A Nasogastric Tube
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
NCMA219 – Skills Laboratory
LEARNING OUTCOMES
◻
◻
◻
◻
A N D
C O U N S E L L I N G
PARTS: OUTER CANNULA
DAY 4: TRACHEOSTOMY CARE
◻
A S S E S S M E N T
♦ Tracheostomy tubes have an
outer cannula that is inserted into
the trachea and a flange that
rests against the neck.
♦ The flange allows the tube to be
secured
in
place
with
tracheostomy tapes or twill ties, or
Velcro collars
Provide definition of tracheostomy Care
Discuss the purpose of tracheostomy care
Provide the indication of tracheostomy care
Mention the parts of tracheostomy tube
Enlist the complications of tracheostomy
PARTS: INNER CANNULA
4
Overview: Tracheostomy
♦ It is inserted and locked into place
inside the outer cannula
Tracheostomy
{small plastic tube inserted through a surgical created
opening}
♦
♦
an opening into the trachea through the neck
o
For a Patient who can’t keep their OWN
Airway open
A curved tracheostomy tube is inserted to extend
through the stoma into the trachea
♦ Purpose is to prevent tube
obstruction by allowing regular
cleaning & replacement.
♦ Many plastic inner cannulas are
cleaned with a solution of full or
half-strength hydrogen peroxide
(H2O2) & clean water ⎯important to
check the manufacturer’s instructions
for cleaning tracheostomy tubes
because silicone & metal tubes can be
damage by (H2O2)
PARTS: OBTURATOR
♦ All tubes also have an obturator, which is
used to insert the outer cannula and is
the removed.
Performed in using one of the Two Techniques:
1.
2.
Traditional open surgical method
− is done in an operating room where a surgical
incision is made in the trachea just below the
larynx
Percutaneous insertion.
− can be done at the bedside in a critical care
unit
♦ This & a spare tracheostomy tube of the
same size & smaller, is kept at the client’s
bedside in case the tube becomes
dislodged & needs to be reinserted.
PARTS: CUFFED TRACHEOSTOMY TUBES
♦ Surrounded by an inflatable cuff that produces an
airtight seal between tube & trachea.
♦ Often used immediately after a tracheostomy &
essential when ventilating a tracheostomy P.T with a
mechanical ventilator.
♦ Not required to children ⎯their tracheas are elastic
enough to seal the air space around the tube.
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
For a client with a new tracheostomy,
sterile technique should be used when
providing tracheostomy care in order to
prevent infection.
➢
➢
➢
➢
Indication of Tracheostomy
{There are main indications}
Airway obstructions
Prolonged intubations
Facilitate ventilations support
Inability of patient to manage secretion /
retained secretions
➢
➢
➢
➢
! EMERGENCY:
Failed orotracheal and nasotracheal intubation,
either tracheostomy or cricothyroidotomy may be
performed.
➢
➢
Complications of Tracheostomy
◻
◻
◻
◻
A N D
C O U N S E L L I N G
Equipment:
4.1 Indications & Complication of Tracheostomy
A.
B.
C.
D.
A S S E S S M E N T
Hemorrhage
Injury to current laryngeal nerve
Aspirations of blood: prevented by use of
cuffed tracheostomy tube.
Injury to esophagus
4.2 Providing Tracheostomy Care
To maintain airway patency
2
To maintain cleanliness and prevent infection at
the tracheostomy site
3
To facilitate healing and prevent skin excoriation
around the tracheostomy incision
4
To promote comfort
and sterile container for solution)
Sterile normal saline (Some agencies may use
a mixture of hydrogen peroxide and sterile
normal saline. Check agency protocol for
soaking solution.)
Sterile gloves (two pairs—one pair is for
suctioning if needed) , Clean gloves
Moisture-proof bag
Commercially
prepared
sterile
tracheostomy dressing or sterile 4*4 gauze
dressing
Cotton twill ties or Velcro collar
Clean scissors
Implementation
1
Prior to performing the procedure, introduce self
and verify the client’s identity using agency
protocol.
2
Explain to the client what you are going to do, why
it is necessary, and how to participate. Provide for
a means of communication, such as eye blinking
or raising a finger, to indicate pain or distress.
3
Follow through by carefully observing the client
throughout the procedure, and offering periodic
eye contact, caring touch, and verbal
reassurance.
4
Perform hand hygiene and observe other
appropriate infection prevention procedures.
5
Provide for client privacy
Purpose
1
Sterile disposable tracheostomy cleaning
kit or supplies including sterile containers,
sterile nylon brush or pipe cleaners, sterile
applicators, gauze squares
Disposable inner cannula if applicable
Towel or drape to protect bed linens
Sterile suction catheter kit (suction catheter
Prepare the client and the equipment.
Assist the client to a semi-Fowler’s or Fowler’s
position to promote lung expansion.
Assessment
1
Respiratory status including ease of breathing,
rate, rhythm, depth, lung sounds, & oxygen
saturation level. Also, the Pulse rate
2
Character and amount
tracheostomy site
3
Presence of drainage on tracheostomy dressing or
ties
4
Appearance of incision (note any
swelling, purulent discharge, or odor)
of
secretions
from
6
redness,
Planning:
Suction the tracheostomy tube, if needed.
Assignment:
Tracheostomy
care
involves
application of scientific knowledge, sterile
technique, & problem-solving, & therefore needs
to be performed by a nurse or respiratory therapist.
T R A N S C R I B E D
If suctioning was required, allow the client to rest
and restore oxygenation.
Open the tracheostomy kit or sterile basins.
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
A S S E S S M E N T
A N D
C O U N S E L L I N G
Based on the client’s respiratory assessments,
place oxygen source over or near the outer
cannula prevents oxygen desaturation by
maintaining oxygen to the client.
Establish a sterile field
∘
Rationale: This prevents oxygen desaturation by
maintaining oxygen to the client.
Remove the soiled tracheostomy dressing. Place
the soiled dressing in your gloved hand and peel
the glove off so that it turns inside out over the
dressing. Remove & discard the gloves & dressing.
∘
Eren: My brother in Christ, don’t follow the
Open other sterile supplies as needed including
sterile applicators, suction kit, tracheostomy
dressing, and disposable inner cannula, if
applicable.
image. Hence, use as a guide on how to
remove it using your hand with sterile glove on
Perform hand hygiene.
Apply sterile gloves. Keep your dominant hand
sterile during the procedure
Clean the Inner Cannula
Pour the soaking solution and sterile normal saline
into separate containers.
Remove the inner cannula from the soaking
solution.
Apply clean gloves.
Remove the oxygen source.
∘
Rationale: Prevent Hypoxia
6
Unlock the inner cannula (if present) and remove it
by gently pulling it out toward you in line with its
curvature.
∘
Clean the lumen and entire inner cannula
thoroughly using the brush or pipe cleaners
moistened with sterile normal saline.
7
Instruction:
Rotate
inner
cannula
counterclockwise to unlock it. Pull cannula out
in a downward motion. Some inner cannulae
will “click” on, some twist on/off. Do not touch
the inner cannula; only handle the white outer
area unless you are wearing sterile gloves.
Place the inner cannula in the soaking solution, if
not a disposable inner cannula
∘
Rationale: This moistens and loosens dried
secretions
Rinse the inner cannula thoroughly in the sterile
normal saline.
After rinsing, gently tap the cannula against the
inside edge of the sterile saline container. Use a
pipe cleaner folded in half to dry only the inside of
the cannula; do not dry the outside
∘
T R A N S C R I B E D
B Y :
Rationale: This removes excess liquid from the
cannula and prevents possible aspiration by the
client, while leaving a film of moisture on the
outer surface to lubricate the cannula for
reinsertion
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
Replace the Inner Cannula, Securing it in Place
Insert the inner cannula by grasping the outer
flange and inserting the cannula in the direction of
its curvature.
A S S E S S M E N T
A N D
C O U N S E L L I N G
Place the dressing under the flange of the
tracheostomy tube.
8
Lock the cannula in place by turning the lock (if
present) into position to secure the flange of the
inner cannula to the outer cannula.
While applying the dressing, ensure that the
tracheostomy tube is securely supported.
∘
Rationale: Excessive movement
of
the
tracheostomy tube irritates the trachea.
Clean the incision site and tube flange.
Using sterile applicators or gauze dressings
moistened w/ normal saline, clean the incision site.
9
Handle the sterile supplies with your dominant
hand. Use each applicator or gauze dressing only
once and then discard.
Hydrogen peroxide may be used to remove crusty
secretions around the tracheostomy site
Change the tracheostomy ties or Velcro collar
Change as needed to keep the skin clean and
dry.
Twill tape and specially manufactured Velcro ties
are available.
∘
Do not use directly on the site. Check agency
policy.
∘
∘
Velcro ties are becoming more commonly
used. They are wider, are more comfortable,
and cause less skin abrasion.
Rationale: Can be irritating to skin
Usually in a half-strength solution mixed with
sterile normal saline; use a separate sterile
container if this is necessary
Clean the flange of the tube in the same manner.
Thoroughly dry the client’s skin and tube flanges
with dry gauze squares
Apply a sterile dressing.
For client safety, the literature recommends a twoperson technique when changing the securing
device to prevent tube dislodgement
Two-Strip Method (TWILL TAPE)
Use a commercially prepared split-gauze
tracheostomy dressing of nontraveling material
Cut two unequal strips of twill tape, one
approximately 25 cm (10 in.) long and the other
about 50 cm (20 in.) long.
∘
T R A N S C R I B E D
B Y :
Rationale: Cutting one tape longer
than the other allows them to be
fastened at the side of the neck for
easy access and to avoid the
pressure of a knot on the skin at the
back of the neck
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
Cut a 1-cm (0.5-in.) lengthwise slit approximately
2.5 cm (1 in.) from one end of each strip
∘
To do this, fold the end of the tape back onto
itself about 2.5 cm (1 in.), then cut a slit in the
middle of the tape from its folded edge.
Leaving the old ties in place, thread the slit end of
one clean tape through the eye of the
tracheostomy flange from the bottom side; then
thread the long end of the tape through the slit,
pulling it tight until it is securely fastened to the
flange.
∘
Rationale: Leaving the old ties in place while
securing the clean ties prevents inadvertent
dislodging of the tracheostomy tube. Securing
tapes in this manner avoids the use of knots,
which can come untied or cause pressure and
irritation.
If old ties are very soiled or it is difficult to thread
new ties onto the tracheostomy flange with old ties
in place, have an assistant apply a sterile glove
and hold the tracheostomy in place while you
replace the ties.
∘
Rationale: This is very important because
movement of the tube during this procedure
may cause irritation and stimulate coughing.
Coughing can dislodge the tube if the ties are
undone.
Repeat the process for the second tie.
Ask the client to flex the neck. Slip the longer tape
under the client’s neck, place a finger between
the tape and the client’s neck, and tie the tapes
together at the side of the neck.
∘
Rationale: Flexing the neck increases its
circumference the way coughing does. Placing
a finger under the tie prevents making the tie
too tight, which could interfere with coughing
or place pressure on the jugular veins.
A S S E S S M E N T
A N D
C O U N S E L L I N G
Have the client flex the neck. Tie the loose ends
with a square knot at the side of the client’s neck,
allowing for slack by placing one finger under the
ties as with the two-strip method. Cut off long
ends.
Tape and pad the tie knot
Place a folded 4*4 gauze square under the tie
knot, and apply tape over the knot.
Check the tightness of the ties.
Frequently
check
the
tightness
of
the
tracheostomy
ties
and
position
of
the
tracheostomy tub
∘
Rationale: Swelling of the neck may cause the
ties to become too tight, interfering with
coughing and circulation. Ties can loosen in
restless clients, allowing the tracheostomy tube
to extrude from the stoma.
Velcro Collar Method
Thread one piece of the collar with the Velcro end
into the slot on one side of the flange.
Take the collar around the back of the client’s
neck, keeping it flat.
Thread the other piece of the collar with the
Velcro end into the slot on the other side of the
flange
Take the second piece of the collar around the
back of the client's neck, keeping it flat.
Have the client flex the neck and secure the two
pieces of the collar together with the Velcro,
allowing space for one to two fingers between the
collar and the client’s neck.
Check the tightness of the collar as with the tie
method
Remove and discard sterile gloves.
→ Perform hand hygiene.
Document all relevant information.
→ Record suctioning, tracheostomy care,
and the dressing change, noting your
assessment
Tie the ends of the tapes using square knots. Cut
off any long ends, leaving approximately 1 to 2 cm
(0.5 in.).
∘
Rationale: Square knots prevent slippage and
loosening. Adequate ends beyond the knot
prevent the knot from inadvertently untying.
Once the clean ties are secured, remove the
soiled ties and discard.
One-Strip Method (TWILL TAPE)
Cut a length of twill tape 2.5 times the length
needed to go around the client’s neck from one
tube flange to the other.
Thread the end of the tape next to the client’s
neck through the slot from the back to the front.
T R A N S C R I B E D
Variation: Using a Disposable Inner Cannula
Check policy for frequency of changing inner
cannula because standards vary among
institutions.
Open a new cannula package.
Using a gloved hand, unlock the current inner
cannula (if present) and remove it by gently
pulling it out toward you in line with its curvature
Check the cannula for amount and type of
secretions and discard properly.
Pick up the new inner cannula touching only the
outer locking portion.
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )
BSN : NCMA 219 ⎯ MCN AT RISK
G E N E T I C
A S S E S S M E N T
A N D
C O U N S E L L I N G
Evaluation
1
Perform appropriate follow-up such as determining
character and amount of secretions, drainage
from the tracheostomy, appearance of the
tracheostomy incision, pulse rate and respiratory
status compared to baseline data, and complaints
of pain or discomfort at the tracheostomy site.
2
Compare findings to previous assessment data if
available.
3
Report significant deviations from normal to the
primary care provider
SAMPLE DOCUMENTATION
12/11/2020 0900 Respirations 18–20/min. Lung sounds
clear. Able to cough up secretions requiring little
suctioning. Inner cannula changed. Trach dressing
changed. Minimal amount of serosanguineous
drainage present. Trach incision area pink to reddish in
color 0.2 cm around entire opening. No broken skin
noted in the reddened area. M.Lacerna Jr. MAN,RN
T R A N S C R I B E D
B Y :
E R E N / K H I A / A B I T R I A
( S Y : 2 0 2 3 - 2 0 2 4 )