.
F.A.DAVIS
• Over 120 step-by-step procedures
• Includes medication safety and
administration
• Rapid reference format
Myers
Hale
7506_FM_ii-xii 09/08/18 12:12 PM Page ii
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2019 by F. A. Davis Company
All rights reserved. This book is protected by copyright. No part of it may be reproduced,
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Durling, RN; Vickie Ann Grosso, RN, PhD, CNE; Melodye M. Harvey, MSN, MHA, RN;
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Quinn, RN, MSN, EdD; Kevin R. Reilly, BSN, MSN, RN; Deborah Rojas, RN, MSN;
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As new scientific information becomes available through basic and clinical research,
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7506_FM_ii-xii 09/08/18 12:12 PM Page iii
iii
Contents
Preprocedure Guidelines
Postprocedure Guidelines
Assessment Overview
Common Formulas and Equivalents
Common Equivalents
Common Standard-to-Metric Formulas
Urinalysis
Laboratory Values—Life Span With Critical Values
Blood Gas Analysis
Arterial Blood Gas
Venous Blood Gas
Acid–Base Imbalance
Common Causes of Acid–Base Imbalance
Cardiac Markers
Progression of Cardiac Markers
Cerebrospinal Fluid (CSF)
Coagulation
Disseminated Intravascular Coagulopathy Panel
Hematology (CBC With Differential)
Medication Levels (Therapeutic)
Antibiotic Levels (Peak and Trough)
Urinalysis
Medication—Safety
Medication Error
Abbreviation Alerts!
Joint Commission Official “Do Not Use” List
Additional Abbreviations, Acronyms, and Symbols
Administration Alerts!
Medication—Administration
“Six Rights of Medication Administration”
Triple-Checking Medication Orders
Assessment and Documentation
Common Medication Calculations
Conversions—Standard-to-Metric
1
1
2
4
4
4
5
5
9
9
10
10
11
11
11
12
12
13
13
14
15
15
16
16
17
17
18
18
21
21
21
21
22
23
7506_FM_ii-xii 09/08/18 12:12 PM Page iv
Procedures and Equipment A-Z
A-C
A
Airway—Maneuver for Opening
Head-tilt, Chin-lift
Jaw Thrust
Airway—Nasal and Oral
Nasopharyngeal Airway (NPA)
Oropharyngeal Airway (OPA)
Antiembolic Devices
Elastic Stockings (TED Hose)
Sequential Compression Device (SCD)
Apical-Radial Pulse (Pulse Deficit)
Aspiration Precautions
Assistive Devices
Canes
Crutches
Walkers—Avoid Using on Stairs
24
24
24
25
25
25
26
26
27
28
29
30
30
30
30
B
Bladder Irrigation, Continuous (CBI)
Bladder Scanner
Blood Administration
Blood Products
Blood Administration—Transfusion Reaction
Treatment for Blood Transfusion Reactions
Anaphylactic
Hemolytic
Febrile, Nonhemolytic
Blood Specimen—Arterial Blood Gas
Blood Specimen—Fingerstick Blood Glucose (FSBG)
Blood Specimen—Venous Sample
Order of Draw for Vacutainer Tubes
Body Positioning
Breast Self-Examination
BLS Summary of CPR Components: 2015
BLS Cardiac Arrest: 2015 Guidelines
iv
31
32
33
34
35
36
36
36
36
37
38
39
40
41
42
43
44
7506_FM_ii-xii 09/08/18 12:12 PM Page v
v
C
Cardiopulmonary Resuscitation (CPR)—2015 Guidelines
Cardiopulmonary Resuscitation (CPR)—Maneuvers
Cardiovascular Assessment
Deep Venous Thrombosis
Cardiac Auscultation Sites
Chest Tubes
Setup of Closed Chest Drainage System
Insertion
Removal
Troubleshooting
Choking (All Ages)—2015 Guidelines
Codes—Staff Response
Cold Therapy
Ice Bag or Pack
Electric Pump Cooling Device
Cranial Nerves: Assessment
45
45
47
48
48
49
49
49
49
50
51
53
54
54
54
55
D–F
D
Defibrillation
Automated External Defibrillator (AED)
Manual Defibrillation
Dialysis—Peritoneal
Dressing Change—Sterile
Dressings
Application Techniques
Dry
Moist-to-Dry
Wound Packing
Dressing Types
Transparent
Hydrogel
Hydrocolloid
Alginate
Foam
56
56
57
58
59
60
60
60
60
60
60
60
60
60
60
60
7506_FM_ii-xii 09/08/18 12:12 PM Page vi
E
Ear Irrigation
Electrocardiogram (ECG)—Assessment
Cardiac Anatomy and Conduction
Components of the ECG
Systematic ECG Assessment
Analyzing the PR Interval (PRI)
Electrocardiogram (ECG)—Lead Placement
Standard 3 Wire Lead Placement
Standard 5 Wire Lead Placement
Electrocardiogram (ECG) —Sample Rhythms
Atrial Fibrillation (A-fib)
Atrial Flutter
Atrioventricular (AV) Block—First Degree
Atrioventricular (AV) Block—Second-Degree Type I
Atrioventricular (AV) Block—Second-Degree Type II
Atrioventricular (AV) Block—Third-Degree
Pacemaker Rhythm—Atrial and Ventricular
Premature Atrial (PAC)/Junctional (PJC) Complexes
Premature Ventricular Complex (PVC)
Sinus Bradycardia
Sinus Tachycardia
Ventricular Fibrillation (VF)
Ventricular Tachycardia (VT)
Edema—Grading Pitting
Enemas
Prepackaged Enemas (e.g., Fleet)
Standard Gravity, Bag-Type Enemas
Eye Irrigation
61
62
62
63
64
64
65
65
65
66
66
66
67
67
68
68
69
69
70
71
71
72
72
73
74
74
74
75
F
Fall—Prevention
Fall—Risk Assessment
Fecal Impaction—Digital Removal
Fetal Monitoring—Electronic
Fetal Heart Rate (FHR)
Variability (Cardiac Rhythm Irregularities)
Fetal Heart Rate Patterns
vi
76
77
78
79
79
79
80
7506_FM_ii-xii 09/08/18 12:12 PM Page vii
vii
G–K
G
Gastrointestinal System Assessment
Glasgow Coma Scale (GCS)
82
84
H
Heat Therapy
85
I
Incentive Spirometer (IS)
Injections
Angle of Injections
Injections—Intradermal (ID)
Injections—Intramuscular (IM)
Injections—Intramuscular Landmarks
Injections—Intramuscular Z-Track Method
Injections—Subcutaneous (SC)
Injections—Subcutaneous Sites
Insulin
Types of Insulin
Rapid-Acting Insulin
Short-Acting Insulin
Intermediate-Acting Insulin
Long-Acting Insulin
Premixed Insulin
Insulin—Mixing Technique
Intake and Output (I&O)
Intravenous (IV)—Access
Inserting a Peripheral IV or Saline Lock
Troubleshooting IV Complications
Intravenous—IV Push Medications
Through a Primary IV Line
Through a Saline Lock
Intravenous Infusion—Continuous
As a Primary Line
As a Secondary Line (through the primary)
Intravenous Infusion—Intermittent IV Piggyback (IVPB)
86
87
87
88
88
89
90
91
92
93
93
93
93
93
94
94
95
97
98
98
99
101
101
101
102
102
102
103
7506_FM_ii-xii 09/08/18 12:12 PM Page viii
L–O
L
Labor
Comparison of True and False Labor
Stages of Labor
104
104
104
M
Medication—Administration Routes
Buccal—Transmucosal
Ears—Drops
Eyes—Drops or Ointment
Inhalation—Handheld Nebulizer
Inhalation—Metered Dose Inhaler (MDI)
Nasogastric—Gastric Tubes
Oral (PO)
Rectal (PR)
Sublingual (SL)
Topical
Transdermal Patch
Vaginal (PV)
Medication—Preparation
Ampule
Vial
Musculoskeletal Assessment
Muscle Strength Grading Scale
105
105
105
105
106
106
107
107
107
108
108
109
109
111
111
111
112
112
N
Nasogastric (NG) Tube
Insertion of NG Tube
Confirming Proper Placement of NG Tube
Removal of NG Tube
Neurologic Assessment
AVPU Scale
Newborn—Assessment
APGAR Score
ABCs and Temperature
Identification and Safety
Initial Head-to-Toe Assessment
viii
113
113
114
114
115
116
117
117
118
118
118
7506_FM_ii-xii 09/08/18 12:12 PM Page ix
ix
Measurements
Vital Signs
Routine Newborn Medication and Lab Tests
119
119
119
Oral Care—Unconscious or Debilitated Patient
Ostomy Care
Types of Ostomies
Applying or Changing an Ostomy Bag
Ostomy Irrigation (intestinal)
Oxygen Administration
Nasal Cannula
Simple Face Mask
Non-Rebreather Mask
Venturi Mask (Ventimask)
Bag-Valve-Mask (BVM)
Humidified Systems
Transtracheal Oxygenation
120
121
121
121
122
124
124
124
124
124
125
125
125
O
P–R
P
FLACC Pain Scale for Pediatric Patients
Pain—Assessment–OPQRST
Pain—Characteristics
Acute Pain
Chronic Pain
Referred Pain
Patient-Controlled Analgesia (PCA)
Postpartum Assessment
Abdomen and Uterus
Involution of the Uterus
Breasts and Breast-Feeding
Complications
Lower Extremities
Perineum
Pulse Oximetry
Conditions That May Produce False Readings
126
127
128
128
128
128
129
130
130
131
131
131
132
132
133
133
7506_FM_ii-xii 09/08/18 12:12 PM Page x
R
Range of Motion Exercises
Neck: Flexion-Extension
Neck: Lateral Flexion
Neck: Rotation
Shoulder: Flexion-Extension
Shoulder: Abduction-Adduction
Shoulder: Circumduction
Shoulder: External and Internal Rotation
Elbow: Flexion-Extension
Hands and Fingers: Flexion-Extension
Wrists: Supination-Pronation
Wrists: Flexion-Extension
Wrists: Abduction-Adduction
Hands and Fingers: Abduction-Adduction
Thumb: Flexion-Extension
Thumb: Opposition
Hip: Flexion-Extension
Hip: Abduction-Adduction
Hip: Circumduction
Hip: Internal and External Rotation
Knee: Flexion-Extension
Ankle: Flexion-Extension
Foot: Eversion-Inversion
Toes: Flexion-Extension
Toes: Abduction-Adduction
Trunk: Flexion-Extension
Trunk: Lateral Flexion
Trunk: Rotation
Respiratory Assessment
Auscultation of Lung Sounds
Respiratory Patterns
Lung Sounds—Differential Diagnosis
Restraints
Types of Restraints
Alternatives to Restraints
Laws Pertaining to Restraints
Common Reasons for Using Restraints
Safety Guidelines
Adverse Events Related to Use of Restraints
x
134
134
134
134
134
135
135
135
135
136
136
136
136
137
137
137
137
138
138
138
138
139
139
139
139
140
140
140
141
142
142
143
144
144
144
144
145
145
146
7506_FM_ii-xii 09/08/18 12:12 PM Page xi
xi
S–U
S
SBAR—Communication Technique
Seizure Precautions
Progression of a Seizure
Create a Safe Environment Before a Seizure
Protect the Pt During a Seizure
Recovery
Sputum/Throat Culture
Standard Precautions
Hand Hygiene
Personal Protective Equipment (PPE)
Sharps—Linen—Refuse—Equipment
Removing Soiled Gloves
Transmission-Based Precautions
Airborne
Droplet
Contact
Reverse isolation (to protect Pt)
Stool—Specimen Collection
Occult Blood (Hemoccult, Guaiac)
Cysts and Spores/Ova and Parasites
Suctioning
Closed System—Ventilated Patient
Naso/Oropharyngeal
Suture and Staple Removal
147
148
148
148
148
149
150
151
151
151
151
151
152
152
152
152
152
153
153
153
154
154
154
156
T
Testicular Self-Examination (TSE)
Tracheostomy Care
Cleaning
Dislodgement
Tube Feeding
Checking Residuals
Tube Feedings—Complications
Complication
Nausea, Vomiting, Bloating
Diarrhea
Constipation
157
158
158
159
160
160
162
162
162
162
162
7506_FM_ii-xii 09/08/18 12:12 PM Page xii
Aspiration, Gastric Reflux
Occluded Tube
Displaced Tube
162
162
162
Urinary Catheter—Insertion
Condom Catheter Application
Indwelling and Straight Catheters
Urinary Catheter—Removal
Urine—Specimen Collection
Catheterized Patients
Clean-Catch Method (Midstream)
First Morning
Random
Second Void
Timed (24-Hour Urine)
163
163
164
166
167
167
167
168
168
168
168
U
V–Z
V
Ventilators—Patient in Distress
Ventilated Patient in Respiratory Distress
Ventilator Alarms
169
169
170
W
Wound Assessment
Staging Pressure Ulcers
Types of Wounds
Wound Culture
Wound Drainage—Hemovac
Wound Drainage—Jackson Pratt (JP, Bulb-Type)
Wound Drainage—Penrose
Wound Irrigation
Wound Therapy—Negative Pressure
171
172
173
174
175
176
177
178
179
Index
181
xii
7506_Tab1_001-023 08/08/18 2:15 PM Page 1
1
Preprocedure Guidelines
■ Confirm that the order (if needed) is in Pt’s chart and ensure that
a signed consent is present (if required).
■ Review medical record for allergies and conditions that may
influence Pt’s ability to tolerate procedure.
■ Observe the “6 Rights of Medication Administration” when
giving medications, and triple check all medication orders.
■ Gather and assemble necessary supplies, and obtain assistance
from additional staff as needed.
■ Perform hand hygiene before contact with Pt, before and after
putting on gloves, and prior to exiting Pt’s room.
■ Use standard precautions during every Pt contact.
■ Prepare the Pt; explain the procedure and offer reassurance.
■ Identify the Pt; use a minimum of two identifiers (e.g., name,
date of birth) and compare against information on Pt’s chart and
ID band. Use verbal confirmation when possible.
■ Ensure there is proper lighting (rooms are often dark).
■ Adjust bed height (usually to level of your elbows), and lower
nearest side rail to facilitate proper body mechanics.
■ Provide comfort and maintain privacy, exposing only what is
minimally necessary to perform procedure.
Postprocedure Guidelines
■ Discard soiled items and sharps into appropriate containers.
■ Follow institutional policy regarding recyclable items.
Clean and store (or remove) reusable equipment.
■ Discard gloves and wash hands prior to touching or handling
unsoiled items (e.g., side rails, personal items).
■ Clean and dry the Pt, and replace linens as necessary.
■ Return the Pt to a position of comfort.
■ Raise side rails and lower bed to lowest position.
■ Ensure tubes and lines are free of kinks and obstruction.
■ Ensure call light and Pt items are within easy reach.
■ Document procedure, Pt’s response, and assessment findings.
■ Document medication, dose, route, time, site, and Pt’s response
(if administered).
SAFETY/
TOOLS
7506_Tab1_001-023 08/08/18 2:15 PM Page 2
SAFETY/
TOOLS
Assessment Overview
Supplies
• Paper and pen
• Penlight
• Watch with second • Stethoscope
hand
• Thermometer
• Blood pressure cuff
Background Data
Biographic data, chief complaint, SAMPLE
history, past medical history, family and
social history, advance directives
General Condition
Hygiene, state of well-being, nutrition,
level of consciousness, emotional status,
speech, affect, posture, gait, coordination,
balance, gross deformities, mobility, range
of motion, nonverbal cues
Vital Signs
Temperature, HR, RR, BP, and pain score
Skin
See Wound
Assessment
page 171–173
Temperature, moisture, color, integrity,
turgor, wounds, pressure ulcers, incisions,
dressings, tubes and lines, lesions, scars,
bruising, redness, body piercings, tattoos
Head and Neck
Head: Shape and symmetry, condition
of hair and scalp
Eyes: Conjunctiva, sclera, pupils, use of
glasses or contacts
Ears: Pain, inflammation, drainage, hearing
aids, hearing impairment
Nose: Drainage, congestion, sense of
smell, NG tube, patency/equality of
nostrils, nasal flaring, septal deviation
Throat and Mouth: Oral hygiene, odor,
mucus membranes, gingival bleeding,
lesions, condition of teeth, dentures,
tongue, swallowing, tonsils
Neck: Stiffness, pain, range of motion,
lymph nodes, thyroid, JVD, tracheal
alignment, retractions
2
7506_Tab1_001-023 08/08/18 2:15 PM Page 3
3
Assessment Overview (continued)
Cardiovascular
See page 4
Fatigue, exertional dyspnea, chest pain,
dizziness, activity intolerance, edema,
cyanosis or clubbing of nails, pulses, capillary refill, heart sounds, ECG tracing, presence of disease (CAD, CHF, MI, etc.)
Respiratory
See page 141–143
Dyspnea, shortness of breath, cough, recent
respiratory infections, lung sounds, oxygen
therapy, oximetry, sputum characteristics,
respiratory rate, rhythm, effort and pattern,
disease (asthma, emphysema, etc.)
Gastrointestinal
See page 82–83
Obesity, dietary habits, nausea, bowel patterns, stool characteristics, hemorrhoids,
gastric tubes, ostomies, disease (reflux,
celiac, IBS, etc.).
Abdomen: Pain, distention, masses, herniations, scars, rigidity, bowel sounds
Genitourinary
Hygiene, pain, sexual history, STDs, voiding
pattern, nocturia, dysuria, discharge,
lesions, urinary catheters
Females: Amenorrhea, vaginal bleeding,
breast self-examinations
Males: Erectile dysfunction, testicular pain,
swelling, lumps, testicular self-examinations
Musculoskeletal
See page 112
Pain, range of motion, muscle strength
(page 112), distal circulation, sensation and movement, casts, amputations, prosthesis (stump
condition), limb-length symmetry, deformities,
physical limitations, assistive devices.
Extremities: Pedal pulses, edema, ulcers,
deep vein thrombosis (DVT)
Neurologic
See page 115–116
Pupils, mental status, cranial nerves, deep
tendon reflexes, paralysis, paresthesia,
stroke or seizure disorder, level of alertness
and orientation, sleep pattern changes,
clonus, Babinski sign in infants >18 mo.
SAFETY/
TOOLS
7506_Tab1_001-023 08/08/18 2:15 PM Page 4
SAFETY/
TOOLS
Common Formulas and Equivalents
Common Equivalents
Volume
1 cc......................................1 mL
1 tsp .................4.92 mL (~5 mL)
1 tbsp ...........14.78 mL (~15 mL)
1 oz ..............29.57 mL (~30 mL)
1 cup ........236.58 mL (~240 mL)
1 pint........473.17 mL (~473 mL)
1 quart .....946.35 mL (~946 mL)
1 liter .............................33.81 oz
Weight
1 mg ............................1000 mcg
1 gram...........................1000 mg
1 kg ...................................1000 g
1 grain ...............................60 mg
1/150 grain .......................0.4 mg
1 kg .....................................2.2 lb
1 liter.....................................1 kg
1 oz .......................................28 g
Common Standard-to-Metric Formulas
Standard
Metric
Weight
lb = kg × 2.2
kg = lb × 0.45 or (lb ÷ 2) – 10%
Temp
°F = (°C × 1.8) + 32
°C = ((°F − 32) × 5) ÷ 9
Volume
oz to mL = oz × 30
mL to oz = mL ÷ 30
Length
Inches = cm × 0.394
cm = inches × 2.54
4
7506_Tab1_001-023 08/08/18 2:15 PM Page 5
5
Urinalysis
pH
5.0–9.0
Protein
Less than 20 mg/dL
Glucose
Negative
Ketones
Negative
Hemoglobin
Negative
Bilirubin
Negative
Urobilinogen
Up to 1 mg/dL
Nitrite
Negative
Leukocyte esterase
Negative
Specific Gravity
1.001–1.029
Laboratory Values—Life Span With
Critical Values
Basic Chemistry and Electrolytes
Reference ranges vary among facilities. Always check normal
reference ranges from your facility’s laboratory.
M, male; F, female.
Note: Bold, red font (in parentheses) indicates critical level.
Lab
Albumin
SAFETY/
TOOLS
Conventional
<1 yr: 2.9–5.5 g/dL
1–40 yr: 3.7–5.1 g/dL
41–60 yr: 3.4–4.8 g/dL
61–90 yr: 3.2–4.6 g/dL
>90 yr: 2.9–4.5 g/dL
SI Units
29–55 g/L
37–51 g/L
34–48 g/L
32–46 g/L
29–45 g/L
7506_Tab1_001-023 08/08/18 2:15 PM Page 6
SAFETY/
TOOLS
Lab
Aldolase (ALD)
Alkaline
phosphatase
Ammonia
Amylase
Anion gap
Aspartate
aminotransferase
(AST; formerly
known as SGOT)
Bilirubin, direct
(conjugated)
Bilirubin, indirect
(unconjugated)
Bilirubin,
total (>15 mg/dL)
Conventional
0–2 yr: 3.4–11.8 units/L
2–16 yr: 1.2–8.8 units/L
Adult: <7.4 units/L
M: 35–142 units/L
F: 25–125 units/L
M: 27–102 mcg/dL
F: 19–87 mcg/dL
30–110 units/mL
SI Units
3.4–11.8 units/L
1.2–8.8 units/L
<7.4 units/L
35–142 units/L
25–125 units/L
19–73 mcmol/L
1462 mcmol/L
30–110 units/mL
8–16 mEq/L
8–16 mmol/L
0–9 days: 47–150 units/L 47–150 units/L
10 days–23 mo: 9–80 units/L 9–80 units/L
M: 2–59 yr: 15–40 units/L 15–40 units/L
M: 60–90 yr: 19–48 units/L 19–48 units/L
F: 2–59 yr: 13–35 units/L 13–35 units/L
F: 60–90 yr: 9–36 units/L 9–36 units/L
<0.3 mg/dL
<5 mcmol/L
<1.1 mg/dL
0–1 day: 1.4–8.7 mg/dL
1–2 days: 3.4–11.5 mg/dL
3–5 days: 1.5–12.0 mg/dL
>1 mo: 0.3–1.2 mg/dL
Blood urea
0–3 yr: 5–17 mg/dL
nitrogen (BUN)
4–13 yr: 7–17 mg/dL
(>100 mg/dL)
14–90 yr: 8–21 mg/dL
(nondialysis Pts)
>90 yr: 10–31 mg/dL
Calcitonin
M: <19 pg/mL
F: <14 pg/mL
++
Calcium (Ca ) 3–12 yr: 8.8–10.8 mg/dL
(<7; >12 mg/dL)
Adult: 8.2–10.2 mg/dL
6
<19 mcmol/L
24–149 mcmol/L
58–97 mcmol/L
26–205 mcmol/L
5–21 mcmol/L
1.8–6.0 mmol/L
2.5–6.0 mmol/L
2.9–7.5 mmol/L
3.6–11.1 mmol/L
<19 ng/L
<14 ng/L
2.20–2.70 mmol/L
2.05–2.55 mmol/L
7506_Tab1_001-023 08/08/18 2:15 PM Page 7
7
Lab
Carbon dioxide (CO2)
(<15; >40 mmol/L)
Chloride (Cl–)
(<80; >115 mEq/L)
Cholesterol
Conventional
<2 yr: 13–29 mEq/L
>2 yr: 23–29 mEq/L
0–1 mo: 98–113 mEq/L
>1 mo: 97–107 mEq/L
<20 yr: <170 mg/dL
>20 yr: <200 mg/dL
Cortisol
a.m.: 5–25 mcg/dL
p.m.: 3–16 mcg/dL
Creatine kinase (CK) M: 50–204 units/L
F: 36–160 units/L
Creatinine
1–5 yr: 0.3–0.5 mg/dL
(>7.4 mg/dL)
6–10 yr: 0.5–0.8 mg/dL
M: >10 yr: 0.6–1.2 mg/dL
F: >10 yr: 0.5–1.1 mg/dL
Ferritin
M: ≥16 yr: 20–250 ng/mL
F: 16–39 yr: 10–20 ng/mL
F: ≥40 yr: 12–263 ng/mL
Folate
>2.5 ng/mL
Glucose
1 day: 40–60 mg/dL
(<40; >400 mg/dL)
2 days–2 yr: 50–80 mg/dL
Child: 60–100 mg/dL
Adult: 65–99 mg/dL
High-density Optimal: >60 mg/dL
lipoprotein (HDL)
Ionized calcium
4.6–5.08 mg/dL
(<3.2; >6.2 mg/dL)
Iron (Fe)
M: 65–175 mcg/dL
(>400 mcg/dL)
F: 50–170 mcg/dL
Iron binding capacity, 250–350 mcg/dL
total (TIBC)
K+ (Potassium) Child: 3.4–4.7 mEq/L
(<2.5; >6.5)
Adult: 3.5–5.0 mEq/L
SAFETY/
TOOLS
SI Units
13–29 mmol/L
23–29 mmol/L
98–113 mmol/L
97–107 mmol/L
<4.4 mmol/L
<5.18 mmol/L
138–690 nmol/L
83–442 nmol/L
50–204 units/L
36–160 units/L
27–44 mcmol/L
44–71 mcmol/L
53–106 mcmol/L
44–97 mcmol/L
20–250 mcg/L
10–20 mcg/L
12–263 mcg/L
>5.7 nmol/L
2.2–3.3 mmol/L
2.8–4.4 mmol/L
3.3–5.6 mmol/L
3.6–5.5 mmol/L
0.9–1.56 mmol/L
1.12–1.32 mmol/L
11.6–31.3 mcmol/L
9–30.4 mcmol/L
45–63 mcmol/L
3.4–4.7 mmol/L
3.5–5.0 mmol/L
7506_Tab1_001-023 08/08/18 2:15 PM Page 8
SAFETY/
TOOLS
Lab
Conventional
Lactate
90–156 units/L
dehydrogenase
(LDH)
Lactic acid
3–23 mg/dL
(≥31 mg/dL)
Lipase
3–73 units/L
Low-density Optimal: <100 mg/dL
lipoprotein (LDL)
Magnesium
Child:1.7–2.1 mg/dL
(Mg++)
Adult: 1.6–2.6 mg/dL
(<1.2; >4.9 mg/dL)
++
Mg
Child: 1.7–2.1 mg/dL
(magnesium)
Adult: 1.6–2.6 mg/dL
(<1.2; >4.9 mg/dL)
Na+ (sodium) 0–1 yr: 133–144 mEq/L
(<120; >160 mmol/L) >1 yr: 135–145 mEq/L
Osmolality
275–295 mOsm/kg
(<265; >320 mOsm/kg)
Phosphorus
2.5–4.5 mg/dL
(<1 mg/dL)
Potassium (K+)
Child: 3.4–4.7 mEq/L
(<2.5; >6.5 mmol/L)
Adult: 3.5–5.0 mEq/L
Prealbumin
12–42 mg/dL
Protein, total
6–8 g/dL
Prostate-specific
<4 ng/mL
antigen (PSA)
Pyruvate kinase
9–22 international
units/g hemoglobin
Sodium (Na+) 0–1 yr: 133–144 mEq/L
(<120; >160 mmol/L) >1 yr: 135–145 mEq/L
8
SI Units
90–156 units/L
0.3–2.6 mmol/L
3–73 units/L
<2.59 mmol/L
0.70–0.86 mmol/L
0.66–1.07 mmol/L
0.70–0.86 mmol/L
0.66–1.07 mmol/L
133–144 mmol/L
135–145 mmol/L
275–295 mmol/kg
0.8–1.4 mmol/L
3.4–4.7 mmol/L
3.5–5.0 mmol/L
120–420 mg/L
60–80 g/L
<4 mcg/L
9–22 international units/g
hemoglobin
133–144 mmol/L
135–145 mmol/L
7506_Tab1_001-023 08/08/18 2:15 PM Page 9
9
Lab
Thyroglobulin
Thyroidstimulating
hormone (TSH)
Thyroxine (T4) free
Thyroxine (T4) total
(<2 mcg/dL;
>20 mcg/dL)
Triglycerides
Tri-iodothyronine
(T3) free
Tri-iodothyronine
(T3) total
Urea nitrogen
(>100 mg/dL)
Uric acid
Conventional
0–50 ng/mL
0.4–4.2 microinternational units/mL
SI Units
0–50 mcg/L
0.4–4.2 microinternational
units/mL
10–19 pmol/L
59–135 nmol/L
71–142 nmol/L
71–155 nmol/L
<1.7 mmol/L
4–7.4 pmol/L
3–5.2 pmol/L
1.08–3.14 nmol/L
1.79–3.8 nmol/L
2.5–6.0 mmol/L
2.9–7.5 mmol/L
0.26–0.45 mmol/L
0.14–0.39 mmol/L
0.8–1.5 ng/dL
M: 4.6–10.5 mcg/dL
F: 5.5–11 mcg/dL
Gravid: 5.5–16 mcg/dL
<150 mg/dL
260–480 pg/dL
Gravid: 196–338 pg/dL
70–204 ng/dL
Gravid: 116–247 ng/dL
Child: 7–17 mg/dL
Adult: 8–21 mg/dL
M: 4.4–7.6 mg/dL
F: 2.3–6.6 mg/dL
Blood Gas Analysis
Arterial Blood Gas
Lab
pH (<7.20; >7.60)
PO2 (<45 mm Hg)
PCO2 (<20; >67 mmHg)
HCO3 (<10; >40 mmol/L)
Base excess
CO2
O2 Saturation
SAFETY/
TOOLS
Conventional
7.35–7.45
80–95 mm Hg
35–45 mm Hg
18–23 mEq/L
(–2)–(+3) mEq/L
22–29 mEq/L
95%–100%
SI Units
7.35–7.45
10.6–12.6 kPa
4.66–5.98 kPa
18–23 mmol/L
(–2)–(+3) mmol/L
22–29 mmol/L
95%–100%
7506_Tab1_001-023 08/08/18 2:15 PM Page 10
SAFETY/
TOOLS
Venous Blood Gas
Lab
pH
PO2
PCO2
HCO3
CO2
O2 Saturation
Conventional
7.32–7.43
20–49 mm Hg
41–51 mm Hg
24–28 mEq/L
25–30 mEq/L
70%–75%
SI Units
7.32–7.43
2.6–6.5 kPa
5.4–6.8 kPa
24–28 mmol/L
25–30 mmol/L
70%–75%
Acid–Base Imbalance
Imbalance
pH
PCO2
Respiratory Acidosis
Uncompensated ↓
↑
Compensated
Normal ↑
PO2
Compensation
Kidneys conNormal Normal serve HCO3;
eliminate H+
↑
↑
to ↑ pH
Kidneys elimiRespiratory Alkalosis
Uncompensated ↑
↓
Normal Normal nate HCO3;
conserve H+
Compensated
Normal ↓
↓
↓
to ↓ pH
HyperventilaMetabolic Acidosis
tion to blow
Uncompensated ↓
Normal ↓
↓
off excess
Compensated
Normal ↓
↓
↓
CO2 and conserve HCO3
Metabolic Alkalosis
Hypoventilation to ↑ CO2
Uncompensated ↑
Normal ↑
↑
Kidneys
Compensated
Normal ↑
↑
↑
keep H+ and
excrete HCO3
10
HCO3
7506_Tab1_001-023 08/08/18 2:15 PM Page 11
11
Common Causes of Acid–Base Imbalance
Respiratory acidosis Asphyxia, respiratory and CNS depression.
Respiratory alkalosis Hyperventilation, anxiety, diabetic
ketoacidosis.
Metabolic acidosis
Diarrhea, renal failure, salicylate (aspirin)
overdose.
Metabolic alkalosis
Hypercalcemia, alkaline (antacid) overdose.
Cardiac Markers
Lab
CK (total)
CK–MB
LDH
Myoglobin
Troponin-I
(>0.5 ng/mL)
Troponin-T
Conventional
M: 50–204 units/L
F: 36–160 units/L
0–3 ng/mL
90–156 units/L
5–70 mcg/L
<0.35 ng/mL
SI Units
50–204 units/L
36–160 units/L
0–3 ng/mL
90–156 units/L
5–70 mcg/L
<0.35 ng/mL
<0.20 mcg/mL
<0.20 mcg/mL
Progression of Cardiac Markers
Lab
AST (SGOT)
CK (total)
CK-MB
LDH
Myoglobin
Troponin-I
Troponin-T
SAFETY/
TOOLS
Onset
6–8 hr
4–6 hr
4–6 hr
12 hr
1–3 hr
2–6 hr
3–5 hr
Peak
12–48 hr
24 hr
15–20 hr
24–48 hr
4–12 hr
15–20 hr
24 hr
Duration
3–4 days
2–3 days
2–3 days
10–14 days
1 day
5–7 days
10–15 days
7506_Tab1_001-023 08/08/18 2:15 PM Page 12
SAFETY/
TOOLS
Cerebrospinal Fluid (CSF)
Lab (Lumbar Puncture)
Color
Protein
Glucose
Lactic acid
Myelin basic protein
Oligoclonal bands
Immunoglobulin G
Gram stain
India ink
Culture
RBC count
WBC count
Conventional
Crystal clear
15–45 mg/dL
40–70 mg/dL
<25.2 mg/dL
<4 ng/mL
Absent
<3.4 mg/dL
Negative
Negative
No growth
Zero
0–5/mL
SI Units
Crystal clear
150–450 mg/L
2.2–3.9 mmol/L
<2.8 mmol/L
<4 mcg/L
Absent
<34 mg/L
Negative
Negative
No growth
Zero
0–5 × 106/L
Lab
Activated coagulation
time (ACT)
Activated partial
thromboplastin time
(aPTT) (>70 sec)
Bleeding time (>14 min)
Fibrinogen (<80 mg/dL)
International normalized
ratio (INR) (>5)
Conventional
90–130 sec
SI Units
90–130 sec
25–39 sec
25–39 sec
2–7 min
200–400 mg/dL
Normal: <2
Target therapeutic:
2–3
2–7 min
2–4 g/L
<2
2–3
Coagulation
12
7506_Tab1_001-023 08/08/18 2:15 PM Page 13
13
Lab
Plasminogen
Platelets (<20,000;
>1,000,000)
Prothrombin
time (PT) (>27 sec)
Thrombin time
Conventional
80%–120% of
normal
150,000–
450,000/mm3
10–13 sec
SI Units
80%–120% of
normal
150–450 × 109/L
11–15 sec
11–15 sec
10–13 sec
Disseminated Intravascular Coagulopathy Panel
Lab
aPTT (activated) (>70 sec)
PT (>27 sec)
Fibrinogen (<80 mg/dL)
Thrombin time
D–Dimer
Conventional
25–39 sec
10–13 sec
200–400 mg/dL
11–15 sec
<300 ng/mL
SI Units
25–39 sec
10–13 sec
2–4 g/L
11–15 sec
<300 ng/mL
Hematology (CBC With Differential)
Lab
Blood volume
Conventional
8.5%–9.0% of body
weight in kg
Red blood cell
M: 4.71–5.14 ×
(RBC)
106 cells/mm3
F: 4.20–4.87 ×
106 cells/mm3
Hemoglobin M: 13.2–17.3 g/dL
(Hgb) (<6; >18 g/dL) F: 11.7–15.5 g/dL
Hematocrit
M: 43%–49%
(Hct) (<18; >54%)
F: 38%–44%
SAFETY/
TOOLS
SI Units
80–85 mL/kg
4.71–5.14 ×
1012 cells/L
4.20–4.87 ×
1012 cells/L
132–173 mmol/L
117–155 mmol/L
0.43%–0.49%
0.38%–0.44%
7506_Tab1_001-023 08/08/18 2:15 PM Page 14
SAFETY/
TOOLS
Lab
Conventional
SI Units
Leukocytes
(WBC) (<2500;
>30,000/mm3)
• Neutrophils
• Bands
• Segments
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils
Platelets (<20,000;
>1,000,000)
Erythrocyte
sedimentation
rate (ESR)
4.5–11 × 103/mm3
4.5–11 × 109/L
59%
3.0%
56%
34%
4.0%
2.7%
0.5%
150,000–450,000/mm3
0.59
0.03
0.56
0.34
0.04
0.027
0.005
150–450 × 109/L
M: 0–49 yr: 0–15 mm/hr
M: >49 yr: 0–20 mm/hr
F: 0–49 yr: 0–25 mm/hr
F: >49 yr: 0–30 mm/hr
0–15 mm/hr
0–20 mm/hr
0–25 mm/hr
0–30 mm/hr
Medication Levels (Therapeutic)
Medication
Conventional
Acetaminophen 10–30 mcg/mL
Critical/Toxic
SI Units
After 4 hr: >150 66–199 mcmol/L
After 12 hr: >50
Amiodarone
0.5–2.0 mg/L
>2
Carbamazepine 4–12 mcg/mL
>12
17–51 mcmol/L
Digoxin
0.5–2.0 ng/mL >2.5
0.6–2.6 nmol/L
Lidocaine
1.5–5.0 mcg/mL >6
6.4–21.4 mcmol/L
Lithium
0.6–1.4 mEq/L >1.5
0.6–1.4 mEq/L
Nitroprusside
<10 mg/dL
>10
Phenobarbital 15–40 mcg/mL >40
65–172 mcmol/L
Phenytoin
10–20 mcg/mL >20
40–79 mcmol/L
14
7506_Tab1_001-023 08/08/18 2:15 PM Page 15
15
Medication
Procainamide
Propranolol
Quinidine
Salicylate
Theophylline
Conventional
4–10 mcg/mL
50–100 ng/mL
2–5 mcg/mL
15–20 mg/dL
10–20 mcg/mL
Critical/Toxic
>12
>150
>8
>30
>20
SI Units
17–42 mcmol/L
6–15 mcmol/L
1.1–1.4 mmol/L
Antibiotic Levels (Peak and Trough)
Antibiotic
Amikacin
Peak
Critical Trough
C: 20–30 mcg/mL >30
1–8 mcg/mL
SI: 34–51 mcmol/L >51
2–14 mcmol/L
Gentamicin C: 6–10 mcg/mL
>12
0.5–1.5 mcg/mL
SI: 12–21 mcmol/L >25
1–3 mcmol/L
Tobramycin C: 6–10 mcg/mL
>12
0.5–1.5 mcg/mL
SI: 12–21 mcmol/L >26
1–3 mcmol/L
Vancomycin C: 30–40 mcg/mL >80
5–10 mcg/mL
SI: 21–28 mcmol/L >55
3–7 mcmol/L
C, conventional; SI, SI units.
Urinalysis
Lab
Appearance
Color
pH
Protein
Glucose
Ketones
Hemoglobin
SAFETY/
TOOLS
Conventional
Clear
Yellow (straw)
5.0–9.0
<20 mg/dL
Negative
Negative
Negative
Critical
>8
>14
>2
>3
>2
>3
>20
>14
7506_Tab1_001-023 08/08/18 2:15 PM Page 16
SAFETY/
TOOLS
Lab
Bilirubin
Urobilinogen
Nitrite
Leukocyte esterase
Specific gravity
Osmolality
RBC
WBC
Renal cells
Transitional cells
Squamous cells
Casts
Conventional
Negative
≤1 mg/dL
Negative
Negative
1.001–1.029
250–900 mOsm/kg
<5/hpf
<5/hpf
None seen
None seen
Rare; usually not significant
Rare hyaline; otherwise, none seen
Medication—Safety
Medication Error
• Discontinue medication immediately.
• Assess for and treat symptoms of adverse reaction (ADR).
• Ascertain if Pt has known allergy to medication given.
• Notify health care provider of medication error and any ADR.
• Document error (incident report) per institutional policy.
• Avoid using such phrases as “given in error.”
• State facts only on MAR (medication, dose, time, route).
• In progress notes, document that health care provider was
notified.
• If there was any ADR, include intervention and outcome.
Do not document that an incident report was filed. NEVER
record “medication error” on the MAR.
16
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Abbreviation Alerts!
Joint Commission Official “Do Not Use” List
Do Not Use
U (unit)
Rationale
Mistaken for “0”
(zero), the number
“4” or “cc”
Mistaken for “IV”
IU (international
(intravenous) or the
unit)
number “10” (ten)
Mistaken for each
Q.D., QD, q.d., qd
other
(daily)
Period after the Q
Q.O.D., QOD, q.o.d.,
qod (every other day) mistaken for “I” and
the “O” mistaken
for “I”
Trailing zero (X.0 mg)* Decimal point is
missed
Lack of leading zero
(.X mg)
Confused for each
MS
other
MSO4 and MgSO4
Can mean morphine
sulfate or magnesium
sulfate
Use Instead
Write “unit”
Write “international unit”
Write “daily”
Write “every
other day”
Write X mg
Write 0.X mg
Write “morphine
sulfate”
Write “magnesium sulfate”
*Exception: A “trailing zero” may be used only where required to demonstrate
level of precision of value being reported (e.g., catheter tube sizes). It may not be
used in medication related documentation.
SAFETY/
TOOLS
7506_Tab1_001-023 08/08/18 2:15 PM Page 18
SAFETY/
TOOLS
Additional Abbreviations, Acronyms,
and Symbols
Do Not Use
> (greater than)
< (less than)
Abbreviated
drug names
Apothecary
units
@
cc
µg
Rationale
Use Instead
Misinterpreted as the
number “7” (seven) or
the letter “L”
Confused with each other
Misinterpreted because of
similar abbreviations for
multiple drugs
Unfamiliar to many
practitioners.
Confused with metric units
Mistaken for the number
“2” (two)
Mistaken for “U” (units)
when poorly written
Write “greater
than”
Write “less than”
Mistaken for mg (milligrams) resulting in
1000-fold overdose
Write drug names
in full
Use metric units
Write “at”
Write “mL” or “ml”
or “milliliters”
(“mL” is preferred)
Write “mcg” or
“micrograms”
© The Joint Commission, 2009; http://www.jointcommission.org/assets/1/18/
Do_Not_Use_List.pdf. Reprinted with permission.
Administration Alerts!
Always Remember! Assessment
and Documentation
■ Assessment needs vary and depend on route and medication.
■ Assess Pt and record VS before and after giving drugs that
may adversely affect RR, HR, BP, LOC, and blood glucose, and
monitor labs as indicated.
■ Evaluate meds for their effectiveness and for ADR to drugs not
previously taken by Pt.
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19
■ Verify allergies and assess for reactions to drugs not previously
taken by Pt.
■ Document drug, dose, route, time given, discontinue (d/c) time
if applicable, Pt’s response, and any ADR.
Always Remember! Critical General Points
■ Confirm MAR is up to date and question unclear medication orders.
■ Follow institution policy regarding double-checking certain highrisk medications (e.g., heparin, insulin) and pediatric dosages.
■ Confirm compatibility if Pt is taking multiple medications.
■ Do not crush sustained-release or enteric-coated capsules or pills.
■ Always use filter needle to withdraw medication from glass
ampule. Discard and replace filter needle with regular injection
needle before injection.
■ Use straw for liquid PO iron to prevent staining of Pt’s teeth.
Always Remember! Medication Rights
Right Pt
Right Medication
Right Dose
Right Time
Right Route
Right Documentation
Always Remember! Triple Check
■ FIRST: When obtaining medication—before opening pill packaging or drawing drug up from a vial/ampule.
■ SECOND: Side-by-side comparison of medication and written
order and MAR while preparing drug.
■ THIRD: After preparation, just before administration at Pt’s
bedside—identify Pt and verify Pt’s name band matches
medication order.
Medication Errors
Prevention
■ Always observe medication rights.
■ Always triple-check all medications given.
■ Always confirm expiration date, strength, and route.
■ Always write out order; avoid using abbreviations or symbols.
SAFETY/
TOOLS
7506_Tab1_001-023 08/08/18 2:15 PM Page 20
SAFETY/
TOOLS
■ Always use commas for dosing units at or higher than 1,000.
■ Always use adequate space among drug name, dose, and unit
of measure.
■ Always double-check dosage range with pharmacist.
■ Always have second nurse witness when mixing insulin and
double check dose and type of insulin you plan to administer.
■ Always confirm dosage calculations and infusion pump
programming.
■ Always clarify orders that are unclear or contain abbreviations.
■ Always label all syringes and discard syringe immediately after use.
■ If taking verbal order, ask prescriber to spell out drug name and
dosage to avoid sound-alike confusion (e.g., hearing Cerebyx
for Celebrex, or 50 for 15) and read back order to prescriber
after you have written it in chart.
■ Always document immediately after administering any
medication.
■ Always review each Pt’s medications for the following:
■ Allergies, ADRs, and toxicity
■ Contraindications or improper drug selection
■ Efficacy or use without an indication
■ Overdose or subtherapeutic dose
■ Medication duplication
■ Potential drug or food interactions
■ Weight changes requiring dosage adjustments
■ Appropriate duration of therapy
■ Adherence with prescribed medication therapy
■ Never borrow medications from other Pts.
■ Never administer medication drawn up by another person.
■ Never document medication until after it has been administered.
■ Never begin new medications before order has been received
in pharmacy because this circumvents built-in checks that can
detect potential error.
Response
■ Discontinue medication immediately.
■ Assess for and treat symptoms of ADR.
■ Ascertain whether Pt has known allergy to medication given.
■ Notify health-care provider of medication error and any ADR.
■ Document error (incident report) per institutional policy.
■ Avoid using such phrases as “given in error.”
20
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21
■ State facts only on MAR (medication, dose, time, route).
■ In progress notes, document that health-care provider was
notified.
■ If there was any ADR, include intervention and outcome.
Do not document that an incident report was filed. NEVER
record “medication error” on the MAR.
Medication—Administration
“Six Rights of Medication Administration”
• Right patient
• Right time
• Right medication
• Right route
• Right dose
• Right documentation
Triple-Checking Medication Orders
1. When obtaining medication—before opening pill packaging
or drawing drug up from a vial/ampule.
2. Side-by-side comparison of medication and written order and
medication administration record (MAR) while preparing drug.
3. After preparation, just before administration at Pt’s bedside—
identify Pt and verify Pt’s name band matches medication order.
Assessment and Documentation
• Assess Pt and record VS before and after giving drugs that
may adversely affect RR, HR, BP, LOC, and blood glucose and
monitor lab results as indicated.
• Confirm MAR is current; question unclear medication orders.
• Follow institutional policy regarding double checking of certain
medications (e.g., heparin, insulin, pediatric dosages).
• Confirm compatibility if Pt taking multiple medications.
• Always use filter needle to withdraw medication from glass
ampule. Discard and replace filter needle with regular injection
needle before injection.
• Observe for reactions to drugs not previously taken by Pt.
• Evaluate meds for their effectiveness and adverse drug
reaction (ADR).
• Document drug, dose, route, time given, discontinue (d/c) time
if applicable, Pt’s response, and any ADR.
SAFETY/
TOOLS
7506_Tab1_001-023 08/08/18 2:15 PM Page 22
SAFETY/
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Common Medication Calculations
I. Basic Formula:
Desired dose
× Quantity = Answer
On-hand amount
Example: A physician orders hydromorphone 1.5 mg IV every
4 hours for pain. The dose on hand is hydromorphone 2 mg/5 mL.
How much should we give the client?
7.5
1.5 mg
× 5 mL =
= 3.75 mL
2.0 mg
2.0
II. Volume per Hour (IV pumps):
Total mL ordered = mL/hour (rounded to a whole number)
Total Time Ordered in Hours
Example: A physician orders 1000 mL of fluid infused over 2 hours.
At what infusion rate should we set the electronic pump?
1000 mL
= 500 mL/hr
2 hr
III. Drops per Minute (manual IV sets):
Total volume × Drip set factor (gtts)
= Rate of flow
Total time (minutes)
Example: A physician assistant orders 1000 mL normal saline
to be infused over 24 hours. The drip set has a drop factor of
20 gtts/mL. At how many drops per minute should we infuse the
IV solution?
1,000 mL × 20 gtts
20,000 mL
=
= 13.88 = 14 gtts/min
24 hr (60)
1440 min
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23
Conversions—Standard-to-Metric
Weight
lb
325
300
275
250
225
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
25
20
15
10
5
SAFETY/
TOOLS
kg
148
136
125
114
102
96
91
86
82
77
73
68
64
59
55
50
46
41
36
32
27
23
18
14
11
9
7
4.5
2.3
Temperature
°F
212
107
106.7
105
104
103
102
101
100.4
100
99.6
98.6
98
97.7
96.8
95.9
95
94.1
93.2
91.4
89.6
87.8
86
82.4
78.8
75.2
71.6
68
32
Height
°C
in.
100 boil
41.7
41
40.6
40
39.4
38.9
38.3
38
37.7
37.5
37.0
36.7
36.5
36
35.5
35
34.5
34
33
32
31
30
28
26
24
22
20
0 freeze
50 (4’2”)
51 (4’3”)
52 (4’4”)
53 (4’5”)
54 (4’6”)
55 (4’7”)
56 (4’8”)
57 (4’9”)
58 (4’10”)
59 (4’11”)
60 (5 ft)
61 (5’1”)
62 (5’2”)
63 (5’3”)
64 (5’4”)
65 (5’5”)
66 (5’6”)
67 (5’7”)
68 (5’8”)
69 (5’9”)
70 (5’10”)
71 (5’11”)
72 (6 ft)
73 (6’1”)
74 (6’2”)
75 (6’3”)
76 (6’4”)
77 (6’5”)
78 (6’6”)
cm
127
130
132
135
137
140
142
145
147
150
152
155
157
160
163
165
168
170
173
175
178
180
183
185
188
191
193
196
199
7506_Tab2_024-055 08/08/18 2:16 PM Page 24
A-C
Airway—Maneuver for Opening
Head-tilt, Chin-lift
1. Push down gently on Pt’s
forehead.
2. Pull up on bony part of chin
with 2–3 fingers of your
dominant hand.
3. Make sure line from chin to
jaw angle is perpendicular to
floor; head and neck should
be slightly extended; an
infant’s head should be in
a neutral position (sniffing
position).
4. Lift mandible upward and outward.
5. Avoid obstructing airway by closing mouth or compressing
chin soft tissue.
Do not perform if neck injury suspected.
Jaw Thrust
1. Place thumbs on each side
of cheekbone and then put
fingers underneath jaw (just
at the top of the neck).
2. Push thumbs down and pull
fingers up.
3. Hold this position so tongue
will not fall back into throat,
blocking airway.
Good technique to use on Pts with a suspected neck or spinal
injury.
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25
Airway—Nasal and Oral
Supplies
• Appropriate airway tube
• Water-soluble lubricant • Gloves
Nasopharyngeal Airway (NPA)
1. Use for conscious Pts with a
gag reflex.
2. Measure from tip of Pt’s nose
to earlobe and select a tube
with a diameter about the
size of the Pt’s smallest
finger.
3. Lubricate the tube with
water-soluble lubricant and
insert with bevel toward
septum using the measured
length of tube.
4. Right nostril: Insert straight
back until flange rests against nostril.
5. Left nostril: Insert straight back, and then rotate 180 degrees
once you reach the posterior pharynx.
Never use in presence of facial or head trauma.
Oropharyngeal Airway (OPA)
1. Use for unconscious Pts
without a gag reflex.
2. Measure from corner of
Pt’s mouth to earlobe.
3. Adults and larger children:
Insert upside down and rotate
180 degrees as it passes back
of tongue, past the soft palette,
until flange rests on Pt’s lips.
4. All ages (small children):
Use tongue depressor, insert
right side up along normal
curve of oral cavity until
flange rests on Pt’s lips.
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7506_Tab2_024-055 08/08/18 2:16 PM Page 26
A-C
Antiembolic Devices
Supplies
• Measuring tape
• Talcum powder
(if recommended)
• Cleansing/hygiene supplies
• Access to electrical outlet (for SCD)
Elastic Stockings (TED Hose)
Thigh-high: Measure each leg from gluteal fold to base of heel.
Measure each calf circumference and thigh at widest parts. If
both legs do not measure the same size, obtain two differentsized stockings, using one from each package to make two pairs.
Knee-high: Measure from base of heel to middle of knee joint
and circumference of calf at the widest point.
Procedure
1. Position and instruct Pt to remain supine for 15 minutes or
elevate feet and legs as tolerated for 15 minutes.
2. Cleanse legs and feet as needed and thoroughly dry; follow
manufacturers’ recommendation on use of talcum powder.
3. Hold stocking by cuff in dominant hand, slide nondominant
hand into stocking to the heel, grasp heel with hand inside
stocking, then turn stocking inside out to level of heel.
4. Instruct Pt to keep toes pointed and gently ease stocking onto
foot, centering Pt’s heel in heel of stocking.
5. Pull remainder of stocking up and over leg, turning it right
side out, to gluteal fold for thigh-high stockings or 1–2 inches
below knee for knee-high stockings.
6. Ensure stocking is straight and free of wrinkles to minimize
risk of skin breakdown and constricted circulation.
7. If using a closed-toe stocking, pull gently on end of stocking
over toe to create a small space in front of toes.
8. Assess every shift (or as ordered) for skin color, temperature,
sensation, movement, and swelling, and remove once per
shift (or as ordered) for 20–30 minutes.
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27
Antiembolic Devices (continued)
Sequential Compression Device (SCD)
• If using thigh-high compression sleeves, measure each thigh at
widest part to ensure proper fit. If both legs do not measure the
same size, obtain two different-sized sleeves.
Procedure
1. Cleanse legs and feet as needed and thoroughly dry.
2. Apply elastic stockings first if they are to be used with SCDs.
3. Position Pt supine.
4. Plug SCD unit into outlet and position (ideally at foot of bed)
to ensure cord and tubing do not create a fall hazard.
5. Position SCD sleeve beneath lower leg, below knee, with air
bladder side against bed; air bladder must be positioned so
that it compresses against calf.
6. Wrap Velcro fasteners of sleeves around lower leg, leaving
1–2 finger widths of space between sleeve and leg.
7. Connect sleeve to compression pump and turn power on.
8. Follow manufacturers’ recommendations for adjusting
compression pressure.
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7506_Tab2_024-055 08/08/18 2:16 PM Page 28
A-C
Apical-Radial Pulse (Pulse Deficit)
Supplies
• Second nurse
• Watch with second hand
Procedure
1. Obtain assistance from
Manubrium Midsternal
second nurse—one nurse
of sternum line
Midclavicular
to palpate radial pulse
line
Clavicle
and the second nurse to
Anterior
axillary
auscultate apical pulse
Angle of
Louis
line
simultaneously.
Apical
2. Expose left chest and
pulse
locate cardiac apex by
before
palpating the fifth interage 4
costal space along the
Apical
left midclavicular line.
pulse in
3. Designate one nurse to
adult
observe watch, stating,
Apical pulse
Body of
“Start” and then “Stop”
sternum
at ages 4 to 6
after 60 seconds.
4. Start counting pulses
simultaneously when nurse observing watch says “Start.”
5. Count pulses for 60 seconds.
6. Stop counting and record measurements when designated
nurse says “Stop.”
7. Compare and record results.
Apical-Radial Pulse Deficit (If Present)
• Subtract radial pulse from apical pulse.
• The difference is the apical-radial pulse deficit.
• Report an apical-radial pulse deficit to the health-care
provider (HCP).
Pts with pulse deficits must be assessed for additional signs of
decreased cardiac output, such as variations in BP, tachycardia,
restlessness, and change in mental status.
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Aspiration Precautions
General Guidelines
1. Assess Pt for dysphagia/aspiration risk using institution-specific
screening tool, and indicate aspiration risk/dysphagia in Pt’s
chart.
2. Observe Pt for drooling, coughing, gagging, and choking; have
suction available and suction airway as needed.
3. Position Pt 90 degrees upright during meals, and instruct Pt
to remain upright for 30–60 minutes after meals; never rush
Pt during meals.
4. Inspect Pt’s mouth for pocketing of food.
5. Instruct Pt to use a chin-to-chest posture during initial
assessment—begin with small sips of water and progress
to larger volumes and different consistencies.
6. Use thickener for thin liquids—follow packaging directions.
7. Place food on unaffected side in Pts with hemiparesis.
8. Monitor Pt’s weight weekly.
Signs of Dysphagia
• Weakness or poor muscle tone of neck, lips, face, or tongue
• Poor posture or head control
• Drooling or difficulty managing secretions
• Poor oral hygiene (e.g., thrush)
• Confusion, dementia, stroke
• Slurred or difficult speech or wet voice after eating
• Cough—during meals or shortly after swallowing
• Generalized weakness or fatigues easily during meals
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Assistive Devices
Pt may be unsteady—be prepared to catch Pt.
Use a gait belt and obtain extra staff as needed.
Canes
1. Position cane on unaffected (stronger) side approximately
6 inches (or closer) lateral to side of foot.
2. Elbow should be flexed at a comfortable angle.
3. Support weight with cane—repeat the following steps:
a. Advance cane forward to a comfortable distance (~12 in)
b. Advance weaker leg so that it is parallel to the cane.
c. Advance stronger leg beyond the cane to a comfortable
distance (heel just beyond the cane).
d. Advance weaker leg until it’s parallel to the stronger leg.
Crutches
1. Position crutch tips 6 inches laterally and 6 inches in front of
Pt’s feet; adjust per Pt comfort level.
2. Adjust crutch height to accommodate 2–3 finger widths
between crutch pad and axillae.
3. Elbows should be slightly flexed when resting palms on hand
grips. Pt should never bear weight on axillary pads.
4. Support weight with crutches and repeat the following steps:
a. Advance both crutches and weaker leg to a comfortable
distance (~12 in), supporting weight with hands.
b. Advance stronger leg until it’s parallel with crutches.
Walkers—Avoid Using on Stairs
1. Position walker so that Pt can comfortably stand upright while
holding hand grips.
2. Elbows should be slightly flexed.
3. Support weight with walker and repeat the following steps:
a. Instruct Pt to move walker forward 6 inches.
b. Ensure that all four legs of the walker are firmly on the
ground.
c. Step forward into walker, using walker for balance and
stability.
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31
Bladder Irrigation, Continuous (CBI)
Supplies
• IV pole
• Irrigation bag
• Irrigation tubing
• Cleansing solution
Setup
1. Hang irrigation bag on IV pole.
2. Connect irrigation tubing to bag and prime it.
3. Cleanse irrigation port of triple-lumen urinary catheter, and
attach irrigation tubing.
4. Ensure drainage port from catheter is patent.
Procedure
1. Begin irrigation at prescribed
rate.
2. Monitor drainage output for
the following:
• Color and clarity—normal
is pink and free of clots
(notify HCP if red or has clots)
• Blood clots, sediment, or
kinks in tubing
• Decreased or no output
(drainage output should
be greater than irrigation
input)
3. Monitor Pt for bladder
distention, spasm, or pain.
4. Calculate urine output by
subtracting total volume of
irrigant infused from total
volume of fluid collected in
drainage bag.
5. Document findings.
A-C
Irrigation bag
Drip chamber
Clamp
Tubing to
irrigation port
Bladder
Inflation
port
Drainage bag
Triple
lumen
catheter
Drainage tubing
7506_Tab2_024-055 08/08/18 2:16 PM Page 32
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Bladder Scanner
Indications
Assessment of:
• Bladder volume
• Urinary retention
• Post-void residual volume
Procedure
1. Assist Pt to a relaxed, supine position.
2. Select gender on bladder scanner.
3. Select male for women with hysterectomy.
4. Apply ultrasound transmission gel to probe head.
5. Position scanning probe midline, 1 inch above symphysis
pubis (pointed at bladder).
6. Do not move probe head during scan.
7. Record volume and notify HCP as indicated.
Volumes less than 250 mL usually will not induce urinary urge.
Contraindicated during pregnancy or if a wound is present
in the area to be scanned.
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Blood Administration
Supplies
• IV start kit
• 0.9% saline solution
• Informed consent
• Blood bank armband and
administration form
• Blood administration tubing
with inline filter
• A separate line for fluid and
medications.
• An 18-gauge catheter for
maximum flow rate and
minimal damage to RBCs
Procedure
1. Identify Pt and obtain informed consent (consider cultural/
religious beliefs).
2. Ascertain if Pt has ever had a blood transfusion reaction.
3. Obtain venous access using an 18-gauge catheter and begin
infusing 0.9% saline solution as prescribed by HCP.
Use only 0.9% sodium chloride solution (normal saline) when
administering blood products.
4. Maintain a separate IV line to administer medications and
IV fluids.
5. Inspect blood bag for expiration date, damage, clots, leaks,
discoloration, and bubbles.
6. Confirm ABO and Rh compatibility by comparing blood
bank armband number with blood bag label and blood
bank administration form; notify blood bank of any
inconsistencies.
7. Have another nurse independently verify ABO and Rh compatibility (double-check).
8. Document beginning volume of each bag (volume varies).
9. Administer pretransfusion medications, such as diphenhydramine, as ordered by HCP.
10. Begin infusion within 30 minutes of receiving blood from
blood bank.
11. Begin transfusion slowly and remain with Pt for the first
15 minutes to assess for transfusion reaction; if no evidence
of reaction, transfuse at ordered rate.
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Blood Administration (continued)
12. Transfusions should not exceed 4 hours (septicemia risk);
change tubing every 4–6 hours and after each unit of blood.
Notify HCP if Pt has fever prior to transfusion.
13. Monitor VS; temperature; and renal, circulatory, and respiratory status before transfusion, within 15 minutes of beginning, and every hour until 1 hour after completion.
Blood Products
Product
Components
Indications
Whole Blood
• Contains all
blood products
• Rarely used
• May be given emergently
to a hemorrhaging Pt
Packed Red
Blood Cells
(PRBCs)
• No clotting
factors or
platelets,
80% plasma
removed
• Acute and chronic
anemia
• Blood loss
Platelets
• Usually given
in pools of
6–10 units
• Increase low platelet
counts or treat
coagulopathies
• One unit will generally
increase platelet count
by 6000 units
Fresh Frozen
Plasma (FFP)
• Plasma and
clotting factors
• Replace clotting factors,
e.g., after multiple transfusions (>6 units PRBCs)
• To reverse effects of
Coumadin
Cryoprecipitate
• Clotting factors
• To treat hemophilia, fibrinogen deficiency, DIC
Do not add medications or IV fluids to blood products except
for normal saline solution.
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35
Blood Administration—Transfusion Reaction
Clinical Findings
Neurological: Anxiety, restlessness.
Respiratory: Shortness of breath, dyspnea, tachypnea,
bronchospasm.
Cardiovascular: Chest pain, tachycardia, hypotension.
Skin: Urticaria, pruritus, erythema, burning at infusion site.
Gastrointestinal/genitourinary: Nausea, vomiting, diarrhea,
hematuria, oliguria, anuria.
Musculoskeletal: Flank, back, or joint pain.
Metabolic: Fever, chills.
Collaborative Management
1. Stop transfusion and run normal saline to maintain IV access.
Do NOT use lactated Ringer’s solution. It contains calcium and
will clot blood in the tubing.
2. Notify health-care provider and blood bank of reaction stat.
3. Recheck Pt ID and blood labels for possible errors.
4. Return unused blood product to blood bank for analysis.
5. Administer ordered medications (see specific reaction).
6. Assess urinary catheter for output, color, and clarity of urine.
If Pt does not have urinary catheter in place, prepare to insert
one for monitoring urinary output.
7. Continue IV fluids to maintain minimum urinary output of
30 mL/hour.
8. Monitor for early detection of any hemodynamic instability
(e.g., dysrhythmias, abnormal lab values, CHF).
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7506_Tab2_024-055 08/08/18 2:16 PM Page 36
A-C
Treatment for Blood Transfusion Reactions
Type of Reaction
Specific Treatment
Anaphylactic
• Support airway, breathing, and
circulation as indicated.
• Administer epinephrine, antihistamines, and corticosteroids.
• Maintain intravascular volume.
Hemolytic
• Maintain renal perfusion with
aggressive fluid resuscitation.
• Consider furosemide to increase
renal blood flow.
• Consider low-dose dopamine
to improve renal blood flow.
• Maintain urine output at
30–100 mL/hour.
Febrile, Nonhemolytic
• Treat fever with acetaminophen.
• If Pt develops chills, cover with
blanket unless temp is >102°F.
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Blood Specimen—Arterial Blood Gas
Supplies
• ABG collection kit
• Ice
• Pt label
• Rolled towel
Procedure
1. Allen Test: Ensure Pt has sufficient collateral circulation.
Occlude blood flow simultaneously to radial and ulnar
arteries. Instruct Pt to clench and release fist; hand should
blanch. Release pressure over ulnar artery; return of color
within 5 seconds indicates sufficient collateral circulation.
2. Cleanse site over radial artery with alcohol swab.
3. Hyperextend Pt’s wrist using rolled towel.
4. Palpate radial artery above insertion site.
5. Enter artery at a 45-degree angle, bevel up; ABG syringe
should fill spontaneously (3–5 mL desired).
6. Remove needle, hold pressure for 5 minutes (10–15 minutes if
Pt is anticoagulated), and apply pressure dressing.
7. Dispose of needle per standard precautions, expel air bubbles,
and cap syringe. Gently roll syringe to mix specimen with
heparin (do not shake).
8. Attach Pt label with nurse initials, date, and time; place on ice
and transport to laboratory immediately.
9. Laboratory slip must include oxygen administration (room air
if not on oxygen) and ventilator settings if applicable.
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7506_Tab2_024-055 08/08/18 2:16 PM Page 38
A-C
Blood Specimen—Fingerstick Blood
Glucose (FSBG)
Supplies
• Glucometer
• Glucose monitor strip
• Warm compress
• Alcohol pad
• Lancets
• Cotton ball or gauze
• Small bandage
• Sharps container
Procedure
Calibrate glucometer prior to obtaining specimen.
1. Select puncture site—preferred site is lateral aspect of fingertip. Avoid using the pad or distal tip, swollen, cold, or cyanotic
sites. Avoid collecting specimen from same side as IV site. For
infants, use lateral or medial side of either heel.
2. Promote capillary dilation as needed with warm compress for
5 to 10 minutes prior to puncture.
3. Cleanse site with alcohol pad and allow area to dry.
4. Position lancet perpendicular to dermal ridges and pierce skin.
Wipe away first drop of blood.
5. Apply second
drop of blood to
glucose monitor
strip. Gentle,
intermittent
pressure will
enhance blood
flow, but avoid
tight squeezing
or “milking” of
finger.
No
6. Insert strip into
Yes
Yes
glucometer and
Always perform
document results.
Use shaded
perpendicular to
7. Apply gentle presareas only!
dermal ridges!
sure to puncture
site with cotton
ball or gauze.
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Blood Specimen—Venous Sample
Supplies
• Tourniquet
• Alcohol swab
• Appropriate size catheter
• Gauze 2 × 2 or cotton ball
• Tape or Coban
• Specimen tubes
• Pt labels
Procedure
1. Select puncture site. Antecubital (AC) fossa is most common
site, but any vein below AC is acceptable.
2. Avoid previous puncture site areas for 24 to 48 hours; avoid
collecting specimens above an IV site or sites that are
infected; edematous; or on the same side as mastectomy,
lymphadenectomy, dialysis shunts, or grafts.
3. Place tourniquet 3–4 inches above intended puncture site
(preferably for no longer than 1 minute).
4. Cleanse site with an alcohol swab from center out, using a
circular motion, and allow to air dry (use iodine if collecting
blood alcohol level or blood culture specimens).
5. Insert needle, bevel up, at 15–30 degrees; stabilize needle
and push specimen collection tube into needle holder.
6. ALWAYS follow recommended “order of draw” when collecting venous blood specimens to prevent erroneous results
due to additive crossover.
7. Remove tourniquet when all specimens collected.
8. Place gauze or cotton ball over puncture site, apply gentle
pressure, remove needle, and secure dressing with tape or
Coban.
9. Gently invert specimen tubes three to five times (do not
shake).
10. Label specimen tubes with Pt’s name, ID number, date, time,
and your initials; send specimens to laboratory.
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7506_Tab2_024-055 08/08/18 2:16 PM Page 40
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Order of Draw for Vacutainer Tubes
Additives
Uses
1 Yellow or
yellow-black
Color of Top
SPS
Cultures on blood or body
fluids
2 Red top
No additive
As a discard tube when
drawing blood using a
butterfly needle (to remove
air in tubing) or when drawing from an IV.
Serum testing, serology,
blood bank, blood chemistry
3 Light blue
Sodium
citrate
Coagulation tests, such
as PT/INR and PTT
(If using a butterfly needle,
use discard tube first.)
4 Red marbled
or gold top
Contains a gel
separator and
clot activator
Serum testing; most chemistry tests; immunology
tests
5 Dark green
top
Sodium
heparin
Blood chemistry, such as
whole blood tests and
plasma testing
6 Light green
top
Lithium
heparin and
gel separator
Metabolic panel; lipid panel;
liver panel
7 Lavender top EDTA
CBC; Hgb; Hct; glycosylated
hemoglobin
8 Light gray
top (oxalate/
fluoride)
Potassium
oxalate and
sodium fluoride
Glucose; glucose tolerance
tests; alcohol levels
9 Pale yellow
Acid citrate
dextrose
Genetic testing; specialized
tests
To ensure accurate test results, tubes with additive must be thoroughly
mixed by rolling tubes between palms; do not shake tubes.
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41
Body Positioning
Dorsal Recumbent
Fowler's
Lateral
Left Lateral Sim's
Lithotomy
Prone
Supine
Trendelenburg
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A-C
Breast Self-Examination
Technique—Pt Teaching
1. Stand in front of mirror.
2. Observe for symmetry, lumps, dimpling, nipple retraction, or
failure of nipple erection.
3. Feel for nodes, irregularity, and tenderness, both in breasts
and in axillary areas.
4. Gently squeeze nipple and observe for secretion and nipple
erection after each nipple is gently stimulated.
5. Lean forward and observe breasts as they are reflected in mirror to detect irregularity, retracted areas, and nipple retraction,
especially on one side only.
1
3
2
Observe for symmetry, lumps,
dimpling, nipple retraction, or
failure of nipple erection
4
Feel for nodes, irregularity,
and tenderness both in
breasts and in axillary
areas
5
Gently squeeze nipple and
observe for secretion and
for nipple erection after
each nipple is gently
stimulated
6
While leaning forward, observe breasts
as they are reflected in mirror to detect
irregularity, retracted areas, nipple
retraction especially on one side only
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43
BLS Summary of CPR Components: 2015
Child*
Infant*
Carotid or
Brachial (NB:
femoral.
umbilicus).
Between nipples, lower half of
Just below the
sternum—child: one hand; adult: nipple line: use
two hands, one atop the other.
two fingers.
Compression
100–120/min. 100–120/min.
100–120/min
Rate
(NB: 120/min).
Compression
At least 2 in., ~1⁄3 AP diameter. ~1⁄3 AP diameter.
Depth
but no more
About 2 in.
About 1½ in.
than 2.4 in.
Airway
Head-tilt—chin-lift; jaw-thrust used for suspected
(All Ages)
trauma (HCP only).
Compression- 30:2 (1 or
30:2 (15:2 if
30:2 (15:2 if
to-Ventilation 2 rescuers)
2 rescuers)
2 rescuers)
Ratio
1 sec/breath.
1 sec/breath.
NB: 3:1 (1 or
2 rescuers).
Ventilations
1 breath every 6 sec; asynchronous with
With Advanced chest compressions, visible chest rise,
Airway
1 sec/breath.
Ventilations
1 every
1 every
1 every
Only (Pulse, but 5–6 sec.
3–5 sec.
3–5 sec (NB:
No Breathing)
40–60/min).
Ventilations
Compressions Compressions
Compressions
if Untrained
only!
only!
only!
or Not
100–120/min. 100–120/min.
100–120/min
Proficient
(NB: 120/min).
Defibrillation
Attach and use AED/defibrillator as soon as available.
Ensure high-quality CPR: Allow complete recoil of compressions;
limit interruptions in chest compressions to <10 sec; rotate compressors every 2 min; note visible chest rise with ventilations;
allow exhalation between breaths.
Pulse Check
(HCP Only)
Compression
Landmarks
Adult*
Carotid.
*Adult: Adolescent (puberty) and older; Child: 1 yr to adolescent; Infant: <1 yr;
Newborn (NB): Birth to 1 mo.
AP = anteroposterior; HCP = health-care provider.
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A-C
BLS Cardiac Arrest: 2015 Guidelines
Recognition and Activation of EMS
■ Victim is unresponsive and not breathing or not breathing
normally.
■ Activate emergency response system.
Pulse Check: No More Than 10 sec
■ Absent: 30 compressions and 2 breaths (15:2 if 2 rescuers for
child/infant).
■ Present, but not breathing: Begin rescue breathing—1 breath
every 5–6 sec (1 breath every 3–5 sec for child/infant).
CPR (C-A-B)
■ Compressions: 30 compressions (15, if 2 rescuers for child/
infant).
■ Airway: Open airway with head-tilt—chin-lift or jaw-thrust.
■ Breathing: Not breathing—give 2 breaths; breathing—recovery
position.
Defibrillation—Use AED/Defibrillator as Soon as
Available
■ Adult: Do not use pediatric pads (must be >8 yr or >80 lb).
■ Child/infant: May use adult pads if pediatric pads are
unavailable.
■ Recheck pulse after every 2 min of CPR.
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45
Cardiopulmonary Resuscitation
(CPR)—2015 Guidelines
Cardiopulmonary Resuscitation (CPR)—Maneuvers
Relief of Foreign Body: see Choking, page 51
Pulse Check: Adult/Child
(carotid)
Hand Placement: Adult/Child
(lower half of sternum; use
heel of one hand for child)
Head-Tilt, Chin-Lift:
Adult/Child
Jaw-Thrust Maneuver:
Adult/Child
(known or suspected trauma)
A-C
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A-C
Cardiopulmonary Resuscitation
(CPR)—2015 Guidelines (continued)
Head-Tilt, Chin-Lift: Infant
(do not hyperextend neck)
Pulse Check: Infant (brachial)
One Rescuer: Infant (one finger
width below nipples)
Two Rescuers: Infant (both
thumbs, hands encircling chest)
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47
Cardiovascular Assessment
CP, palpitations, syncope, fatigue, extremity changes
(numbness, tingling, cold feet or hands, leg cramps,
edema, lymphedema), activity intolerance, dyspnea
on exertion, shortness of breath, orthopnea, number
of pillows used for sleeping, hyperlipidemia, MI, CAD,
PVD, DM, HTN, CHF, DVT, stents, CABG, pacemaker
History
Medication Beta/CA-channel blockers, nitrates, diuretics, ACE
inhibitors, anticoagulants, antiarrhythmics
Neck
Venous distention (JVD), bruits, pulsations
Chest
Scars, symmetry, movement, deformity
Auscultate lungs for pulmonary edema.
Compare apical and radial pulses for apical-radial
pulse deficit (page 28).
Heart valves for normal S1, S2 (lub, dub) heart sounds.
Abnormal sounds include extra beats (S3, S4), bruits,
murmurs, pericarditic rubs, and artificial valve clicks.
PMI for pulsations, thrills, or heaves.
Abdomen
Scars, edema, ascites, pulsations, thrills
Extremities Color, temperature, moisture, hair growth.
Nail beds for cyanosis and clubbing.
Lower extremities for swelling and edema.
Capillary refill: Normal <3 seconds; delayed >3 seconds
Compare pulses right to left.
Grade radial and pedal pulses.
Grade peripheral edema (see Edema—Grading
Pitting)
0
1
2
3
4
PulseStrength
Grading
Scale
A-C
Absent
Weak
Normal
Full
Bounding
7506_Tab2_024-055 08/08/18 2:16 PM Page 48
A-C
Cardiovascular Assessment (continued)
Deep Venous Thrombosis
Never massage affected extremities.
• History: Recent surgery, leg or pelvic fracture, prolonged bed
rest, birth control pills, estrogens, smoking, recent childbirth.
• S/S: Pain, tenderness, edema, swelling, redness, warmth.
• Homans’ sign: Calf pain on dorsiflexion of foot.
Cardiac Auscultation Sites
BASE
Base right
(aortic)
Base left
(pulmonic)
Erb’s point
Left sternal
border (tricuspid)
Apex (mitral),
PMI
APEX
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49
Chest Tubes
Setup of Closed Chest Drainage System
Use strict aseptic technique during setup.
Water-Seal System
• Two-chamber system: Add NS or sterile water to second chamber (water-seal chamber) to level indicated.
• Three-chamber system: Add NS or sterile water to second
chamber (water-seal chamber) to prescribed level.
Waterless System
• Two-chamber system: These systems are not used with suction, are ready to go, and require no additional setup.
• Three-chamber system: These systems are used with suction.
Connect suction control chamber tubing to suction source.
Insertion
Preinsertion
• Assist physician by positioning Pt, administering prescribed
analgesics, and setting up and testing drainage system.
Postinsertion
• Position Pt to facilitate optimal drainage:
• Pneumothorax: Semi-Fowler’s or higher
• Hemothorax: High-Fowler’s
• Assess Pt for respiratory distress, insertion site for drainage
and crepitus, and assess drainage system for complications.
Removal
1. Administer prescribed analgesia 30 minutes prior to removal.
2. Position Pt sitting or lying on side opposite the chest tubes.
3. Remove sutures if used to secure chest tube in place.
4. Position and hold occlusive dressing at insertion site.
5. Instruct Pt to inhale deeply and hold breath.
6. Remove chest tube with one continuous, quick motion.
7. Secure occlusive dressing over insertion site.
8. Monitor Pt for signs of respiratory distress.
Never pull against resistance! Stop and notify HCP immediately.
A-C
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A-C
Chest Tubes (continued)
Troubleshooting
Supplies
• New drainage system
• Sterile connectors
• Toothless clamps
• Sterile occlusive dressing
• Tape
• Sterile water or saline
• Betadine swabs
• One-way (Heimlich) valve
Air Leak
Intermittent bubbling during expiration is normal. Continuous
bubbling in water seal chamber suggests an air leak.
1. Clamp chest tube using toothless clamps close to chest wall.
If Bubbling Stops: Air leak is within Pt or at insertion site.
Unclamp chest tube, reinforce insertion site with occlusive
dressing, and notify physician.
If Bubbling Continues: Clamp chest tube (using second toothless clamp) at drainage unit. If bubbling stops, air leak is in
tubing. Replace tubing. If bubbling continues, air leak is in
drainage system. Replace system.
Dislodgement from Patient
1. Immediately pinch skin opening together, then cover chest
tube insertion site with sterile occlusive dressing. Tape three
sides of dressing, leaving one side open for air to escape.
2. Notify physician stat; continue to monitor Pt for distress.
Disconnection in System
1. While preparing to reattach tube and connections (1) submerge distal end of tube under 1–2 inches of sterile water or
normal saline or (2) attach a one-way (Heimlich) valve.
2. Clean exposed ends with Betadine swabs for 30 seconds (air
dry for 30 seconds). Reconnect and retape drainage system.
3. Replace all contaminated connections, including new drainage
system, as quickly as possible to prevent a pneumothorax.
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51
Choking (All Ages)—2015 Guidelines
Conscious Victim
• If able to cough effectively, encourage coughing.
• If unable to talk or cough effectively:
Adult or child: Administer abdominal thrusts (*chest thrusts
if pregnant or obese) until obstruction relieved or victim
becomes unresponsive.
Infant: Alternate five back blows and five chest thrusts until
obstruction relieved or victim becomes unresponsive.
Victim Becomes Unresponsive
1. Send someone to activate EMS system.
2. Lay victim supine and begin CPR (no pulse check).
3. Look inside mouth while opening airway—remove obstruction
if visible.
4. Continue CPR for five cycles or 2 minutes. If you are alone,
activate EMS and then resume CPR.
Repeat: Inspect mouth, remove obstruction if seen, give two
rescue breaths, give 30 chest compressions, and repeat until
obstruction relieved.
Abdominal Thrusts
A-C
Chest Thrusts
7506_Tab2_024-055 08/08/18 2:16 PM Page 52
A-C
Choking (All Ages)—2015
Guidelines (continued)
Infant Chest Thrusts
Infant Back Slaps
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53
Codes—Staff Response
Advance Directives and DNR
• Advance directives/DNR orders are legal documents that
indicate whether a Pt wishes to be resuscitated (and to what
extent) in the event of respiratory or cardiac arrest.
If there is any doubt as to the interpretation or location of a
Pt’s advance directives, then a code must be called and full resuscitative efforts initiated.
Clinical Presentation
• Unresponsive with no detectible respirations or pulse.
• Respiratory arrest (or prearrest).
• Critically unstable hemodynamically.
Before Arrival of Code Team
• Stay calm! Call out for STAT help or press bedside code button.
Note: Always include floor, unit, and room number.
• Clear immediate Pt area of any obstacles (tables, chairs).
• Instruct visitors to wait outside room.
• Begin resuscitation (CPR) while waiting for code team.
After Code Team Has Arrived
• Assist code team resuscitation efforts including compressions,
ventilations, medications, defibrillation, or documentation.
• Notify physician or physician on call and request chaplain to
notify and communicate with Pt’s family.
Documentation
• All code team members must sign code record.
• Record all times and interventions and attach ECG strips to
code record in chronological order. Clinical tip: Record times
and interventions (e.g., drugs, shocks, etc.) directly onto ECG
strips for easier recall after the code.
• Document a brief summary with outcome in Pt’s chart.
• Attach code record to Pt’s chart after completed.
A-C
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A-C
Cold Therapy
Avoid using cold therapy on extremities in Pts with peripheral
neuropathy or diabetes.
1. Review medical record for contraindications or conditions that
may influence Pt’s ability to tolerate cold applications.
2. Establish baseline vital signs (including temperature) and
assessment of area to be treated.
3. Follow physician orders regarding frequency and duration.
4. Place absorbent pads underneath area to be treated.
5. Apply cold therapy directly over injury.
6. Assess skin condition every 5 minutes during therapy.
7. Discontinue or adjust cold therapy if Pt complains of pain,
burning sensation, or numbness.
8. Discontinue cold therapy after 20 minutes of continuous
application, or as ordered by physician.
9. Provide instruction to Pt if cold therapy to be managed by Pt.
Supplies
• Absorbent pads
• Cold therapy apparatus
• Plastic, resealable bags
• Washcloth
• Pillowcase
• Ice and water
Ice Bag or Pack
1. Fill per manufacturer guidelines (two-thirds full if using plastic
bag) and remove excess air prior to sealing closed.
2. If using chemically activated ice pack, activate by squeezing.
3. Wrap ice bag/ice pack in washcloth or pillowcase if it does not
have a cloth-like exterior (e.g., if using plastic bag).
Electric Pump Cooling Device
1. Follow manufacturer recommendations and fill reservoir with
appropriate amounts of ice and water.
2. Wrap cooling pad in pillowcase if needed.
3. Apply cooling pad directly to (or around) body part.
4. Connect cooling pad hoses to cooling device.
5. Plug in and turn on cooling device and adjust temperature
according to physician orders.
Position cooling device and secure hoses and electrical cord.
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Cranial Nerves: Assessment
Nerve
I
S
II
S
III
M
IV
M
V
B
VI
M
VII
B
VIII S
IX
B
X
B
XI
M
XII
M
Name
Olfactory
Function
Smell
Test
Have Pt identify familiar odors
(e.g., coffee).
Optic
Visual acuity Visual acuity (eye chart).
Visual field Peripheral vision.
Oculomotor Pupillary
Assess pupils for equality
reaction
and reactivity to light.
Trochlear
Eye
Have Pt follow your finger
movement without moving head.
Trigeminal Facial
Touch face and assess for
sensation
sharp and dull sensation.
Mastication Have Pt hold mouth open.
Abducens Abduction
Have Pt follow your finger
of eye
without moving head.
Facial
Facial
Have Pt smile, wrinkle face,
expression puff cheeks.
Sense of
Differentiate between sweet
taste
and salty taste.
Acoustic
Hearing
Snap fingers close to Pt’s ears.
Balance
Feet together, arms at side
with eyes closed for 5 sec.
Glossopha- Swallowing Have Pt swallow and then
ryngeal
and voice
say “Ah.”
Vagus
Gag reflex
Use tongue depressor or
swab to elicit gag reflex.
Spinal
Neck motion Have Pt shrug shoulders or
accessory
turn head against resistance.
Hypoglossal Tongue
Have Pt stick out tongue and
movement move it from side to side.
B = both sensory and motor; M = motor only; S = sensory only.
A-C
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D-F
Defibrillation
Automated External Defibrillator (AED)
1. Turn on AED and follow voice prompts.
2. Without interrupting CPR, attach appropriate-sized pads (refer
to package insert) and plug pad cable into AED unit if needed.
3. Press “Analyze” button (may not be necessary with some models) and wait for instructions.
4. If instructed to shock, announce “shock indicated, stand clear,”
and ensure no one is touching Pt.
5. Depress the shock button if prompted.
6. Immediately resume CPR and await instruction.
For pediatric (<25 kg) and infant Pts, use pediatric electrodes
with a pediatric attenuator if possible; otherwise, adult electrodes
are acceptable.
Do not use pediatric electrodes on adult Pts.
AED
AED
Do not touch Pt while AED is analyzing rhythm.
Do not place electrode over ICD or transdermal medication
patch; remove medication patch.
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Defibrillation
Manual Defibrillation
1. Turn unit on and verify all cables are connected.
2. Turn “Lead Select” to “Paddles” or “Defibrillator.”
3. Select 120 to 200 J (biphasic) or 360 J (monophasic).
4. Apply conductive medium to paddles or apply gel defibrillation pads to Pt’s chest (see diagram).
5. Position paddles on Pt’s chest (see diagram).
6. Confirm VFib or pulseless VT.
7. Charge defibrillator and say, “Charging, stand clear!”
8. Say, “I’m going to shock on three. One, I’m clear; two, you’re
clear; three, everybody’s clear.”
9. Defibrillate and immediately resume CPR.
10. Reassess rhythm after 2 minutes of CPR.
Paddles: Apply 25 lb of pressure to paddles and depress both
discharge buttons simultaneously.
Pads (Hands-Free): Press “Shock” button on defibrillator/AED
or depress paddle discharge buttons (docked in defibrillator)
simultaneously.
D-F
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D-F
Dialysis—Peritoneal
Supplies
• Prescribed dialysate
• Drainage tubing
• Infusion tubing
• Peritoneal catheter
• Collection container
Procedure
1. Ensure dialysate is Dialysis solution bag
Peritoneal cavity
prewarmed (body
temperature).
2. Assist Pt to a
relaxed, supine
position.
3. Connect drainage
tubing to collection container.
4. Ensure collection
container is positioned below Pt.
5. Hang dialysate at
Catheter
bedside (above Pt);
connect dialysis
infusion tubing
primed with
Drainage bag
dialysate solution.
6. Connect primed tubing to peritoneal catheter.
7. Instill 500 mL of dialysate solution to check patency of peritoneal catheter; close infusion clamps, then unclamp drainage
tubing and drain fluid.
8. Open infusion clamps and infuse prescribed amount over
5–10 minutes. Follow physician orders for specific infusion
amount, dwell time, and number of infusion–drainage
cycles.
9. Upon completion, close clamp to peritoneal catheter and
cover catheter tip with sterile cap.
10. Monitor Pt and change dressing per policy.
Use strict aseptic technique during procedure.
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Dressing Change—Sterile
Supplies
• Sterile and nonsterile gloves
• Irrigation and/or cleansing
solution
• Antiseptic solution
• Medicated ointment
• Prescribed dressing
• Sterile scissors
• Tape or Montgomery ties
Procedure
A. Remove old dressing using nonsterile gloves:
1. Pull tape toward incision, parallel to skin.
2. Be careful not to dislodge drainage tubes or sutures.
3. Assess condition and appearance of wound, including size,
color, and presence of exudate, odor, ecchymosis, or induration (see Wound Assessment).
4. Discard gloves and wash hands.
B. Using sterile technique, don face mask and sterile gloves,
open supplies, set up a sterile field, and fill sterile containers
with prescribed solutions.
C. Cleanse wound with prescribed solution:
1. Start from area of least contamination—cleanse toward area
of most contamination (use separate swabs).
2. Cleanse outward using circular motion around drains.
3. Apply antiseptic/medicated ointments as prescribed.
D. Apply prescribed dressing (see Types of Dressings):
1. Cut dressings to fit around drain if present (sterile scissors).
2. Reinforce with thick cover dressing (ABD or Surgipad).
3. Secure dressing with 2-inch tape or rolled gauze, or use
Montgomery ties for frequent (every 4–6 hr) dressing
changes.
4. Record date and time on paper tape and secure to dressing.
D-F
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D-F
Dressings
Application Techniques
Dry: Apply dry, sterile gauze directly to wound, and then cover
with sterile 4 × 4 gauze or Surgipad.
Moist-to-Dry: Soak sterile gauze in sterile solution and wring
out excess. Apply moist gauze to wound, cover with a dry, sterile
4 × 4 gauze, then cover everything with Surgipad or gauze.
Wound Packing: Use sterile forceps and gently pack wound with
moist, sterile gauze until all wound surfaces are in contact with
moist gauze, including undermined areas. Do not allow moist
gauze to touch surrounding skin, and do not pack wound beyond
skin level. Cover with dry, sterile 4 × 4 gauze, then cover everything with Surgipad or gauze.
Dressing Types
Transparent: For superficial wounds, blisters, and skin tears.
Ideal for stage I and II ulcers.
• Waterproof; maintains moisture and prevents bacterial
contamination.
Hydrogel: For dry, sloughy wound beds; cleanses and debrides.
Ideal for stage II, III, and IV ulcers.
• Provides moist wound environment. Reduces pain and
soothes.
Hydrocolloid: For wounds with low to moderate exudate. Ideal
for stage II and III ulcers.
• For autolytic debridement of dry, sloughy, or necrotic wounds.
Alginate: For wounds with moderate to heavy exudate. Ideal for
stage III and IV ulcers.
• Available in pads, ropes, or ribbons.
Foam: Used after debridement or desloughing of ulcers. Ideal
for stage III and IV ulcers. Highly absorbent. May be left on for
3–4 days.
• For wounds with heavy exudate, deep cavities, weeping ulcers.
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Ear Irrigation
Pt may experience dizziness during procedure.
Supplies
• Mineral oil
• Absorbent pads
• Irrigation solution
• Basin
• 50-mL syringe
• Cotton balls
Procedure
1. Impacted cerumen (ear wax) can be removed by instilling
2–3 drops of mineral oil twice per day for 2–3 days and should
be done prior to irrigation.
2. Position Pt—either sitting or lying—and turn Pt’s head opposite
the ear to be irrigated.
3. Place absorbent pad(s) beneath Pt’s head and shoulders and
position basin under Pt’s ear (Pts sitting upright may assist by
holding basin).
4. Fill 50 mL syringe with irrigation solution.
5. Pts >3 years old: pull helix upward and back; Pts ≤3 years old:
pull lobe downward and back.
6. Maintain one-half inch between tip of syringe and opening of
ear canal (never insert tip).
7. Irrigate toward superior aspect of ear canal using continuous,
gentle pressure.
8. Dry outer ear and place cotton ball in ear for 10 min.
D-F
7506_Tab3_056-081 09/08/18 12:14 PM Page 62
D-F
Electrocardiogram (ECG)—Assessment
Cardiac Anatomy and Conduction
R
P
T
Atrial Q
Ventricular
S repolardepolarization Ventricular ization
depolarization
SA node
Internodal
pathways
AV node
Left bundle branch
Purkinje
fibers
Bundle of His
Right bundle branch
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63
Electrocardiogram (ECG)—
Assessment (continued)
Components of the ECG
QT Interval (0.30–0.52 sec)
Rates (bpm)
Atria: 60–100
Junction: 40–60
Ventricles: 20–40
0.04 sec
R
0.20 sec
T
P
Isoelectric Line
Q S
PR Interval
(0.12–0.20 sec)
QRS Interval
(0.06–0.10 sec)
D-F
ST Segment
U
Standard
Calibration
1 mV (1 cm)
7506_Tab3_056-081 09/08/18 12:14 PM Page 64
D-F
Electrocardiogram (ECG)—
Assessment (continued)
Systematic ECG Assessment
Rate
Normal (60–100), fast (>100), or slow (<60)?
Rhythm
Regular or irregular?
P waves
Present? Are they 1:1 with the QRS?
PRI
Normal (0.12–0.2 sec)? Is it consistent?
QRS
Normal (0.06–0.10 sec) or wide (>0.10 sec)?
Any extra or abnormal complexes?
Extra
Analyzing the PR Interval (PRI)
Normal sinus
rhythm (NSR)
PRI consistent and normal, between 0.12
and 0.20 seconds (3–5 small boxes)
Junctional rhythm
PRI <0.12 seconds, but consistent
1° AV block
PRI >0.20 seconds, but consistent
2° AV block type I
(Mobitz I or
Wenckebach)
Progressive lengthening of PRI until QRS
dropped
2° AV block type II
(Mobitz II)
Consistent PRI; however, there are additional P waves that do not precede a QRS
complex.
3° AV block
(complete heart
block)
PRI is not consistent, nor is there any correlation between P wave and QRS.
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65
Electrocardiogram (ECG)—Lead Placement
Standard 3 Wire Lead Placement
1. Place the white electrode
just below the Pt’s right
clavicle.
2. Place the black electrode
below the Pt’s left clavicle
near the shoulder.
3. Place the red electrode
below the Pt’s left pectoral muscle near the
apex of the heart.
Lead-I
White RA
LA Black
Lead-III
LL Red
Lead-II
Mnemonic: White to the right. Smoke (black) over fire (red).
Standard 5 Wire Lead Placement
1. Place white, black, and
red electrodes in same
position as 3-lead ECG.
2. Place green electrode opposite the red electrode.
3. Place brown precordial
electrode to the right of
the sterna border in the
4th intercostal space.
D-F
Midclavicular
Black
White
MCL1(V1)
Midaxillary
MCL6(V6)
MC4R
7506_Tab3_056-081 09/08/18 12:14 PM Page 66
D-F
Electrocardiogram (ECG)—Sample Rhythms
Atrial Fibrillation (A-fib)
Rate: Atrial: 350 bpm or greater; ventricular: variable
Rhythm: Irregular
P Waves: No true P waves; chaotic atrial activity
PR Interval: None
QRS: Normal (0.06–0.10 sec)
Irregular R-R intervals
Atrial Flutter
Rate: Atrial: 250–350 bpm; ventricular: variable
Rhythm: Atrial: regular; ventricular: variable
P Waves: Flutter waves have a sawtoothed appearance; some
may not be visible, being buried in the QRS
PR Interval: Variable
QRS: Usually normal (0.06–0.10 sec), but may appear widened if
flutter waves are buried in QRS
Flutter waves
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Electrocardiogram (ECG)—Sample
Rhythms (continued)
Atrioventricular (AV) Block—First Degree
Rate: Depends on rate of underlying rhythm
Rhythm: Regular
P Waves: Normal (upright and uniform)
PR Interval: Prolonged (>0.20 sec)
QRS: Normal (0.06–0.10 sec)
Atrioventricular (AV) Block—Second-Degree Type I
Rate: Depends on rate of underlying rhythm
Rhythm: Atrial: regular; ventricular: irregular
P Waves: Normal (upright and uniform), more P waves than QRS
PR Interval: Progressively longer until one P wave is blocked and
a QRS is dropped
QRS: Normal (0.06–0.10 sec)
Blocked beat
X
D-F
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D-F
Electrocardiogram (ECG)—Sample
Rhythms (continued)
Atrioventricular (AV) Block—Second-Degree Type II
Rate: Atrial: usually 60–100 bpm; ventricular: slower than atrial
rate
Rhythm: Atrial regular and ventricular regular or irregular
P Waves: Normal; more P waves than QRS
PR Interval: Normal or prolonged but constant
QRS: May be normal, but usually wide (>0.10 sec) if the bundle
branches are involved
Atrioventricular (AV) Block—Third-Degree
Rate: Atrial: 60–100 bpm; ventricular: 40–60 bpm if escape focus
is junctional, <40 bpm if escape focus is ventricular
Rhythm: Usually regular; atria and ventricles act independently
P Waves: Normal (upright and uniform); may be superimposed
on QRS complexes and T waves
PR Interval: Varies greatly
QRS: Normal if ventricles are activated by junctional escape
focus; wide if escape focus is ventricular
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Electrocardiogram (ECG)—Sample
Rhythms (continued)
Pacemaker Rhythm—Atrial and Ventricular
Rate: 75 bpm
Rhythm: Regular
P Waves: Normal following pacemaker spike
PR Interval: 0.20 seconds
QRS: 0.20 seconds following pacemaker spike
Atrial pacemaker spike Ventricular pacemaker spike
Premature Atrial (PAC)/Junctional (PJC) Complexes
Rate: Depends on rate of underlying rhythm
Rhythm: Irregular whenever a PAC occurs
P Waves: Present; in the PAC, may have a different shape
PR Interval: Varies in PAC; otherwise normal (0.12–0.20 sec)
QRS: Normal (0.06–0.10 sec)
Start300 150 100 80 75 60 50 43 Premature Atrial/Junctional Complexes
P
PAC (P wave present)
No P
Rhythm: Variable
P: Present in PAC only
PRI: Variable
D-F
PJC (no P wave)
QRS: 0.06-0.08 (normal)
7506_Tab3_056-081 09/08/18 12:14 PM Page 70
D-F
Electrocardiogram (ECG)—Sample
Rhythms (continued)
Premature Ventricular Complex (PVC)
Rate: Depends on rate of underlying rhythm
Rhythm: Irregular whenever a PVC occurs
P Waves: None associated with the PVC
PR Interval: None associated with the PVC
QRS: Wide (>0.10 sec), bizarre appearance
PVC
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Electrocardiogram (ECG)—Sample
Rhythms (continued)
Sinus Bradycardia
Rate: Slow (<60 bpm)
Rhythm: Regular
P Waves: Normal (upright and uniform)
PR Interval: Normal (0.12–0.20 sec)
QRS: Normal (0.06–0.10 sec)
Sinus Tachycardia
Rate: Fast (>100 bpm)
Rhythm: Regular
P Waves: Normal (upright and uniform)
PR Interval: Normal (0.12–0.20 sec)
QRS: Normal (0.06–0.10 sec)
D-F
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D-F
Electrocardiogram (ECG)—Sample
Rhythms (continued)
Ventricular Fibrillation (VF)
Rate: Indeterminate
Rhythm: Chaotic
P Waves: None
PR Interval: None
QRS: None
Ventricular Tachycardia (VT)
Rate: 100–250 bpm
Rhythm: Regular
P Waves: None or not associated with the QRS
PR Interval: None
QRS: Wide (>0.10 sec), bizarre appearance
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Edema—Grading Pitting
2 mm
4 mm
6 mm
8 mm
1+
2+
3+
4+
Procedure
1. Observe for edema of the foot, ankles, and legs.
2. Gently compress the Pt’s soft tissue with your thumb over a
bony area for at least 5 seconds.
3. Observe for indentation.
4. If no indentation is noted, the Pt does not have pitting edema.
5. If slight pitting of 2 mm or less is noted and disappears rapidly,
grade the edema as 1+.
6. If a 2- to 4-mm indentation is observed and disappears in
10–15 seconds, grade the edema as 2+.
7. If noticeably deep pitting of 4–6 mm is noted that lasts for
more than 1 minute and the dependent extremity looks fuller
and swollen, grade the edema as 3+.
8. If very deep pitting of 6–8 mm is noted that lasts as long as
2–5 minutes and the dependent extremity is grossly distorted,
grade the edema as 4+.
Measuring the edematous extremity in millimeters with a
measuring tape is more accurate and less subjective than the grading scale.
D-F
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D-F
Enemas
Supplies
• Absorbent pads
• Water-soluble lubricant
• Enema bag and tubing
• Warm tap water
Prepackaged Enemas (e.g., Fleet)
1. Remove cap, and apply water-soluble lubricant to tip.
2. Insert lubricated tip 3–4 inches (adult) into rectum.
3. Squeeze entire contents into rectum.
Standard Gravity, Bag-Type Enemas
1. Fill enema bag with 750–1000 mL warm tap water.
2. Prime and clamp enema bag tubing.
3. Apply water-soluble lubricant to tip of tubing.
4. Insert lubricated tip 3–4 inches (adult) into rectum (maintain
position of tip until enema complete).
5. Position bag at hip level and open clamp.
6. Raise bag 12–18 inches until enema complete.
7. Lower bag or reduce rate for Pt discomfort.
8. Close clamp when complete and remove tip.
9. Encourage Pt to retain solution for prescribed time.
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Eye Irrigation
Supplies
• Absorbent pads
• Sterile irrigation solution
• Basin
• Bulb syringe
• IV tubing
• Morgan lens
Procedure
1. Establish baseline assessment of eye(s)—redness, swelling,
blurred vision, pain, itching, discharge, contacts, foreign
debris, etc.
2. Assist with removal of contact lenses if present.
3. Position Pt—lying on affected side if only one eye or supine
if both eyes are being irrigated.
4. Place absorbent pad(s) beneath Pt’s head and shoulders and
position basin under affected eye.
5. Gently remove foreign debris from eyelids and lashes, wiping
from inner to outer canthus.
6. Gently retract eyelid(s) and instruct Pt to look toward
forehead.
7. Keep irrigation tip 1 inch over inner canthus and instill irrigation
solution using a bulb syringe, IV tubing, or a Morgan lens.
8. Direct a continuous, gentle stream at the inner canthus so
that irrigation fluid flows across the cornea, toward the outer
canthus.
9. Encourage periodic blinking, but calmly reinforce the
importance of keeping eye(s) open.
10. Reassess eyes including pupillary response.
D-F
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D-F
Fall—Prevention
Hospitals and Skilled Nursing Facilities
1. Assess Pt’s fall risk upon admission.
2. Assess for gait changes, postural instability, spasticity,
impaired vision, orthostatic hypotension, and impaired
mental processing (dementia, delirium, stroke, etc.).
3. Implement bowel and bladder programs to decrease urgency
and incontinence.
4. Use treaded socks for all Pts.
5. Approach Pt toward unaffected side to maximize participation
in care and transfer Pt toward stronger side.
6. Actively engage Pt and family in all aspects of fall prevention
program.
7. Instruct Pt in all activities prior to initiating assistive devices
and teach Pt to use grab bars.
8. Instruct patient in medication time and dose, side effects,
and interactions with food and medications.
9. Lock all moveable equipment before transferring patients.
10. Place patient care articles within reach.
11. Eliminate spills, clutter, electrical cords, and unnecessary
equipment.
12. Provide adequate lighting.
In the Home
1. Arrange furniture to ensure unobstructed pathway.
2. Keep all pathways well lit.
3. Install lights and light switches at top and bottom of stairs.
4. Excess cords should be coiled and next to wall.
5. Avoid using throw rugs.
6. Fix uneven or damaged steps and install handrails on both
sides of entire length of stairs.
7. Use steady step stool with a grip bar and keep often-used
items at waist level.
8. Install grab bars in tub and in bathroom next to toilet.
9. Ensure bathroom floor and tub have nonslip surfaces.
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Fall—Risk Assessment
Risk Factor
Intervention
Assessment Data
Age >65 years old
History of falls
• Monitor frequently.
• Room close to nurses’ station.
• Implement fall prevention precautions.
Medications
Polypharmacy
CNS depressants
BP/HR lowering
Diuretics and
cathartics
• Assess for medications that may affect BP,
HR, balance, or LOC.
• Educate about use of sedatives, narcotics,
and vasoactive drugs.
• Encourage nonopioid pain management.
Mental Status
Altered LOC or
orientation
• Routinely reorient Pt to situation.
• Maintain a safe environment.
• Utilize pressure-sensitive alarms in bed and
chairs.
Cardiovascular
Orthostasis
• Change positions slowly.
• Review MAR for vasoactive drugs.
Neurosensory
Visual impairment
Neuropathy
Difficulty with
balance or gait
• Provide illumination at night.
• Minimize clutter.
• Provide protective footwear.
• Provide appropriate assistive devices and
instruct on proper use.
GI/GU
Incontinence
Urinary frequency
Diarrhea
• Ensure call light is within easy reach.
• Create toileting schedule.
• Provide bedside commode or urinal.
• Ensure an unobstructed, well-lit path to toilet.
Musculoskeletal
Decreased ROM
Amputee
• ROM exercises and stretching.
• PT or OT consult if ordered.
• Appropriate assistive devices.
Assistive Devices
Use of cane,
walker, or WC
• Ensure assistive devices are not damaged
and appropriately sized.
• Instruct Pt on proper and safe use.
Environment
Cluttered room
• Minimize clutter.
• Ensure call light is within easy reach.
D-F
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D-F
Fecal Impaction–Digital Removal
Supplies
• Gloves
• Absorbent pads
• Bedpan
• Water-soluble lubricant
Procedure
1. Place absorbent pads underneath Pt and position bedpan
within comfortable reach.
2. Assist Pt to a left-lateral position (knees flexed) with Pt’s back
toward nurse.
3. Apply water-soluble lubricant to gloved index and middle
fingers of dominant hand.
4. Gently insert lubricated fingers into rectum moving toward
umbilicus along rectal wall.
5. Use a scissor motion to break impacted fecal mass into
manageable fragments.
6. Move smaller fecal fragments toward rectum for removal.
Stimulation of the vagus nerve can cause cardiac arrhythmias—
continuously assess Pt for fatigue, bradycardia, CP, and syncope.
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Fetal Monitoring—Electronic
Supplies
• Ultrasound gel
• Fetal monitoring setup
Toco transducer
(uterine contractions)
Ultrasound
transducer
(FHR)
Scalp
electrode
Intrauterine
pressure catheter
Fetal Heart Rate (FHR)
Normal: 120–160 bpm (can be higher for short periods of time,
less than 10 min).
Tachycardia: Sustained FHR >160 for more than 10 minutes.
Common etiology can include early fetal hypoxia, immaturity,
amnionitis, maternal fever, and terbutaline.
Bradycardia: Sustained FHR <120 for more than 10 minutes.
Common etiology can include late or profound fetal hypoxia,
maternal hypotension, prolonged umbilical cord compression,
and anesthetics.
Variability (Cardiac Rhythm Irregularities)
None: 0–2 variations/min (abnormal)
Minimal: 3–5 variations/min (abnormal)
Average: 6–10 variations/min (normal)
Moderate: 11–25 variations/min (normal)
Marked: More than 25 variations/min (abnormal)
D-F
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D-F
Fetal Monitoring—Electronic (continued)
Fetal Heart Rate Patterns
Reassuring (Normal) Pattern
• Baseline FHR 130–140 bpm; preserved beat-to-beat
• Long-term variability
• Accelerations last 15 or more seconds above baseline
• Accelerations peak at 15 or more bpm
Early Decelerations
• Mirror image of contraction.
• Starts and stops with contractions.
Etiology: Head compression
Management: Observation
Variable Pattern
• Occurs at unpredictable times during contractions.
• Size and shape vary.
Etiology: Cord compression
Management: Lateral position, oxygen, c-section if not corrected
Late Decelerations
• Reverse mirror image of contractions.
• Starts after contraction begins; stops after contraction ends.
Etiology: Uteroplacental insufficiency
Management: Lateral position, stop or slow pitocin, oxygen,
IV fluids, c-section if not corrected.
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Fetal Monitoring—Electronic (continued)
Early deceleration
Variable deceleration
Fetal head compression
Umbilical cord compression
(HC)
(CC)
Example:180 Uniform Shape
180 Variable shape
FHR
FHR
100
100
Early onset
Variable onset
50
50
UC
UC
0
0
Late deceleration
Cause:
Cause: Uteroplacental insufficiency
(UPI)
Example: 180 Uniform shape
FHR
100
Late onset
1 min.
50
UC
0
D-F
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G-K
Gastrointestinal System Assessment
History
Pain, bloating, changes in bowel pattern,
diarrhea, constipation, changes in weight
or appetite, indigestion, reflux, nausea,
vomiting, stomach ulcers, Helicobacter
pylori, hemorrhoids, GI bleed, UC, IBS,
blood or mucus in stool, NSAID use
Medication
Antacids, proton pump inhibitors,
H2-receptor antagonists, laxatives,
antiemetics, antibiotics, antispasmodics
Abdominal Pain
(differential
diagnosis)
• RUQ: Cholecystitis, hepatitis, MI,
pancreatitis, perforated ulcer
• LUQ: Gastritis, peptic ulcer, MI,
pancreatitis, splenic enlargement
• RLQ: Appendicitis, ectopic pregnancy,
gynecologic pathology, renal calculi,
testicular torsion, aortic dissection
• LLQ: Diverticulitis, colitis, aortic dissection, renal calculi, ectopic pregnancy,
gynecologic pathology, testicular torsion
• Epigastric: MI, ulcer, pancreatitis
• Diffuse: Gastroenteritis, IBS, ischemic
bowel, diabetic ketoacidosis
Inspect
(abdomen)
Skin, distention, scars, obesity, herniations,
bruising, pulsations
Auscultate
(bowel tones—
before palpation)
• Hypoactive; every minute.
• Normal; every 15–20 seconds.
• Hyperactive; as often as every 3 seconds.
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Gastrointestinal System
Assessment (continued)
Percuss
(abdomen)
• Dullness: solid organ (liver)
• Tympany: hollow organs (bowels)
• Resonance: air-filled organs (lungs)
• Flatness: dense tissue (muscle, bone)
Palpate
(abdomen—
after auscultation)
• Pulsations (aortic aneurysm)
• Masses (stool, tumors)
• Tenderness (appendicitis)
• Rigidity (GI bleed, guarding)
RUQ
LUQ
LEFT LOBE
STOMACH (CUT)
LIVER
DIAPHRAGM
SPLEEN
KIDNEY
RIGHT LOBE
GALLBLADDER
DUODENUM
BILE DUCT
KIDNEY
TRANSVERSE
COLON (CUT)
PANCREATIC DUCT
PANCREAS
DESCENDING
COLON
ASCENDING
COLON
CECUM
VERMIFORM
APPENDIX
UTERUS
OVARIES
SMALL INTESTINE
UMBILICUS
RECTUM
BLADDER
ANUS
RLQ
LLQ
G-K
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G-K
Glasgow Coma Scale (GCS)
Adult—Child
Infant
Eyes Open
Spontaneous
On command
To pain
Unresponsive
Spontaneous
To voice
To pain
Unresponsive
4
3
2
1
Best Verbal
Oriented
Confused
Inappropriate
Incomprehensible
Unresponsive
Coos, babbles
Irritable, fussy
Cries to pain
Grunts, moans
Unresponsive
5
4
3
2
1
Best Motor
Obeys commands
Localizes pain
Withdraws
from pain
Abnormal flexion
Purposeful
Localizes pain
Withdraws
from pain
Abnormal
flexion
Abnormal
extension
Unresponsive
6
5
Abnormal
extension
Unresponsive
Score
4
3
2
1
Reporting: The total GCS score should be broken down into its
relative components (e.g., a GCS of 11 can be stated as E3V3M5).
Score: 13–14 indicates mild brain injury; 9–12 indicates moderate
brain injury; 3–8 indicates severe brain injury.
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Heat Therapy
Carefully monitor pediatric and older adult Pts. Use caution
when applying heat to highly vascular areas, large surface areas,
or Pts with sensory impairment.
Supplies
• Heat therapy device
• Bath towel
• Heating pad
• Pillowcase
General Guidelines
1. Educate Pt and family on use of heat therapy device if
applicable.
2. Cover area to be treated with a bath towel or place uncovered
heating pad into a pillowcase to prevent direct contact of
uncovered heating device with Pt’s skin.
3. Secure heating pad over affected area.
4. Adjust device temperature according to manufacturer guidelines or physician orders.
5. Monitor heating device temperature and assess condition of
skin every 5 minutes.
6. Refer to physician orders regarding time that heat therapy is to
be used—usually no longer than 30 minutes.
G-K
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G-K
Incentive Spirometer (IS)
Supplies
• IS device
• Pillow
General Guidelines
1. Assist Pt to a comfortable, sitting position.
2. Keep IS device upright at all times during use.
3. Instruct Pt to exhale completely, make a tight seal around
mouthpiece with lips, then inhale slowly and completely—
exhale slowly after 3–5 seconds.
4. Inhale at a rate sufficient to raise piston while keeping
work-of-breathing filter (coaching ball) within set parameters.
5. Set indicator to Pt’s maximum inspiration point.
6. Between attempts, instruct Pt to rest and breathe normally to
prevent fatigue and hyperventilation, and encourage the Pt to
cough to clear airway.
7. Instruct Pt how to splint incision for comfort; hold pillow
firmly against area while coughing.
8. Increase indicator as treatment progresses.
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Injections
Angle of Injections
G-K
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G-K
Injections (continued)
Injections—Intradermal (ID)
1. Select site; inner aspect of forearm is most common.
2. Position Pt, arm supported, forearm facing up.
3. Don gloves.
4. Cleanse site with antiseptic using moderate friction in a
circular motion, moving outward from injection site. Avoid
touching injection site once prepared.
5. Apply traction. Stretch skin toward hand opposite direction of
needle.
6. Insert needle bevel side up just below skin at 10–15 degrees.
7. Continue to advance needle another 1–2 mm.
8. Inject medication slowly until a small wheal (raised area)
appears. A well-defined wheal indicates injection into ID
tissue; lack of a wheal indicates injection into SC tissue.
9. Remove needle quickly at same angle as injection.
10. If indicated, mark area around the wheal with a pen.
Injections—Intramuscular (IM)
1. Position Pt according to injection site. Site selection is based
on Pt’s age and size and the quantity to be injected.
2. Don gloves.
3. Cleanse site with antiseptic using moderate friction in a circular
motion, moving outward from injection site. Avoid touching
injection site once prepped.
4. Landmark the site. Spread thumb and index finger
(nondominant hand) apart, forming a V over injection site,
pulling skin taut.
5. Insert needle at a 90-degree angle with a quick, smooth
motion.
6. Stabilize syringe with nondominant hand.
Aspiration for blood return is no longer recommended as
the standard of care.
7. Inject medication slowly and remove needle quickly at same
angle as injection.
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Injections (continued)
Injections—Intramuscular Landmarks
Deltoid Site
Ventrogluteal Site
Anterior
superior
iliac spine
Iliac crest
Gluteus
medius
Acromial
process
Deltoid
muscle
Scapula
Humerus
Deep
brachial
artery
Radial
nerve
Greater
trochanter
Dorsogluteal Site*
Vastus Lateralis Site
Posterior
superior
iliac spine
Gluteus
medius
Femoral artery
Greater
trochanter
of femur
Gluteus
minimus
Gluteus
maximus
Greater
trochanter
of femur
Sciatic nerve
Vastus lateralis
*Site is controversial and no longer recommended in some
institutions.
G-K
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G-K
Injections (continued)
Injections—Intramuscular Z-Track Method
1. Prepare injection. Draw up
prescribed amount of
medication and an additional
0.2–0.5 mL of air to create an
air lock after injection.
2. Replace needle.
3. Don gloves.
4. Cleanse site with antiseptic
using moderate friction in a
circular motion, moving
outward from injection site.
Avoid touching injection site
once prepped.
5. Identify injection site (ventrogluteal or dorsogluteal preferred).
6. Pull skin taut from midline to one
side, using nondominant hand.
7. Hold syringe so that air bubble
floats to plunger, opposite the
needle.
8. While maintaining skin
retraction, insert needle at
a 90-degree angle.
Aspiration for blood return
is no longer recommended
as the standard of care.
9. Inject medication (including air
bubble) slowly and smoothly.
Hold needle in place for
10 seconds.
10. Remove needle at same angle
of injection while releasing skin.
11. Cover site with adhesive
bandage if needed.
Do not massage site after
medication is injected.
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Injections (continued)
Injections—Subcutaneous (SC)
ANTICOAGULANT ALERT!
Heparin should only be subcutaneously injected into the
abdomen to decrease bleeding and bruising; low molecular
weight heparin (LMWH) should only be injected into the right or
left sides of the abdomen to decrease pain and bruising.
Draw up medication with additional 0.2 mL air to ensure all
medication is injected and to create an air lock.
Do not aspirate prior to injection or massage site after injection
because it increases the risk of bleeding and bruising.
INSULIN ALERT!
Insulin syringes are measured in units and are NOT interchangeable with tuberculin (TB) syringes.
1. Position Pt according to injection site. If injecting heparin, use
abdomen at a site farthest from previous injection, at least
2 inches from umbilicus. Rotate sites.
2. Don gloves.
3. Cleanse site with antiseptic using moderate friction in a circular
motion, moving outward from injection site. Avoid touching
injection site once prepared.
4. Pinch or spread skin. If less than 1 inch can be pinched
between fingers, pinch skin and insert needle at a 45-degree
angle. If more than 1 inch can be pinched, spread skin and
insert needle at a 90-degree angle.
5. Insert needle with a quick, smooth motion.
6. Inject medication slowly. Aspirating for blood return prior to
injection is not necessary as inadvertent entry into a blood
vessel is highly unlikely.
7. Remove needle quickly at same angle as injection.
8. Gently wipe site with an alcohol swab and cover with a bandage.
9. Avoid massaging site after injection unless specifically
instructed. This may alter the rate of absorption.
G-K
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G-K
Injections (continued)
Injections—Subcutaneous Sites
2 inches
from
umbilicus
ID site
(anterior
forearm)
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Type
Rapid-acting
insulin
Short-acting
insulin
Caution: Regular
insulin is the
ONLY insulin
that can be given
by the IV route.
Intermediateacting insulin
Insulin
1–2 hr
Onset
5 min
10–20 min
Sub-Q route:
30–60 min
IV route:
10–30 min
30–60 min
Types of Insulin
Agent
Insulin lispro (Humalog)
Insulin aspart (Novolog)
Regular insulin
(Humulin R)
Concentrated insulin
(Insulin U-500)
Caution: Do not give
by IV route.
NPH (Humulin N,
Novolin R)
Peak
60–90 min
1–3 hr
Sub-Q route:
2–4 hr
IV route:
15–30 min
2–3 hr
8–12 hr
Duration
4–6 hr
3–5 hr
Sub-Q route:
5–7 hr
IV route:
30–60 min
5–7 hr
18–24 hr
G-K
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G-K
Type
Long-acting
insulin
Premixed insulin
Insulin (continued)
Duration
24 hr
Peak
None
24 hr
Onset
3–4 hr
1–4 hr
24 hr
24 hr
24 hr
15 min
2.8 hr
3–14 hr
4–8 hr
15–30 min
3–4 hr
30 min
Types of Insulin
Agent
Insulin glargine (Lantus)
Caution: Cannot be
mixed with other
insulins.
Insulin detemir (Levemir)
NPH/regular (Humulin
50/50, Humulin 70/30;
Novolin 70/30)
Aspart protamine/aspart
(NovoLog Mix 70/30)
Lispro protamine/lispro
(Humalog Mix 75/25)
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Insulin—Mixing Technique
Use only insulin syringes when mixing insulin.
Do not dilute or mix with noninsulin medications.
Supplies
• Insulin syringe
• Alcohol swab
General Guidelines
1. Clean each vial seal with an alcohol swab.
2. Aspirate enough air into syringe so that it is equal to volume
of solution to be withdrawn from vial A.
3. Maintain vial A in an upright position.
4. Inject air into vial A, being careful not to contact solution.
Remove syringe and set vial A aside.
5. Aspirate enough air into syringe so that it is equal to volume
of solution to be withdrawn from vial B.
6. Inject air into vial B, then withdraw exact amount of desired
volume of solution. Remove syringe.
7. Insert syringe back into vial A (already pressurized) and withdraw the exact amount of desired solution.
Avoid pushing plunger and injecting medication from vial B
into vial A.
G-K
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G-K
Insulin—Mixing Technique (continued)
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Intake and Output (I&O)
• Post I&O record on door of room; instruct visitors on use.
• Ensure all cups and pitchers are graduated.
• Obtain and record current weight.
• Provide Pts with a urinal or a toilet insert; instruct on use.
Intake
Oral Intake
• Water: Record amount of water in pitcher at beginning of shift.
Record any water added during shift and subtract amount of
water remaining in pitcher at end of shift.
• Ice chips: Divide volume of ice chips consumed in half.
• Other: Use package volume or institution standards to record
all other liquids (e.g., broth, juice, soda).
IV Fluids
Record volume in IV bag(s) at beginning of shift. Record any
volume added during shift and subtract amount of volume
remaining at end of shift.
NG and Gastric Tubes
• Feedings: Record volume of feeding at beginning of shift. Record
any volume (include fluid to prepare medication) added during
shift and subtract amount of feeding remaining at end of shift.
• Irrigation: Record volume of irrigant if irrigant left in to drain out.
Output
• Record all liquid output including urine, emesis, liquid stools,
wound drains, gastric tubes, and ostomies.
• Weigh saturated pads and linens and subtract dry weight.
• Record source and amount of drainage if multiple sites.
• Refer to physician orders regarding time intervals for recording
I&O (every shift, hourly, etc.).
• If urinary or NG irrigation performed, subtract total irrigant
infused from total output recorded.
• Report extreme differences in I&O. Suspect fluid excess if intake
is greater than output:
One kg gained equals about 1 liter retained.
G-K
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G-K
Intravenous (IV)—Access
Supplies
• Tourniquet
• Tape
• Warm pack
• Antiseptic solution
• Nonlatex gloves
• Appropriate size IV
catheter
• Sterile dressing
Inserting a Peripheral IV or Saline Lock
1. Apply tourniquet proximal to insertion site.
2. Palpate vein with fingertips. To further enhance dilation,
gently tap vein, have Pt clinch fist repeatedly, or dangle arm
below heart. Tip: Place a warm pack over insertion site or wrap
thorax in warm blanket for 2–3 minutes prior to using tourniquet.
3. Cleanse site with antiseptic using moderate friction in a circular
motion, moving outward from insertion site. Allow to air dry.
4. Put on gloves. Avoid touching insertion site once prepared.
5. Inject numbing agent (if using). Discard needle in sharps
container.
6. Apply traction. Stretch the skin in the opposite direction of
catheter insertion.
7. Insert needle bevel side up at 15–30 degrees.
8. Observe for “flash back” (presence of blood) in flash chamber.
Lower needle almost parallel to skin and advance 3–4 mm
(ensures catheter is in vein).
9. Advance catheter to hub while maintaining skin traction.
10. Stabilize catheter and release tourniquet. Apply digital pressure
just above end of catheter tip while gently stabilizing hub of
catheter.
11. Remove needle, engage safety mechanism (if using a safety
needle), and discard in sharps container.
12. Connect primed access apparatus:
• IV tubing: Open clamp and observe for free flow of fluid
(adjust rate)
• Saline lock: Flush with NS to verify patency (engage slide
clamp after flushing).
13. Secure catheter and tubing with sterile dressing and tape per
policy.
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Troubleshooting IV Complications
Blood Backing Up Into IV Tubing
■ Ensure IV bag has fluid and hang a new bag as needed. If bag is
allowed to run dry, the tubing may fill with air; stop IV, attach a
new bag, and reprime drip chamber. Insert a large syringe into
a port distal to air and then clamp IV tubing distal to that port.
Open roller clamp and aspirate air until tubing is reprimed.
■ Ensure bag is hanging above both the level of the Pt’s heart and
the IV insertion site.
■ Assess for unintentional, arterial cannulation; palpate for a
pulse under insertion site and inspect for pulsation of blood
in tubing. Discontinue IV and hold direct pressure for at least
5 min.
Decreased or No Infusion Rate
■ Assess IV site for infiltration.
■ Straighten extremity if IV insertion site is close to a joint.
■ Maintain alignment of extremity with a padded arm board.
■ Inspect entire length of tubing for kinks or holes.
■ Inspect stopcocks and other flow-control devices.
■ Ensure that burette (pediatrics) contains correct amount of
fluid.
■ Raise height of IV bag if not using an infusion pump.
■ Flush with 3 mL of NS—if a significant amount of resistance
is encountered, seek assistance per institutional policy. If
assistance is unavailable, discontinue IV and start a new one,
preferably on the opposite arm.
Infiltration
■ Assessment: Swelling, tenderness, decreased or no infusion
rate, blanching of skin, site is cool to touch.
■ Discontinue IV and restart in a new site. Apply warm compress
to the affected area.
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Leaking Fluid at IV Site
■ Assess IV site for infiltration.
■ Inspect connection between tubing and IV catheter.
■ If all connections are patent, err on side of safety and assume
that site is infiltrating or catheter is defective, even if IV is
infusing freely. Call for an IV therapy consult.
Pain at IV Site
■ Assess IV site for infiltration, phlebitis, and irritation from tape.
■ Ensure adequate stabilization of IV catheter.
■ Straighten extremity if IV insertion site is close to a joint.
■ Maintain alignment of extremity with a padded arm board.
■ Determine whether a medication being infused can cause pain
or irritation.
■ Seek assistance per institutional policy if unsuccessful at
relieving pain or discomfort.
Phlebitis
■ Assessment: Classic sign is red line along course of vein.
Other signs include redness, heat, swelling, and tenderness.
■ Discontinue IV and restart in a new site. Apply warm compress to the
affected area.
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Intravenous—IV Push Medications
Verify allergies, and medication rights, and triple-check order.
Use second nurse if required to verify and/or cosign any calculation.
Ensure compatibility with IV solution.
• Use filter needle if drawing medication up from a glass ampule.
• Dilute medication (if needed) according to pharmacy policy.
• Document medication, dose, route, date, and time.
Through a Primary IV Line
1. Clean distal injection port with alcohol swab for 30 sec.
2. Inject medication over appropriate time interval.
3. If not compatible with IV solution, stop primary IV and flush
line with 10 mL saline. Pinch line above injection port and
inject medication.
4. Clear line of residual medication by flushing with 10 mL 0.9%
saline solution (normal saline). Resume previous rate.
Through a Saline Lock
1. Clean injection port with alcohol swab for 30 sec.
2. Open slide clamp (if present).
3. Flush with 3–5 mL normal saline.
4. Inject medication over appropriate time interval.
5. Flush with 3–5 mL normal saline.
6. Engage slide clamp after flushing.
7. Discard syringe and/or needle in sharps container.
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Intravenous Infusion—Continuous
• Verify medication rights and triple-check order.
• Follow institutional policy regarding use of infusion pumps.
• Document medication, infusion rate, date, and time.
As a Primary Line
1. Ensure compatibility if medication being added to primary bag.
2. Set infusion rate according to health care provider orders.
As a Secondary Line (through the Primary)
1. Ensure medication is compatible with primary IV solution.
2. Clean injection port with alcohol swab for 30 sec. Use injection
port below primary line roller clamp; this allows for independent adjustment of flow rates without altering the other line.
3. Set secondary infusion rate according to health care provider
orders; both primary and secondary infusions run simultaneously at independent rates.
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Intravenous Infusion—Intermittent IV
Piggyback (IVPB)
Supplies
• Secondary administration set
• Antiseptic swab
General Guidelines
Refer to Medication—Administration (page 105)
1. Verify medication rights,
Secondary
ensure IVPB bag is cor"piggyback"
rectly labeled, confirm
Extension
medication is compatible
hook
with primary IV solution,
and ensure IVPB tubing
Primary
is primed.
2. Follow institution policy
Clamp
regarding use of infusion
pumps.
Piggyback line
3. IVPB bag must be higher
Primary line
than primary IV bag.
Primary Y port
Hang primary bag from
an extension hook so that
Clamp
it is lower than the IVPB
bag.
4. Clean proximal injection
Secondary
port
port on primary line with
To patient
alcohol swab for 30 sec.
5. Connect primed IVPB
line to cleaned injection port.
6. Adjust IVPB roller clamp to desired rate.
7. Remove IVPB after infusion is complete and primary IV begins
to infuse.
8. Confirm primary infusion rate is correct.
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Labor
Comparison of True and False Labor
True Labor
False Labor
Contractions
Consistent pattern
Inconsistent
Frequency of
contractions
Progressively
increasing
Inconsistent
Duration of
contractions
Progressively
increasing
Inconsistent
Intensity of
contractions
Progressively increasing; increases with
walking
Inconsistent; no
increase with walking
Cervix
Progressive
effacement and
dilatation
No significant change
Discomfort
Mostly low back and
abdominal
Mostly abdominal and
groin
Stages of Labor
• Stage I: From onset of contractions through full effacement and
dilatation of cervix (latent phase, 0–3 cm; active phase, 4–7 cm;
transition phase, 8–10 cm). Duration: 8–18 hours.
• Stage II: From full dilatation of cervix until delivery of baby.
Duration: 15–90 minutes.
• Stage III: From birth of baby until expulsion of placenta.
Duration: ≤20 minutes.
• Stage IV: First 1–4 hours after expulsion of placenta.
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Medication—Administration Routes
Buccal—Transmucosal
1. Offer water to moisten mucous membranes if dry; if on fluid
restrictions, Pt can swish and spit.
2. Don gloves and place medication between cheek and gum on
either side of Pt’s mouth. Avoid areas with inflammation or
bleeding.
3. Instruct Pt to allow medication to dissolve: Do not chew or
swallow.
Ears—Drops
1. Position: side-lying or sitting with head tilted to the side.
2. Gently grasp the rigid, upper cartilage of external ear (auricle).
• Pts >3 years: pull auricle upward and back.
• Pts ≤3 years: pull lobe downward and back.
3. Administer only sterile, prescribed drops into ear; do not allow
dropper to touch Pt’s ear.
4. Release ear and clean off any excess medication from around
the outside of the Pt’s ear.
5. Pt should maintain position for 3–5 minutes.
Note: AD = right ear; AS = left ear; AU = both ears
Eyes—Drops or Ointment
1. Position: upright with head tilted back slightly.
2. Stand so that dominant hand is toward Pt’s forehead.
3. Wipe excessive tearing or drainage from lower eyelid as
needed. Use a separate tissue or cotton ball for each eye,
and wipe from inner to outer canthus.
4. Hold dropper or ointment tube in dominant hand.
5. Position heel of dominant hand on Pt’s forehead.
6. Use a cotton ball and your nondominant hand to gently pull
lower eyelid down. Instruct Pt to look toward forehead.
7. Administer prescribed drops into conjunctival sac (apply
ointment from inner to outer canthus), being careful not to
allow dropper tip or ointment applicator tip to touch Pt.
8. Instruct Pt to gently close eyes for 1–2 minutes.
Note: OD = right eye; OS = left eye; OU = both eyes
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Medication—Administration Routes (continued)
Inhalation—Handheld Nebulizer
1. Position: sitting upright as tolerated.
2. Pour prescribed volume of medication into nebulizer reservoir.
3. Assemble nebulizer—place cap over reservoir, attach T-piece
to cap, attach large tube and mouthpiece to both ends of
T-piece, attach oxygen tubing to bottom of reservoir, and
connect tubing to oxygen or compressed air source.
A simple mask can be used by removing oxygen tubing connector and then connecting nebulizer cap directly to mask
(no T-piece).
4. Adjust oxygen flow rate to 6–8 LPM, or as ordered. Note that
lower flow rates produce larger (heavier) droplets that tend to
settle in the upper airways; higher flow rates produce smaller
(lighter) droplets, which are ideal for infiltrating the smaller,
lower airways.
5. Instruct Pt to take slow, deep breaths with lips sealed tightly
around mouthpiece. Explain need to maintain nebulizer in an
upright position.
6. Therapy is complete when misting stops, usually after about
6–8 minutes. Tap side of reservoir to dislodge any remaining
medication. Rinse reservoir with sterile water and allow to
air dry.
Inhalation—Metered Dose Inhaler (MDI)
1. Position the Pt sitting upright as tolerated.
2. Shake inhalers that contain liquid medication; attach spacer if
using.
3. Instruct Pt to tilt head back slightly, seal lips around mouthpiece and exhale completely.
4. Administer medication—press down on inhaler as Pt begins
to inhale. Instruct Pt to inhale deeply and slowly and hold
breath for 10 seconds.
5.
Wait 1 min between inhalations of same medication;
wait 2–3 min between different medications.
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Medication—Administration Routes (continued)
Injections (see pages 87–92)
Intravenous (see pages 98–103)
Nasogastric—Gastric Tubes
1. Position: semi-Fowler’s if in bed or sitting upright if in chair.
2. Place absorbent pad over Pt’s chest beneath NG tube.
3. Prepare medication—pill(s): crush using a mortar and pestle,
pill crusher, or between two spoons; capsule(s): open and
empty contents into medicine cup.
Never crush sustained-release or enteric-coated pills; liquid
medication is preferred to ensure more accurate dosing.
4. Mix with 10–20 mL of warm water.
5. Unclamp NG tube and confirm proper placement (page 114).
6. Flush NG tube with 30 mL of water.
7. Draw up and administer prepared medication.
8. Flush NG tube with 30 mL of water.
9. Clamp NG tube for 30 minutes and instruct Pt to remain upright
for 30–45 minutes.
Do not mix medications with tube-feeding formula.
Oral (PO)
1. Position: upright as tolerated.
2. Offer water or juice as permitted. Pt may prefer med cup over
handling medication with his or her hands.
3. Observe Pt until all medication is swallowed: Never leave
medication at Pt’s bedside.
4. Use straw for liquid PO iron to prevent staining of Pt’s teeth.
Rectal (PR)
5. Position: side-lying with knees flexed (left lateral preferred).
Drape Pt as needed for privacy. Consider placing absorbent
pad beneath Pt’s hips.
6. Don gloves and lubricate rounded end of suppository with
water-soluble lubricant.
7. Spread buttocks and gently insert rounded end of suppository
into rectum to the full length of your finger.
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Medication—Administration Routes (continued)
8. Instruct Pts to squeeze buttocks together for 3–5 minutes and
to remain on their side for 15–20 minutes.
9. Wipe away excess lubricant with tissue or washcloth.
Sublingual (SL)
1. Offer water to moisten mucous membranes if dry. If on fluid
restrictions, Pt can swish and spit.
2. Don gloves and place medication under Pt’s tongue. Avoid
areas with inflammation or bleeding.
3. Instruct Pt to allow medication to dissolve and not to chew or
swallow.
Topical
Intact Skin
1. Don nonsterile gloves if skin is intact or sterile gloves if
incision or open wound is present.
2. Unless contraindicated, wash area with warm, soapy water
and blot dry.
Nonintact Skin (Incision or Open Wound)
1. Don sterile gloves and use sterile technique.
2. Unless contraindicated, wash area with sterile cleansing
solution and blot dry with sterile gauze.
Creams, Gels, Lotions, Ointments
1. Don gloves.
2. Squeeze (or pour) onto fingertips and apply to area with a gentle massaging motion until medication is absorbed. Refer to
medication package for application-specific instructions.
3. Use a sterile tongue depressor if obtaining medication from a
multidose container.
Nitroglycerin
Avoid skin contact with nitroglycerin ointment or paste.
1. Wash off old nitroglycerin with warm soap and water and blot dry.
2. Squeeze ordered number of inches onto ruled application paper
supplied with the nitroglycerin. Use plastic wrap alternatively.
3. Apply to upper chest or upper arm (area with least amount
of hair). Secure application paper/plastic wrap with tape.
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Medication—Administration Routes (continued)
Sprays
1. Apply light coat to area. Refer to packaging for instructions.
2. If spray to be applied to chest or higher, instruct Pt to close
eyes and look away during application and to gently cover
nose and mouth with clean gauze.
Transdermal Patch
1. Don gloves to avoid contact with medication when applying
(or removing) patch. Discard old patch per institutional
policy.
2. Choose appropriate site: Skin should be intact, clean and dry,
free of irritation or breakdown, and free of hair.
3. If replacing old patch, clean and dry site with washcloth and
warm soap and water. Rotate sites whenever possible.
4. Write date and time on patch just prior to application.
5. Remove adhesive backing and apply patch. Hold gentle pressure with palm or finger for 10 seconds—do not massage.
Vaginal (PV)
1. Position: supine with knees flexed. Drape Pt as needed for
privacy. Consider placing absorbent pad beneath Pt’s hips.
2. Don gloves.
3. Spread labia and clean vaginal opening with a warm washcloth,
wiping front to back. Use a different corner for each wipe.
4. Discard and replace gloves.
Applicator
1. Fill applicator with prescribed amount of cream and lubricate
applicator with water-soluble lubricant.
2. Spread labia and gently insert applicator (using a rolling motion)
downward toward sacrum; insert full length of applicator unless
resistance is met.
3. Release labia and administer the full amount of cream. Remove
applicator (with plunger depressed) and dispose in biohazard
container.
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Medication—Administration Routes (continued)
Suppository
1. Lubricate rounded end of suppository with water-soluble
lubricant.
2. Spread labia and gently insert rounded end of suppository
along posterior wall of vagina to the full length of your finger.
3. Instruct Pt to remain supine for 5–10 minutes
4. Provide Pt with perineal pad to absorb drainage.
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Medication—Preparation
Ampule
Always use a filter needle or a filter straw when drawing up
medication from an ampule.
1. Gently shake or flick top of ampule to ensure all medication is
at bottom of ampule.
2. Hold body of ampule in one hand and grasp top of ampule
using gauze or unopened alcohol swab with other hand.
3. Snap top of ampule off—away from yourself.
4. Tilt ampule and insert filter needle into liquid and withdraw
desired amount of medication plus an additional 0.2–0.5 mL
of air. Avoid touching rim of ampule with filter needle.
5. Remove and discard filter needle and replace it with needle
intended for injection.
Expel air until desired volume of medication remains in
syringe.
Vial
Needleless (harpoon-type) vial access devices can only be
used on single-use vials.
1. Clean rubber top of vial with an alcohol swab or alcohol-based
4% chlorhexidine (CHG) wipe.
2. Draw air into syringe equal to amount to be withdrawn
from vial.
3. Insert needle or vial access device at a 45-degree angle with
bevel up and bring needle upright to 90 degrees as you
penetrate rubber top—prevents coring of rubber top.
4. Position needle tip above fluid level and inject air.
5. Invert vial and slowly withdraw medication—keep syringe
vertical.
6. Tap base of syringe to move air bubbles to hub of syringe.
7. Inject and withdraw medication as needed until correct dose
is obtained and no air remains in syringe.
8. Confirm correct dose of medication and withdraw needle.
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Musculoskeletal Assessment
History
Pain (chronic or acute), stiffness, weakness,
trauma, fractures, dislocations, deformities,
limitations, immunizations (e.g., tetanus, polio)
Medications
Pain medications including prescribed narcotics,
anti-inflammatory drugs, bisphosphonates (such
as Fosamax, Boniva), and OTC medications
Mobility
Gait, balance, coordination, limitations
Spine
• Posture, spinal curvature
• Spinal deformities (scoliosis, kyphosis, lordosis)
Extremities
• Limb length discrepancy
• Grip strength
• Push-pull strength of feet
Muscle Strength Grading Scale
No muscle movement
0
Visible muscle movement, but no joint
1
movement
Joint movement, but not against gravity
2
Movement against gravity, but not
3
against resistance
Movement against resistance, but less
4
than normal
Normal strength
5
ROM
• Assess for limitations and pain during movement of neck, shoulders, elbows, wrists, spine,
hips, knees, and ankles.
• Test flexion, extension, rotation, lateral bend,
abduction, adduction, circumduction, supination, pronation, inversion, and eversion where
applicable.
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Nasogastric (NG) Tube
Insertion of NG Tube
1. Positioning: upright in highFowler’s—maintain a chin-to-chest
posture during insertion (reduces
chance of intubating trachea).
2. Measure tube from tip of nose
to earlobe, then down to xiphoid.
Mark point on tube with tape.
3. Lubricate tube with water-soluble
lubricant (petroleum-based jelly
degrades PVC tubing).
4. Insert tube through nostril until
you reach previously marked point
on tube. Instruct Pt to take small
sips of water during insertion to
help pass tube.
5. Secure tube to Pt’s nose using
tape. Be careful not to block nostril. Tape tube 12–18 inches below
insertion line and then pin tape
to Pt’s gown. Allow slack for
movement—double lumen (Salem
sump): secure (unclamped) above
level of stomach.
6. Position HOB at 30–45 degrees
to minimize risk of aspiration.
7. Document type and size of NG
tube, which nostril, how Pt tolerated procedure, how tube placement was confirmed, and whether
tubing was left clamped or attached to feeding pump or suction.
Withdraw tube immediately if Pt
becomes cyanotic or develops dyspnea. An inability to speak suggests
intubation of trachea.
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Nasogastric (NG) Tube (continued)
Confirming Proper Placement of NG Tube
• Always use more than one method to ensure proper tube
placement; never rely on just one.
• For small-bore nasointestinal tubes (may collapse under pressure when aspirating), or if incorrect placement is otherwise
suspected, confirm placement by x-ray.
Observation
• Verify marking on tube is at Pt’s nostril.
• Compare length of exposed tube to initial length documented
in Pt’s chart.
Aspiration
• Aspirate gastric contents using a 20-mL syringe.
• Gastric aspirate should appear green with particulate matter
or brown if blood is present.
Measurement of pH
• Dip litmus paper into gastric aspirate.
• A pH of 1–3 (<5) suggests placement in stomach.
X-Ray
• Obtain an x-ray per facility policy to confirm placement before
instilling fluids, nutrition, or medications. Attach to suction if
ordered.
Removal of NG Tube
1. Positioning: upright, 30–45 degrees.
2. Discontinue suction.
3. Unpin tube from Pt’s gown.
4. Remove tape from Pt’s nose.
5. Confirm placement, then clear tube by flushing with 50 mL
of air.
6. Clamp tube (prevents aspiration), instruct Pt to hold breath,
and remove tube in one gentle but swift motion.
7. Assess for signs of aspiration.
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Neurologic Assessment
Mental Status
• Affect, mood, appearance, behavior, and
grooming.
• Clarity of speech and coherence.
• Alert, lethargic, confused, obtunded, or
stuporous.
• Orientation to person, place, time.
Motor
• Involuntary movements, muscle symmetry,
atrophy.
• Muscle Tone: Flex and extend wrists, elbows,
ankles, and knees; slight, continuous resistance
to passive movement is normal. Note any decreased (flaccid) or increased (rigid or spastic)
muscle tone.
• Motor Strength: Have Pt move against resistance (see Muscle Strength Grading Scale).
Reflexes
Deep Tendon Reflexes:
0
Absent
1+
Diminished
2+
Normal
3+
Hyperactive without clonus
4+
Hyperactive with clonus
• Babinski (Plantar Reflex): Stroke lateral aspect
of sole of each foot with reflex hammer. Normal
response is flexion (withdrawal) of toes.
Positive (abnormal) Babinski is characterized
by extension of big toe with fanning of other
toes.
• Clonus: With knee supported in partially flexed
position, quickly dorsiflex foot; rhythmic
oscillations are positive for clonus.
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Neurologic Assessment (continued)
Gait/Balance
• Observe gait while Pt walks across room and
back.
• Have Pt walk heel-to-toe or on heels in a
straight line.
• Have Pt hop in place on each foot.
• Have Pt do a shallow knee bend.
Coordination
• Rapid Alternating Movements: Instruct Pt to
touch tip of thumb with tip of index finger as
fast as possible.
• Point-to-Point Movements: Instruct Pt to touch
his or her nose and your finger alternately.
Continually change position of your finger
during test.
• Romberg Test: Be prepared to catch Pt!
Request that Pt stand with feet together, eyes
closed for 10 seconds. If Pt becomes unstable,
test is positive, indicating proprioceptive or
vestibular problem.
• Proprioception: While standing, instruct Pt to
close eyes and alternate touching index fingers
to nose.
Sensory
• Using your finger and a toothpick, instruct Pt to
distinguish between sharp and dull sensations.
Compare left to right (Pt’s eyes closed).
Alert
Pt is alert and requires no stimulation.
Verbal
Pt responds only to verbal stimulation.
Painful
Pt responds only to painful stimulation.
Unresponsive
Pt is unresponsive to any stimulation.
AVPU Scale
For Glascow Coma Scale, see page 84.
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Newborn—Assessment
APGAR Score
Component
Interval
Appearance (color)
1 min
5 min
• pink torso and extremities ............................2
• Pink torso, blue extremities ..........................1
• Blue all over....................................................0
Pulse (heart rate)
1 min
5 min
• >100 .................................................................2
• <100 .................................................................1
• Absent .............................................................0
Grimace (irritability/reflexes)
1 min
5 min
• Vigorous cry....................................................2
• Limited cry ......................................................1
• No response to stimulus................................0
Activity (muscle tone)
1 min
5 min
• Actively moving..............................................2
• Limited movement .........................................1
• Flaccid .............................................................0
Respiratory Effort
1 min
5 min
• Strong, loud cry..............................................2
• Hypoventilation, irregular..............................1
• Absent .............................................................0
Totals*
*8–10, normal; 4–6, moderate depression; 0–3, aggressive resuscitation (see
Initial Steps to Neonatal Resuscitation).
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Newborn—Assessment (continued)
ABCs and Temperature
• Baby should be pink and have a loud, vigorous cry; for darkskinned Pts, assess oral mucosa and/or conjunctivae.
• Suction nose and mouth to clear excess secretions, mucus.
• Stimulate breathing with vigorous rubbing and drying.
• Dry baby and maintain warmth (wrap in blankets, warmer, etc.).
Identification and Safety
• Place ID bands on baby and mother immediately after delivery.
• Record baby’s footprints in chart.
• Always transport newborn in a bassinet.
• Only staff with proper identification can care for newborn.
Initial Head-to-Toe Assessment
Perform regular, head-to-toe assessment, similar to adult, but
note the following newborn adaptations.
• Appearance: Baby should be pink (for dark-skinned Pts, assess
oral mucosa, conjunctivae, palms, soles of feet, etc.); have
a loud, vigorous cry; and be well flexed with full ROM and
spontaneous movements.
• Fontanels: Anterior is diamond-shaped, ~4 cm at widest point
(closes at 12–18 months); posterior is triangular, ≤1 cm at
widest point (closes at 2–3 months).
• Molding: Skull may be oddly shaped with overlapping cranial
bones.
• Mouth: Inspect mouth for cleft lip and cleft palate.
• Heart murmur: Soft murmur considered normal in first few
days.
• Breathing: Abdominal breathing normal in newborns.
• Umbilical cord: Should have one vein and two arteries. Should
be clamped, may or may not be pulsating, no sign of bleeding.
• Extremities: Legs and arms equal length to each other and all
fingers and toes accounted for.
• Male genitalia: Testes palpable in scrotum or inguinal canal.
• Female genitalia: Large labia minora and vaginal discharge of
blood or mucus considered normal.
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Newborn—Assessment (continued)
Measurements
• Weight: Normal range is 6–10 lb.
• Length: Normal range is 18–22 in.
• Head circumference: Normal range is 13–14 in (33–35 cm).
• Chest circumference: Normal range is 12–13 in (30–33 cm).
Vital Signs (See APGAR Score)
• Assess and document APGAR at 1 and 5 minutes after delivery.
Note: Some hospitals also require a 10-minute APGAR score.
• Assess and record vital signs.
Newborn Normal Range Vital Signs
Preterm
Newborn
RR
50–70
30–60
HR
140–180
120–160
SBP
40–60
60–90
Temp
36.8–37.5°C
36.8–37.5°C
Routine Newborn Medication and Lab Tests
• Eyes: Medicated with antibiotic ointment per institution policy.
• Vitamin K injection: Given to prevent hemorrhage.
• PKU (phenylketonuria): Should be obtained 24 hours after
feeding begins. Normal serum blood level is <4 mg/dL. Sample
is obtained from heel stick.
• Coombs’ test: Done if mother’s blood is Rh negative. Determines
if mother has formed harmful antibodies against her fetus’s
RBCs and transferred them to her baby via placenta. Heel stick
sample.
• Immunizations: Physician may order first hepatitis B vaccine
(Hep-B) to be given soon after birth, before discharge.
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Oral Care—Unconscious or Debilitated Patient
Ensure suction is set up and working.
Avoid using water in ventilated Pts—use saline.
1. Position Pt in sidelying position with
head of bed (HOB)
down.
2. Position absorbent
pad beneath Pt’s
head.
3. Position emesis
basin under Pt’s
mouth.
4. Use a bite block
or padded tongue
depressor to assist
with holding Pt’s
mouth open.
5. Apply toothpaste
to moistened
toothbrush.
6. Brush teeth in the normal manner. (a) Hold bristles at a
45-degree angle to the gumline. Use short circular motions
and brush inner and outer tooth surfaces including gumline. (b) Brush biting surfaces back and forth. (c) Brush
Pt’s tongue.
7. Draw up 10 mL of water or approved mouthwash and gently
rinse along sides of Pts mouth. Suction as needed or allow
rinse to drain into basin.
8. Clean soft tissues of the oral cavity per institution policy. Use
a different swab for each area.
9. Apply water-soluble lip moisturizer.
10. Dry Pt’s face and mouth and reposition as needed.
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Ostomy Care
Types of Ostomies
• Colostomy: May be permanent or temporary. Used when only
part of large intestine is removed. Commonly placed in sigmoid
colon, stoma is made from large intestine and is larger in appearance than an ileostomy. Contents range from firm to fully
formed.
• Ileostomy: May be permanent or temporary. Used when entire
large intestine is removed. Stoma is made from small intestine
and is smaller than a colostomy. Contents range from paste-like
to watery.
Applying or Changing an Ostomy Bag
1. Positioning: Supine.
2. Don gloves and gently remove old pouch.
3. Discard gloves, wash hands, and don new pair of gloves.
4. Wash area around stoma with soapy water, then dry skin
completely.
5. Inspect appearance of stoma and condition of skin, and
note amount, color, consistency of contents, and presence
of unusual odor (Note: a healthy stoma should be pink-red,
and peristomal skin should be free from any redness or
ulceration).
6. Cover exposed stoma with gauze pad to absorb drainage.
7. Apply skin prep in circular motion; allow to air dry for
30 seconds.
8. Apply skin barrier in circular motion.
9. Measure stoma using stoma guide and cut ring to size.
10. Remove paper backing from adhesive-backed ring, center
ring over stoma, and gently press it to skin.
11. Smooth out any wrinkles to prevent seepage of effluent.
12. Center faceplate of bag over stoma and gently press down
until closed.
13. Document appearance of stoma; condition of skin; amount,
color, and consistency of contents; and presence of any
unusual odor.
L-O
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L-O
Ostomy Care (continued)
Ostomy Irrigation (intestinal)
Ensure irrigant is NEVER warmer than 100°–105°F.
Supplies
• Toilet or commode
• Absorbent pads
• Bedpan
• Irrigation bag
• Prescribed solution
• Irrigation tubing
• Drainage pouch
• Water-soluble lubricant
• Cone-tip catheter
• Pouch clip
• Rubber band
• Clean ostomy pouch
• Dressing supplies
Procedure
1. Attempt to perform irrigation at the same time interval in
accordance with Pt’s normal elimination patterns.
2. Position ambulatory Pts on or near toilet or commode.
Position nonambulatory Pts with HOB elevated to
45–90 degrees. Place absorbent pads under Pt and use
a bedpan for drainage.
3. Fill irrigation bag with prescribed solution, typically
500–1000 mL (250–500 mL if first time) of warm (body
temperature) tap water.
4. Elevate irrigation bag so that bottom of bag is at shoulder
level if Pt is sitting or 18–20 inches above stoma opening if
on bed rest.
5. Prime irrigation tubing: open clamp, fill tubing with irrigation
solution, then close clamp.
6. Remove ostomy pouch if applicable and attach irrigation
drainage pouch over stoma.
Cramping during irrigation usually indicates that the irrigant
solution is too cold, the flow rate is too fast, air was introduced
into the intestine (line was not purged of air), or the bowel is ready
to empty (irrigation is complete).
7. Place open end of drainage pouch into toilet or bedpan so
that irrigant drains freely using gravity.
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Ostomy Care (continued)
8. Apply water-soluble lubricant to cone-tip catheter and insert
cone into stoma with just enough pressure to occlude stoma.
Cone tip may need to be attached if not preassembled.
9. Secure cone in place during irrigation and for 10 seconds
after irrigation is complete. Pt may hold cone if able and
willing.
10. Open irrigation tubing clamp and adjust rate to allow irrigant
to flow into the intestine over 5–10 minutes. If Pt complains of
cramping, slow irrigation flow rate and encourage deep
breathing until cramping subsides.
11. Close irrigation tubing clamp and remove cone from stoma.
12. Secure irrigation drain pouch opening in the closed position.
13. Instruct Pt to remain on toilet for 15–20 minutes (allows
drainage of initial returns). For Pts on bed rest, returns should
be allowed to drain into bedpan.
14. Secure drainage pouch opening (pouch clip or rubber band).
15. Ambulate Pt as tolerated to enhance elimination; nonambulatory Pts can massage abdomen to enhance elimination.
16. Remove drain pouch after 1 hour and clean stoma.
17. Apply clean ostomy pouch or dressing as applicable.
L-O
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L-O
Oxygen Administration
Device
Rate (LPM)
FiO2
Nasal Cannula
• For lower percentage supplemental
oxygen.
• Flow rate of 1–6 L/min.
• Delivers 25%–45% oxygen.
• Pt can eat, drink, and talk.
• Extended use can be very drying; use
humidifier.
1
2
3
4
5
6
25%
29%
33%
37%
41%
45%
Simple Face Mask
• For higher percentage supplemental
oxygen.
• Flow rate of 6–10 L/min.
• Delivers 35%–60% oxygen.
• Lateral perforations permit exhaled
CO2 to escape.
• Permits humidification.
6
7
8
9
10
35%
41%
47%
53%
60%
Non-Rebreather Mask
• For high percentage FiO2.
• Incorporates a reservoir bag.
• Flow rate of 10–15 L/min.
• Delivers up to 100% oxygen.
• One-way flaps prevent entrainment
of room air during inspiration and
retention of exhaled gases (namely
CO2) during expiration.
10–15
80–100%*
Venturi Mask (Ventimask)
• For precise titration of percentage
of oxygen.
• Flow rate of 4–8 L/min.
• Delivers 24%–60% oxygen.
• Uses either a graduated dial or
colored adapters selected to
deliver desired FiO2.
Blue
White
Orange
Yellow
Red
Green
124
*Both flaps removed
results in lower
(80%–85%) FiO2
*One flap removed
results in higher
(85%–90%) FiO2
*Both flaps in place
results in max
(95%–100%) FiO2
24%
28%
31%
35%
40%
60%
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125
Oxygen Administration (continued)
Bag-Valve-Mask (BVM)
• For manual ventilation of Pt who has no or ineffective respirations; can deliver 100% oxygen.
• Appropriate mask size and fit are essential to create good seal.
Hold mask with thumb and index finger; grasp underneath
ridge of jaw with remaining three fingers.
Humidified Systems
• For Pts requiring long-term oxygen therapy to prevent drying of
mucous membranes.
• Setup may vary between brands. Fill canister with sterile water
to recommended level, attach to oxygen source, and attach
mask or cannula to humidifier.
Transtracheal Oxygenation
• For Pts with a tracheostomy who require long-term oxygen
therapy and/or intermittent, transtracheal aerosol treatment.
• Ensure proper placement (over stoma, tracheal tube).
• Assess for and clear secretions as needed.
• Assess skin for irritation.
L-O
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P-R
FLACC Pain Scale for Pediatric Patients
Face
• No particular expression or smile
• Occasional grimace or frown, withdrawn, disinterested
• Frequent to constant quivering chin, clenched jaw
Legs
• Normal position or relaxed
• Uneasy, restless, tense
• Kicking, or legs drawn up
Activity
• Lying quietly, normal position, moves easily
• Squirming, shifting back and forth, tense
• Arched, rigid or jerking
Cry
• No cry (awake or asleep)
• Moans or whimpers; occasional complaint
• Crying steadily, screams or sobs, frequent complaints
Consolable
• Content, relaxed
• Reassured by occasional touching, hugging, or being
talked to; distractible
• Difficult to console or comfort
126
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
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Pain—Assessment–OPQRST
Onset
When did pain begin; sudden or gradual onset?
Provokes
Palliation
Precipitation
What provokes pain (exertion, spontaneous
onset, stress, postprandial, etc.)? What makes it
better (position, being still)? What makes it
worse (inspiration, palpation)?
Quality
Characteristics; dull, achy, sharp, stabbing,
pressure, deep, surface? Similar to previous
episodes of pain?
Radiation
Related s/s
Does it radiate (jaw, back, arms, etc.)? Any
related symptoms (dyspnea, nausea, indigestion, fever, etc.)?
Severity
Explain pain scale (0 being no pain and 10 being
worst pain imaginable) and have Pt rate pain
(see above).
Time
Constant or intermittent? Duration? Frequency?
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Pain—Characteristics
Acute Pain
Chronic Pain
Onset
Current
Continuous or
intermittent
Duration
<6 months
>6 months
ANS response
Increased HR, RR, and
BP; diaphoresis;
pupillary dilation;
muscle tension
Rarely present
Relevance to
healing
Diminishes as
healing occurs
Continues long
after healing
Analgesics
Responsive
Rarely responsive
Referred Pain
Anterior
Posterior
Heart
Lung and diaphragm
Esophagus
Liver and gallbladder
Stomach
Pancreas
Gallbladder
Kidney
Small intestine
Appendix
Ovary
Colon
Urinary bladder
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Patient-Controlled Analgesia (PCA)
Common PCA Settings
• Loading (Bolus) Dose: A one-time dose that can be administered after setting up the pump.
• Basal Rate: Amount of drug to be delivered automatically by
the pump over 1 hour.
• On-demand Dose: Amount of drug to be delivered with each
push of the button.
• Lock-out Interval: Preset number of minutes required between
each on-demand dose.
• Lock-out Dose Limit: Maximum dose allowed within a preset
time frame, usually 1- or 4-hour intervals.
Setup
Always confirm dose calculations and PCA setup parameters
with a second nurse.
1. Obtain medication cartridge (or vial). Always perform triplecheck and refer to the Six Rights of Medication Administration.
2. Remove air from the cartridge, if needed, by pressing the
injector into the cartridge and connecting the PCA tubing to
the cartridge according to manufacturer’s guidelines.
3. Prime tubing and then clamp to prevent giving Pt a bolus.
4. Insert cartridge and lock PCA pump according to manufacturer’s guidelines.
5. Turn PCA pump on and set parameters to HCP orders.
6. Ensure PCA is attached to an appropriate outlet (preferred)
or that the batteries are new or fully charged.
7. Clean injection port nearest to Pt and connect PCA tubing.
8. Open clamp and administer loading dose if prescribed.
(a) Set lock-out interval to 0 minutes; (b) set volume to be
delivered as the bolus volume previously calculated; (c) press
the loading dose button.
9. Close PCA pump door and lock with PCA key.
10. Open clamps (if needed) and press start to initiate basal rate.
11. Position PCA control button within easy reach of Pt and
ensure that it is placed well away from the Pt call light.
P-R
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Postpartum Assessment
• Monitor for signs of postpartum hemorrhage and shock.
• If preeclamptic, assess blood pressure every hour.
• It is considered normal to have slight fever (100.4°F) for first
24 hours postpartum; temp >101.4°F indicates infection.
• Urinary retention is likely to occur postpartum; encourage
fluids and monitor intake and output for first 12 hours.
• Encourage early ambulation; instruct Pt to change position
slowly because postural hypotension is common postpartum.
Abdomen and Uterus
• The uterus should be
firm, about the size
of a grapefruit, centrally located, and
at the level of the
umbilicus immediately postpartum.
• Deviation to the
right may indicate
distended bladder.
• If postvoid uterus is
still boggy, massage
top of fundus with
fingers held together
and reassess every
15 minutes.
• Assess for bladder
fullness (full bladder may inhibit uterine contractions and
cause uterine bleeding). Have mother void if bladder is full.
• Mother and/or partner may be instructed to massage fundus.
• Auscultate bowel sounds and inquire daily about BMs.
• Constipation is common from anesthesia and analgesics as
well as fear of perineal pain.
• Increased fiber and fluid intake, along with early and routine
ambulation, will help to reduce occurrence of constipation.
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Postpartum Assessment (continued)
Involution of the Uterus
• Immediately after delivery and within a few hours, the uterus
should rise to the level of the umbilicus and remain there for
the first 24 hours.
• After this, it decreases ~1 cm/day while descending into the
pelvic cavity.
• By day 10, it should no longer be palpable in the abdominal
cavity.
Breasts and Breast-Feeding
• Colostrum appears within 12 hours, and milk appears in
~72 hours postpartum.
• Breasts become engorged by postpartum day 3 or 4 and should
subside spontaneously within 24–36 hours.
• Assess breasts for infection and assess nipples for irritation.
• Encourage wearing of bra between feedings.
Complications
• Pain: Assess for mastitis, abscess, milk plug, thrush, etc. Proper
positioning of infant (football carry) will minimize soreness. Breast
shields are used to prevent clothing from rubbing on nipples.
• Engorgement: Apply moist heat for 5 minutes before breastfeeding. Use ice compress after each feeding to reduce swelling
and discomfort. Avoid bottles and pacifiers while breasts are
engorged because these may cause nipple confusion or
preference.
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P-R
Postpartum Assessment (continued)
• Mastitis: Encourage rest and continuation of feeding or pumping.
Administer prescribed antibiotics.
Note: Breast milk is not infected and will not harm infant.
Lower Extremities
• Thrombophlebitis: Unilateral swelling, decreased pulses,
redness, heat, tenderness, and positive Homans’ sign (calf pain
or tenderness on dorsiflexion of foot). Leg exercises and early
ambulation help minimize occurrence of venous stasis and clot
formation.
Perineum
• Episiotomy: Assess for swelling, bleeding, and infection.
• Hemorrhoids: Encourage sitz baths to help reduce discomfort.
• Lochia: Amount, character, and color. Explain stages and duration
of lochial discharge and instruct Pt to report any odor.
• Lochia rubra: 1–3 days postpartum, mostly blood and clots.
• Lochia serosa: 4–10 days postpartum, serosanguineous.
• Lochia alba: 11–21 days postpartum, creamy white, scant flow.
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Pulse Oximetry
SpO2
Intervention
≥95%
• Considered normal and generally requires no
invasive intervention.*
• Continue routine monitoring of Pt.
91%–94%
• Considered borderline.*
• Assess and adjust probe placement.
• Begin oxygen at 2 L/min titrated to SpO2 >95%.
85%–90%
• Elevate head and encourage Pt to cough and
breathe deeply.
• Assess airway and suction as needed.
• Administer oxygen and titrate to SpO2 >95%.
• If condition fails to improve, assist ventilations
manually and prepare to intubate.
<85%
• Administer 100% oxygen, sit Pt upright, encourage coughing and deep breathing, and suction
as needed.
• Assist ventilations manually and prepare to
intubate if condition fails to improve.
• Consider reversal agents for possible druginduced respiratory depression.
Conditions That May Produce False Readings
False High Readings
False Low Readings
Anemia
Alkalosis
CO poisoning
Hypovolemia
Pt movement
Cool extremities
Drugs (vasoconstrictors)
Nail polish/nail infection
Pt movement
Poor peripheral circulation
Reynaud’s disease
*Consider readings within overall context of Pt’s medical history and physical exam.
NEVER withhold treatment based solely on a “normal” SpO2
reading.
P-R
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P-R
Range of Motion Exercises
Neck: Flexion-Extension
Neck: Rotation
Neck: Lateral Flexion
Shoulder: Flexion-Extension
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Range of Motion Exercises (continued)
Shoulder: AbductionAdduction
Shoulder: External and
Internal Rotation
Shoulder: Circumduction
Elbow: Flexion-Extension
P-R
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P-R
Range of Motion Exercises (continued)
Hands and Fingers:
Flexion-Extension
Wrists: Flexion-Extension
Wrists: Supination-Pronation
Wrists: Abduction-Adduction
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Range of Motion Exercises (continued)
Hands and Fingers:
Abduction-Adduction
Thumb: Opposition
Thumb: FlexionExtension
Hip: Flexion-Extension
P-R
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P-R
Range of Motion Exercises (continued)
Hip: Abduction-Adduction
Hip: Internal and External
Rotation
Hip: Circumduction
Knee: Flexion-Extension
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Range of Motion Exercises (continued)
Ankle: Flexion-Extension
Toes: Flexion-Extension
Foot: Eversion-Inversion
Toes: Abduction-Adduction
P-R
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P-R
Range of Motion Exercises (continued)
Trunk: Flexion-Extension
Trunk: Rotation
Trunk: Lateral flexion
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Respiratory Assessment
History
Cough (productive or nonproductive), dyspnea,
hemoptysis, cerebral palsy (CP), swelling of
lower extremities, energy level, sleep pattern,
COPD (asthma, chronic bronchitis, emphysema),
TB, pneumonia, URI, environmental allergies
Medication
Bronchodilators, acetylcysteine, aminophylline,
theophylline, anticholinergics, corticosteroids
Respirations
Rate, depth, effort, pattern
Inspect
• Signs of distress (nasal flaring or sternal
retractions).
• Size and shape of chest, symmetry of chest
wall movement, and use of accessory muscles.
• Lower extremities for edema and nail beds
for cyanosis and clubbing indicating chronic
hypoxia.
• Trachea for scars, stomas, or deviation from
midline.
Palpate
• Anterior and posterior thorax for subcutaneous emphysema, crepitus, and tenderness.
• Assess tactile fremitus; palpate chest as
Pt says “99.”
Percuss
• Anterior and posterior thorax for tympany
(hollow organs), resonance (air-filled organs),
dullness (solid organs), or flatness (muscle
or bone).
Auscultate
• All anterior and posterior lung fields, noting
normal, abnormal, or absence of lung sounds.
• Order of auscultation: Begin at the top, near
the shoulders, and work toward the
bottom, near the diaphragm, moving from
left to right, working in a zigzag pattern.
P-R
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P-R
Respiratory Assessment (continued)
Auscultation of Lung Sounds
Anterior view
Posterior view
Respiratory Patterns
• Normal (eupnea): Regular and comfortable at 12–20 breaths/
minute
• Tachypnea: >20 breaths/minute
• Bradypnea: <12 breaths/minute
• Hyperventilation: Rapid, deep respiration >20 breaths/minute
• Apneustic: Neurologic: Sustained inspiratory effort
• Cheyne-Stokes: Neurologic: Alternating patterns of depth
separated by brief periods of apnea
• Kussmaul: Rapid, deep, and labored; common in DKA
• Air trapping: Difficulty during expiration: emphysema
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Respiratory Assessment (continued)
Lung Sounds—Differential Diagnosis
Rales/Crackles
Simulated by rolling hair near ear
between two fingers, best heard on
inspiration in lower bases, unrelieved
by coughing (e.g., CHF, pneumonia).
Wheezes
High-pitched, squeaking sound, best
heard on expiration over all lung fields,
unrelieved by coughing (e.g., asthma,
COPD, emphysema).
Rhonchi
Coarse, harsh, loud gurgling or rattling,
best heard on expiration over bronchi
and trachea, often relieved by coughing
(e.g., bronchitis, pneumonia).
Stridor
Life-threatening! Harsh, high-pitched,
easily audible on inspiration, progressive narrowing of upper airway requiring
immediate attention (e.g., partial airway
obstruction, croup, epiglottitis).
Unilaterally Absent
or Diminished
Inability to hear equal, bilateral breath
sounds (e.g., pneumothorax, tension
pneumothorax, hemothorax, or history
of pneumectomy).
Documentation
Rate, rhythm, depth, effort, sounds
(indicate if sound is inspiratory and/or
expiratory), and fields of auscultation.
P-R
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P-R
Restraints
Types of Restraints
• Safety-oriented restraints: Bed rails, wheelchair trays,
mittens to prevent infants from scratching themselves
• Chemical restraints: Medications administered to sedate or
restrict the Pt’s movement; use is highly restricted; most often
used during surgical procedures
• Physical restraints: Fabric body holders, straitjackets,
safety vests and jackets (such as Posey vests), limb restraints,
and papoose boards for infants
Restraints are used only to protect Pt or staff from injury
and should NEVER be used for convenience or punishment.
Alternatives to Restraints
• Provide regular orientation to reality and diversional activities.
• Encourage family to be involved with diversion and supervision.
• Move Pt closer to nurse’s station.
• Use pressure-sensitive alarms in beds and chairs or sitters.
• Conceal tubes and lines with pajamas or scrubs.
• Teach relaxation techniques to decrease anxiety and fear;
overstimulation should be avoided.
Laws Pertaining to Restraints
• According to federal law, alternative methods to promote
safety should be attempted before using restraints; safety
should be the nurse’s priority.
• A physician’s order must be obtained prior to restraining
Pt and is valid for a maximum of 24 hours.
• Restraint orders must be reassessed by the ordering provider
and reordered every 24 hours.
• In an emergency, an order must be obtained within 24 hours
of restraint.
• Once a Pt is restrained, the nurse is responsible for the Pt’s
safety and well-being and care should be appropriate for the
type and severity of the restraint.
• Failure to properly monitor a restrained Pt may result in criminal
and/or civil prosecution.
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Restraints (continued)
• Family should be notified to obtain consent if clinically
reasonable.
• All interventions and PT responses related to the use of restraints
should be carefully documented.
Common Reasons for Using Restraints
• To prevent injury from falls.
• To prevent a confused Pt from roaming through the health-care
facility endangering him/herself.
• To prevent a confused Pt from trying to remove medically
necessary tubes, intravenous lines, or protective dressings.
• To reduce risk for falls when a Pt has an unsteady gait.
• To prevent a Pt from inflicting self-harm or injury (suicidal).
• To prevent a Pt from inflicting harm upon health care workers,
other Pts, and/or visitors (homicidal).
• To ensure infant/child safety when a child cannot remain still
during procedures or to prevent a child from hurting him/
herself.
Safety Guidelines
• Pt should be restrained in an anatomically correct position.
• All bony prominences should be adequately padded.
• Restraints should not interfere with circulation or treatment.
• Restraint straps should be secured to bed frame—never attach
to hand rails.
• All physical restraints should be secured using quick-release
slipknots.
• Call light should be easily accessible to Pt.
• You should be able to fit two fingers easily under restraints.
• Restraint sites (e.g., skin, distal CSM) should be assessed every
15 minutes.
• Physical restraints should be removed every 2 hr if possible—
for aggressive Pts, remove only one restraint at a time.
• Allow ample opportunity for supervised ambulation and
toileting.
P-R
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P-R
Restraints (continued)
Adverse Events Related to Use of Restraints
• Accidental or intentional removal of restraints by Pt, family, or
staff, resulting in possible removal of tubes, intravenous lines,
and injury to Pt or others
• Injury to restrained extremity (arm or leg); dislocation or contusion of extremity
• Fracture or muscle strains during application with violent Pt
• Exposure to blood or body fluid while restraining violent
Pt (biting, spitting, urinating, etc.)
• Numbness and/or tingling in restrained extremity.
• Strangulation
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SBAR—Communication Technique
SBAR (Situation-Background-Assessment-Recommendation)
technique provides a framework for communication between
members of the health care team about a Pt’s condition.
Prior to calling HCP, have available the Pt’s chart, list of current
medications, allergies, IV fluids, most recent vital signs, lab results
and other diagnostic tests (with previous tests, if available, for
comparison), and code status.
S
B
A
R
Identify the SITUATION you are calling about.
• Identify self, unit, Pt, room no., and admitting HCP if
speaking to on-call resident or HCP.
• Briefly state the presenting problem: what is it, time of
onset, and severity.
Describe pertinent BACKGROUND information
related to the situation.
• Admitting diagnosis, recent surgeries
• Vital signs and pertinent assessment data
• Medications, allergies, IV fluids
• Lab and diagnostic test results
• Code status
Describe your ASSESSMENT of the situation.
• What do you see?
• What is your impression?
• Examples may include allergic reaction, bleeding,
infection, respiratory distress, MI, uncontrolled pain
or nausea, etc.
Present your RECOMMENDATION on what you would
like—examples may include:
• Pt needs to be seen now
• Order change or new orders
• HCP input
Developed by Michael Leonard, MD, and Doug Bonacum and Suzanne Graham
at Kaiser Permanente of Colorado, Evergreen, Colorado, USA.
S-U
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S-U
Seizure Precautions
Progression of a Seizure
• Aura (before the seizure starts): An auditory or sensory
warning or recognition by Pt that seizure is imminent.
• Ictal Phase (active seizing): Tonic posturing or clonic
jerking.
• Postictal Phase (after the seizure has subsided): AMS, extreme
confusion, fatigue, fear, and disorientation.
Create a Safe Environment Before a Seizure
1. Maintain bed in lowest position with side rails raised.
2. Install seizure pads to side rails, headboard, and footboard—
bath blankets may be used.
3. Ensure suction and basic airways (oral or nasal) are readily
available at the bedside and in working order.
4. Instruct family and visitors on use of call bell.
5. Transfer or admit Pt to a room closest to nurse’s station.
6. Establish an IV in Pts with a known seizure history and whose
seizures are known to be frequent or prolonged.
Protect the Pt During a Seizure
1. If Pt is in bed: Lower head of bed and raise side rails. Place
pillows or blankets between Pt and rails if seizure pads have
not already been installed, and call for help.
2. If Pt is out of bed: Assist Pt to floor, protect from injury by
placing pillow or something soft under Pt’s head, clear area
of hard or sharp objects (e.g., furniture), and call for help.
3. Position Pt on side to facilitate drainage of secretions and
prevent the tongue from obstructing airway.
4. Do not attempt to restrain Pt during seizure.
5. Do not insert or force anything into Pt’s mouth or attempt to
hold open the airway or jaw. An oral airway may be inserted
for prolonged seizure or signs of hypoxia (e.g., cyanosis);
consider using a nasal airway.
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Seizure Precautions (continued)
Recovery
1. Keep Pt on side until able to protect airway.
2. Suction oropharynx to clear secretions as needed.
3. Examine for injuries; change bedding and clothing if soiled.
4. Stay with Pt and withhold food or drink until fully alert.
5. Reorient and reassure Pt; allow Pt to sleep if tired.
6. Assess mental status and VS every 15 minutes.
7. Monitor lab results (seizure medication levels, blood
sugar, etc.).
8. Document type of seizure and duration.
Inappropriate positioning after a seizure may be a contributing
factor in sudden unexpected death in epilepsy (SUDEP). Avoid
positioning Pt facedown! This can lead to rebreathing exhaled
CO2, increasing Pt’s risk for fatal, hypoxic-related arrhythmias.
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Sputum/Throat Culture
General Guidelines
Cultures should be obtained prior to antimicrobial therapy.
Expectorated Specimens
1. Instruct Pt to brush teeth or rinse mouth prior to specimen
collection to avoid contamination with normal oral flora.
2. Assist Pt to upright position and provide over-bed table.
3. Instruct Pt to take two to three deep breaths and then cough
deeply.
4. Sputum should be expectorated directly into a sterile
container.
5. Label specimen container and immediately send to laboratory.
Throat Culture
Contraindicated in Pts with acute epiglottitis.
1. Instruct Pt to tilt head back and open mouth.
2. Use tongue depressor to prevent contact with tongue or
uvula.
3. Using a sterile Culturette, swab both tonsillar pillars and
oropharynx.
4. Place Culturette swab into Culturette tube and squeeze bottom
to release liquid transport medium.
5. Ensure swab is immersed in liquid transport medium.
6. Label specimen container—send to laboratory at room
temperature.
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Standard Precautions
Hand Hygiene
• Perform before and after every Pt contact.
• Wash hands with soap and warm water for 20 seconds.
• Alcohol-based hand sanitizers are acceptable before and after
casual Pt contact (e.g., obtaining vital signs).
Personal Protective Equipment (PPE)
• Gloves: Use whenever contact with body fluids, mucous
membranes, nonintact skin, or contaminated items is likely.
Remove and discard immediately after use, before touching
noncontaminated items or caring for other Pts.
• Eye protection and masks: Use during Pt-care activities that are
likely to generate splashes or sprays of body fluids.
• Respirator (N95-type): Use as part of airborne precautions
whenever caring for Pts confirmed or suspected to be infected
with highly infectious pathogens transmitted by airborne
particles (e.g., tuberculosis, measles).
• Gown: Use during Pt-care activities to protect exposed skin and
clothing when contact with body fluids is likely.
Sharps—Linen—Refuse—Equipment
• Never recap used needles.
• Dispose of sharps in puncture-resistant containers.
• Place soiled linen and contaminated refuse in leak-proof bags;
follow institution policy regarding recycling.
• Disinfect and store reusable equipment after use.
Removing Soiled Gloves
1. Without touching exposed skin, grasp palm of glove with
other gloved hand and peel glove off, turning it inside out.
2. Hold removed glove in hand that is still gloved.
3. Without touching outside of remaining glove, carefully slide
one or two fingers inside cuff of remaining glove and peel
second glove off, inside out, over first glove so that second
glove encloses it completely.
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Standard Precautions (continued)
Transmission-Based Precautions
• Airborne: Private, negative-airflow room, N95 mask, Pt to wear
surgical mask on transport or if coughing excessively.
• Droplet: Private room, surgical mask, Pt to wear surgical mask
on transport or if coughing excessively.
• Contact: Private room, gloves and gown during Pt contact.
• Reverse isolation (to protect Pt): Private, positive-pressure
airflow room, surgical mask, restriction of visitor access.
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Stool—Specimen Collection
Preservatives are poisonous; avoid contact with skin.
Occult Blood (Hemoccult, Guaiac)
1. Open collection card.
2. Obtain small amount of stool with wooden collection stick and
apply onto area labeled box A; the freshest sample possible
will yield optimal results.
3. Use other end of wooden collection stick to obtain second
sample from different area of stool and apply it onto area
labeled box B; specimens should not contact urine or toilet
water.
4. Close card, turn over, and apply one drop of control solution
to each box as indicated.
5. A color change is positive, indicating blood in stool.
6. Note: If Pt is collecting specimens at home, instruct Pt to
collect specified number of specimens, keep them at room
temperature, and drop them off in designated timeframe.
Cysts and Spores/Ova and Parasites
1. Using spoon attached to cap, place bloody or slimy/whitish
(mucous) areas of stool into each container. Do not overfill
containers.
2. Place specimen in empty container (clean vial) up to fill line,
replace cap, and tighten securely.
3. Place enough specimen in container with liquid preservative
(fixative) until liquid reaches fill line; replace cap and tighten.
4. Shake container with preservative until specimen is mixed.
5. Write Pt ID information, date, and time of collection on each
container; keep at room temperature; and send specimens to
laboratory immediately after collection.
6. If Pt is collecting specimens at home, instruct Pt to collect
specified number of specimens, keep them at room temperature, and drop them off in designated timeframe.
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Suctioning
Closed System—Ventilated Patient
1. Place Pt on pulse oximeter during and following procedure.
2. Adjust fractional inspired oxygen (FiO2) setting on mechanical
ventilator to 1.0.
Manual ventilation is no longer recommended because it has
been shown to be ineffective for providing delivered FiO2 of 1.0.
3. Ensure that suction is turned on no higher than 150 mm Hg;
suctioning pressure should be set as low as possible while
effectively clearing secretions.
4. Stand with your nondominant hand toward Pt’s head.
5. Insert suction catheter just far enough to stimulate a cough
reflex (shallow).
6. Apply intermittent suction while withdrawing catheter and
rotating 360 degrees for no longer than 10–15 seconds to
prevent hypoxia.
7. Repeat until Pt’s airway is clear.
8. Suction oropharynx after suctioning of airway is complete.
9. Hyperoxygenate Pt for at least 1 minute, especially in Pts who
are hypoxemic; do not hyperventilate unless ordered.
10. Monitor Pt for adverse reactions/complications.
11. Rinse catheter in basin with sterile saline between suction
attempts (apply suction while holding tip in saline).
12. Rinse suction tubing when done, and discard soiled supplies.
Naso/Oropharyngeal
1. Explain procedure and administer pain medication before
suctioning.
2. Adjust bed to comfortable working position and lower closest
side rail.
3. Place Pt in a semi-Fowler’s position if conscious; and in lateral
position if unconscious.
4. Place towel or waterproof pad across Pt’s chest.
5. Turn on wall unit suction device to 100 to 200 mm Hg for
adult client, 95 to 110 mm Hg for child, or 50 to 95 mm Hg
for infant, or turn on portable unit to 10 to 15 mm Hg for
adult, 5 to 10 mm Hg for child, or 2 to 5 mm Hg for infant.
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Suctioning (continued)
6. Open sterile suction package and set up sterile container;
pour in sterile saline solution.
7. Don sterile gloves; grasp catheter with dominant hand and
connect to suction tubing with unsterile, nondominant hand.
8. Moisten catheter by dipping into container of sterile saline;
occlude Y-tube to check suction.
9. Estimate distance from earlobe to nostril and place thumb
and forefinger of nondominant hand at that point on catheter.
10. Gently insert catheter along side of mouth toward trachea to
suction oropharynx or along floor of an unobstructed nostril
toward trachea to suction nasopharynx; leave suction off by
leaving Y-connector open.
Never apply suction as catheter is introduced.
11. Apply suction by obstructing Y-tube connector with your
thumb and gently rotate catheter as it is being withdrawn;
do not suction for more than 10 to 15 seconds at a time.
12. Flush catheter with saline and repeat suction as needed,
waiting 20 to 30 seconds between each attempt; alternate
nares when repeated suctioning is required. Do not force
catheter through nares.
13. Encourage Pt to cough and breathe deeply between
suctioning.
14. Remove gloves and dispose of gloves, catheter, and
container.
15. Auscultate chest and listen to breath sounds to assess
effectiveness of suctioning.
16. Record time of suctioning and describe look and amount of
secretions; note character of Pt’s respirations before and after
suctioning.
17. Offer oral hygiene if needed.
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Suture and Staple Removal
Supplies
• Suture removal kit
• Sterile tissue forceps
• Suture scissors
• Staple remover
• Dressing
Suture Removal
1. Use a suture removal kit. If unavailable, obtain a pair of sterile
tissue forceps and small suture scissors.
2. Cleanse incision if indicated.
3. Grasp end of suture nearest to suture knot.
4. Carefully position scissors around suture and cut near skin—
forceps should be between scissors and suture knot to avoid
accidently pulling knot through skin.
5. Cut suture and gently remove in direction of knot.
6. Sutures can be discarded in trash.
7. Apply dressing if needed.
Staple Removal
1. Use a staple remover only.
2. Cleanse incision if indicated.
3. Open staple remover and carefully position both tips of lower
jaw of staple remover between staple and skin.
4. Use one gentle motion to close staple remover onto staple as
you gently lift staple up and out of skin.
5. Staples must be discarded into an approved sharps container.
6. Apply dressing if needed.
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Testicular Self-Examination (TSE)
• Testicular Cancer Research Center (TCRC) recommends
monthly TSE.
• TSE is best performed after a warm bath or shower (heat
relaxes the scrotum and makes it easier to spot anything
abnormal).
1. Stand in front of a mirror and check for any swelling on scrotal
skin.
2. Examine each testicle with both hands.
3. Place index and middle fingers under testicle with the
thumbs placed on top.
4. Roll testicle gently between thumbs and fingers; you shouldn’t
feel any pain during exam.
• It is normal for testicles to differ slightly in size.
• Cancerous lumps usually are found on the sides of testicle
but can also show up on the front.
5. Find the epididymis, the soft, tubelike structure behind the
testicle that collects and carries sperm. If you are familiar with
this structure, you won’t mistake it for a suspicious lump.
• Lumps on the epididymis are not cancerous.
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Tracheostomy Care
• A tracheostomy is a surgically created opening in the trachea.
• A tracheostomy tube is placed in the incision to secure an
airway and to prevent it from closing.
• Tracheostomy care is generally done every 8 hours and
involves cleaning around the incision, as well as replacing the
inner cannula of the tracheostomy tube.
• After the site heals, the entire tracheostomy tube is replaced
once or twice per week, depending on the HCP’s order.
Sterile technique should be used during the procedure.
Supplies
• Prepackaged tracheostomy kit
• Suction kit
• New Velcro straps (if soiled)
• 0.9% saline solution
• Sterile gloves
Cleaning
1. Preoxygenate Pt with 100% oxygen and administer sedative if
Pt is agitated; administer pain medication, especially during
the first 4 days after surgery.
2. Remove gauze dressing from tracheostomy site and note the
amount and color of drainage.
3. Perform tracheostomy and oro-nasopharyngeal suctioning
(See Suctioning, pp. 154–155).
4. Using sterile technique, clean skin around stoma and external
portion of tube with hydrogen peroxide using cotton-tipped
applicators.
5. Note the condition of the skin and stoma.
6. If Pt has a disposable inner cannula, remove old cannula,
discard, and insert new cannula.
7. If Pt has a nondisposable inner cannula, remove inner
cannula, clean with hydrogen peroxide, rinse with 0.9 saline
solution, and reinsert; tap cannula against side of sterile
container to remove excess solution; do not dry.
Only trained personnel should replace tracheostomy tube.
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Tracheostomy Care (continued)
8. Suction Pt again if needed and assess respiratory status.
9. Wipe area with gauze dampened with 0.9% saline solution
and apply a new tracheostomy dressing.
Dislodgement
If Tracheostomy Is Less than 4 Days Old
Stat intervention is required because tract can collapse suddenly; notify HCP and RT stat.
1. Open tracheostomy with a sterile hemostat, suction catheter,
or sterile gloved finger to maintain airway and to keep edges
of tracheostomy from collapsing.
2. If Pt cannot breathe, ventilate using BVM.
3. If you cannot be sure someone clinically prepared to reinsert
tracheostomy tube will arrive within 1 minute, call a Code.
If Tracheostomy Is More than 4 Days Old
• Tract will be well formed and will not close quickly.
• Notify HCP and RT that tube needs to be replaced.
• Obtain replacement tube, if not already at Pt’s bedside.
• Stay with Pt and prepare for insertion of new tube.
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Tube Feeding
1. Position HOB to 30–45 degrees.
2. Release tube from Pt’s gown.
3. Confirm correct tube placement (page 161).
4. Check residuals.
Checking Residuals
1. Check before each feeding, before administration of medication,
or every 4 hours for continuous feeding.
2. Using 60-mL syringe, withdraw from gastric feeding tube any
residual formula that may remain in stomach.
3. If residual volume is greater than predetermined amount
(usually >100 mL), stomach is not emptying properly, and
next feeding is withheld and rechecked in 1 hour.
4. If residuals are still high after 1 hour, notify HCP.
5. High residuals can indicate gastroparesis and intolerance to
advancement to higher volume of formula.
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Tube Feeding (continued)
A. Nasogastric feeding tube
connected to feeding pump
Enteral
feeding
bag
Enteral
feeding
pump
Nasogastric
tube
B. Feeding tube placement sites
Nasogastric tube
Nasoduodenal tube
Nasojejunal tube
Internal crossbar
in contact with
mushroom catheter
Mushroom catheter tip
Stomach wall
C. Gastrostomy tube
insertion site
Gastrostomy
tube
Jejunostomy
tube
External circle clamp
External crossbar contact
Tubing clamp
Plug-in adapter
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Tube Feedings—Complications
Complication
Common Causes and Interventions
Nausea, Vomiting,
Bloating
• Large residuals: Withhold or decrease
feedings.
• Medication: Review meds and
consult HCP.
• Rapid infusion rate: Decrease rate.
Diarrhea
• Too rapid administration: Reduce rate.
• Refrigerated TF: Administer at room
temperature.
• Tube migration into duodenum: Retract
tube to reposition in stomach and
reconfirm placement.
Constipation
• Decreased fluid intake: Provide adequate
hydration.
• Decreased dietary fiber: Use formula
with fiber.
Aspiration,
Gastric Reflux
• Improper tube placement: Verify
placement.
• Delayed gastric emptying: Check
residuals.
• Positioning: Keep HOB elevated
30–45 degrees.
Occluded Tube
• Inadequate flushing: Flush more
routinely.
• Use of crushed meds: Switch to liquid
meds.
Displaced Tube
• Improperly secured tube: Retape tube.
• Confused Pt: Follow institution policy.
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Urinary Catheter—Insertion
Condom Catheter Application
Use only materials supplied by manufacturer for securing
catheter sheath to penis. Failure to do so may result in
compromised blood flow to the penis.
1. Establish baseline assessment of condition of penis.
2. Provide perineal care and dry thoroughly.
3. Refer to manufacturer measuring guide to ensure correct
sizing and application.
4. Ensure foreskin is not retracted in uncircumcised Pts.
5. Roll sheath onto penis, leaving 1–2 inches between tip of
penis and end of condom catheter.
6. Secure sheath according to manufacturer instructions.
7. Secure tubing to Pt’s leg according to institution policy.
8. Hang drainage bag on bed frame below level of bladder.
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Urinary Catheter—Insertion (continued)
Indwelling and Straight Catheters
1. Positioning: For female, knees up, legs apart; for male, legs
flat, slightly apart.
2.
If inserting indwelling catheter, it is no longer the standard
of practice to check for leaks by pre-inflating balloon.
3. Lubricate catheter tip with water-soluble lubricant; saturate
cotton balls with cleansing solution.
4. With nondominant hand (now contaminated), and using
dominant (sterile) hand to hold swabs with sterile forceps.
• For females, hold labia apart; swab from front to back, in
following order: (1) labia farthest from you; (2) labia nearest
to you; and (3) center of meatus between labia. Use one
swab per swipe.
• For males, retract foreskin; swab in a circular motion from
meatus outward. Repeat three times, using a different swab
each time.
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Urinary Catheter—Insertion (continued)
5. Gently insert catheter (about 2–3 inches for females and
6–9 inches for males) until return of urine is noted. For straight
catheter, collect specimen or drain bladder and remove and
discard catheter. For indwelling catheter, insert an additional
inch and inflate balloon.
For uncircumcised males, reposition foreskin after insertion.
6. Attach catheter to drainage bag using sterile technique.
7. Secure tubing to Pt’s leg according to institution policy.
8. Hang drainage bag on bed frame below level of bladder.
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Urinary Catheter—Insertion (continued)
Urinary Catheter—Removal
1. Use a 10-mL syringe to withdraw all water from balloon.
Some catheter balloons are overinflated or have up to a 30-mL
balloon. Withdraw and discard water until no more water can
be removed.
2. Hold a clean 4 ⫻ 4 at meatus with nondominant hand. With
dominant hand, gently pull catheter. If you meet resistance,
stop and reassess if balloon is completely deflated. If balloon
appears to be deflated and catheter cannot be removed easily,
notify HCP.
3. Wrap tip in clean 4 ⫻ 4 as it is withdrawn to prevent leakage of
urine. Use a sterile 4 ⫻ 4 if a culture of catheter tip is desired.
4. Provide bedpan, urinal, or assistance to bathroom as needed.
5. Document time of removal and how Pt tolerated procedure.
6. Document amount and time of spontaneous void.
7. If Pt does not void within 8 hours, palpate bladder or obtain
bladder volume using a bladder scanner and notify HCP.
Catheter may need to be reinserted.
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Urine—Specimen Collection
Catheterized Patients
1. Ensure tubing is empty; clamp distal to collection port for
15 minutes.
2. Cleanse collection port with antiseptic swab and allow to
air dry.
3. Use needle and syringe to withdraw required amount of
specimen.
4. Remember to unclamp tubing after specimen is collected.
Clean-Catch Method (Midstream)
• Indicated for microbiologic and cytological studies.
1. Wash hands thoroughly.
• Males: Cleanse meatus, pull back foreskin.
• Females: Cleanse labia and meatus from front to back.
2. Void small amount into toilet.
• Males: Keep foreskin pulled back
• Females: Hold labia apart
3. Void into specimen collection container without interrupting
flow of urine
4. Secure lid tightly.
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Urine—Specimen Collection (continued)
First Morning
• Yields a very concentrated specimen for screening substances
less detectible in a more dilute sample.
1. Instruct Pt to void into specimen container upon awakening.
Random
• Indicated for routine screening and may be collected at any
time.
1. Instruct Pt to void into specimen container.
Second Void
1. Instruct Pt to void and drink a glass of water.
2. Wait 30 minutes, and then ask PT to void into a specimen
collection container.
Timed (24-Hour Urine)
• Used to quantify substances in urine and to measure substances whose level of excretion varies over time.
• Ideally, collection should begin between 6:00 a.m. and
8:00 a.m.
• Keep specimen container refrigerated or on ice for entire
collection period.
• Start time begins with collection and discard of first void.
1. Instruct Pt to discard first void of day and record date and
time on collection container.
2. Catheterized Pts: Time begins after bag and tubing have been
replaced.
3. Add each subsequent void to collection container.
4. Instruct Pt to void at same time the following morning and
add it to collection container.
5. Catheterized Pts: At 24 hours, empty remaining urine into
collection container.
6. This is the end of the 24-hour collection period.
7. Record date and time and send specimen to laboratory.
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Ventilators—Patient in Distress
When ventilator alarms, always check Pt first!
• Pt not in distress: Check ventilator to determine source of
problem.
• Pt in distress: Have respiratory therapist (RT)/HCP notified stat
and follow steps below; assist with reintubation as needed.
Ventilated Patient in Respiratory Distress
• Disconnect ventilator tubing from ET tube and manually ventilate Pt.
• Have RT/HCP notified stat if not already done.
Patient Is Easy to Manually Ventilate
• Ventilator is probable source of problem. Notify RT.
• Manually ventilate Pt while RT assesses ventilator.
Patient Is Difficult to Manually Ventilate
• Dislodgement: If tube dislodged, remove and manually ventilate Pt. Suction oropharynx to clear secretions.
• Obstruction: Suction ET tube to clear secretions. Notify RT.
If unable to clear obstruction or pass suction catheter, extubate
and manually ventilate (suction oropharynx as needed to clear
secretions).
• Pneumothorax: If ineffective ventilation continues after airway,
ET, and ventilator are all determined to be patent, inspect and
auscultate Pt’s chest. If there is unequal chest wall movement
and/or decreased air movement on one side, it may be related
to a tension pneumothorax (other causes may include an
incorrectly positioned ET tube or atelectasis).
• Equipment: Inspect cuff for air leak (check cuff pressure if
manometer available). Notify RT/HCP if air leak cannot be fixed.
If ineffective ventilation continues and no physical or mechanical
cause can be found, consider sedating Pt.
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Ventilators—Patient in Distress (continued)
Alarm
Ventilator Alarms
Common Causes and Interventions
Low-Pressure
Causes: System disconnects or leaks.
1. Reconnect Pt to ventilator.
2. Evaluate cuff and reinflate if needed
(if ruptured, tube must be replaced).
3. Evaluate connections and tighten or
replace as needed.
4. Check ET tube placement (auscultate lung
fields and assess for equal, bilateral breath
sounds).
High-Pressure
Causes: Resistance within the system such
as a kink or water in the tubing, Pt biting ET
tube, copious secretions, or plugged ET tube.
1. Suction Pt if secretions suspected.
2. Insert bite block as needed.
3. Reposition Pt’s head and neck, or reposition tube.
4. Sedation may be required to prevent Pt
from fighting ventilator, but only after you
exclude physical or mechanical causes.
High Respiratory
Rate
Causes: Anxiety or pain, secretions in ET
tube or airway, or hypoxia.
1. Suction Pt.
2. Look for source of anxiety (e.g., pain,
environmental stimuli, inability to
communicate, restlessness, etc.).
3. Evaluate oxygenation.
Low Exhaled
Volume
Causes: Tubing disconnect or inadequate
seal.
1. Evaluate/reinflate cuff; if ruptured, ET
tube must be replaced.
2. Evaluate connections; tighten or replace
as needed; check ET tube placement,
reconnect to ventilator.
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Wound Assessment
Appearance
Color (pink, healing; yellow/green, infection;
black, necrosis), sloughing, eschar, longitudinal streaking, etc.
Size
Measure length, width, and depth in
centimeters.
Incisions
Approximated edges, dehiscence, or
evisceration
Undermining
Use a sterile, cotton-tipped applicator to probe
gently underneath edges until resistance is met.
With a felt-tipped pen, mark where applicator
can be felt under skin.
Induration
Abnormal firmness of tissues with margins.
Assess by gently pinching tissue distal to
wound edge; if indurated you will be unable
to pinch fold of skin.
Tissue Edema
Note if edema is pitting or nonpitting.
If wound is crepitant, notify HCP immediately
(may indicate gangrene).
Granulation
Bright red, shiny, and granular. Indicates that
wound is healing.
Poorly vascularized tissue appears pale pink,
dull, or dusky red.
Drainage
Type (sanguineous, serosanguineous, purulent), amount, color, and consistency.
Odor
Foul odor indicates infection.
Staging
See Staging Pressure Ulcers next page.
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Wound Assessment (continued)
Staging Pressure Ulcers
Stage I
• Intact, nonblanching
erythematous area.
• Indicates potential
for ulceration.
Epidermis
Dermis
Fat
Muscle
Bone
Stage I
Stage II
• Interruption of
epidermis, dermis,
or both.
• Presents as abrasion, blister, or very
shallow crater.
Stage III
• Full-thickness
crater.
• Involves damage
and/or necrosis
down to, but not
penetrating, fascia.
Stage IV
• Full-thickness crater.
• Similar to stage III,
but penetrates fascia and involves
muscle and bone.
• May involve
undermining.
Stage II
Stage III
Stage IV
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Wound Assessment (continued)
Types of Wounds
Abrasion
A scrape of the superficial layers of the skin;
usually unintentional.
Abscess
A localized collection of pus due to infection;
must be opened and drained to heal.
Contusion
A closed wound caused by blunt trauma; also
known as a bruise or ecchymotic area.
Crushing
A wound caused by force leading to compression of tissue; often associated with bone
fracture; minimal or no break in the skin.
Incision
An open, intentional wound caused by a sharp
instrument; usually a surgical instrument.
Laceration
An open, jagged wound of the skin or mucous
membranes; tissues are torn.
Penetrating
An open wound in which the item causing the
wound is lodged into the body tissues.
Puncture
An open wound caused by a sharp object; tissue
often collapses around entry point, increasing
risk for infection.
Tunnel
A wound with an entrance and an exit site
(e.g., gunshot wound).
V-Z
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V-Z
Wound Culture
1. Remove old
dressing if
present.
2. Discard gloves,
wash hands, and
don new gloves.
3. Irrigate wound
thoroughly with
sterile saline or
irrigation solution ordered by
HCP.
4. Discard gloves,
wash hands, and
don new gloves.
5. Swab healthy
looking area of
wound bed:
• Levine technique: Rotate
sterile swab
over a small
(1 cm) area with sufficient pressure to express fluid from within
the wound tissue.
• Zigzag technique: While applying light pressure, swirl sterile
swab between fingers, sliding swab from one edge of the
wound to the other edge using 10-point zigzag pattern.
6. Place entire swab into culture tube (activate medium if needed)
and secure lid tightly.
7. Transport specimen to laboratory per institution policy.
8. Apply a new sterile dressing as ordered.
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Wound Drainage—Hemovac
Empty drain when half full or greater.
1. Don nonsterile gloves, goggles, and facemask.
2. Change dressing and clean wound if ordered or as necessary
based on assessment findings.
3. Detach drain from Pt’s gown (usually a safety pin).
4. Open drain port and invert port over a graduated container
and empty contents; avoid touching the port or the plug tip.
5. Place collection device on a firm surface and, without standing
directly over it, compress device and secure the plug into the
port; cleanse port and plug with alcohol swab as indicated.
6. Ensure that port is closed securely and that drainage device
remains compressed completely.
7. Reattach drain to Pt’s gown and ensure that tubing is free of
kinks and tension.
8. Drain should not be secured in a manner that prevents bulb
from decompressing (e.g., do not stuff drain into TED hose
cuff, elastic bandaging).
9. Record amount and characteristic of drainage.
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V-Z
Wound Drainage—Jackson Pratt (JP, Bulb-Type)
Empty drain when half full or greater.
1. Don nonsterile gloves, goggles, and facemask.
2. Change dressing and clean wound if ordered or as necessary
based on assessment findings.
3. Detach drain from Pt’s gown (usually a safety pin).
4. Open drain port, invert over a graduated container, and squeeze
bulb to empty contents; avoid touching the port or plug tip.
5. Recompress bulb, close port, and release bulb; point away
from self when recompressing.
6. Ensure that port is closed securely and that bulb remains
compressed completely.
7. Reattach drain to Pt’s gown and ensure that tubing is free of
kinks and tension.
8. Drain should not be secured in a manner that prevents bulb
from decompressing (e.g., do not stuff drain into TED hose
cuff, elastic bandaging).
9. Record amount and characteristic of drainage.
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177
Wound Drainage—Penrose
1. Assess pain level and administer prescribed pain medication
as needed.
2. Don nonsterile gloves, goggles, and facemask.
3. Remove old dressing and assess wound/incision.
4. Discard soiled dressing and gloves; wash hands.
5. Open sterile supplies such as scissors, safety pin, gloves, and
drain dressing.
6. Don sterile gloves.
7. Firmly grasp drain at level of skin and gently pull out to
prescribed amount; monitor Pt for discomfort.
8. Insert the sterile safety pin through drain at level of skin.
9. Trim dressing approximately 1 inch above level of skin using
sterile scissors.
10. Cleanse wound using sterile swabs and prescribed cleansing
solution.
11. Position precut drain dressing around drain.
12. Redress wound and secure with tape as needed.
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V-Z
Wound Irrigation
1. Assess pain level and administer
prescribed pain medication as
needed.
2. Don nonsterile gloves, goggles,
and facemask.
3. Remove and discard old dressing;
assess wound.
4. Place absorbent pad(s) underneath Pt.
5. Position Pt to facilitate downward flow of irrigant over wound
into collection container.
6. Discard nonsterile gloves and
don sterile gloves.
7. Fill 35-mL syringe with
prescribed irrigant.
• Open wounds: Attach
19-gauge catheter. Hold catheter tip 1 inch over wound bed
and irrigate using continuous, gentle pressure.
• Semiclosed wounds: Use sterile, soft-tip catheter. Gently
insert (never force) tip of catheter 1/2 inch into wound and
irrigate using continuous, gentle pressure.
8. Refill syringe and continue irrigation until irrigant draining into
collection container is clear.
9. Apply sterile dressing (see Dressing Change, p. 59).
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Wound Therapy—Negative Pressure
Supplies
• Suction unit
• Collection canister
• Appropriate
dressing
• Semipermeable
transparent
adhesive dressing
• Skin prep product
• Sterile 4 × 4 gauze
• Clean procedure
gloves
• Two pairs of
sterile gloves
• Sterile scissors
• Waterproof pad
• Goggles, mask,
and gown
• 10- to 30-mL
irrigation syringe
• 0.9% saline solution for irrigation
Procedure
1. Administer pain medication and allow time for medication to
take effect.
2. Select appropriate dressing per manufacturer instructions.
3. Place dressing directly against wound surface to allow for
equal suction throughout wound bed.
4. Place suction unit upright on a level surface.
5. Remove canister from sterile package and insert it into pump.
6. Connect tubing to canister, ensuring that tubing remains
clean before connecting to tubing from dressing.
7. Assist the Pt to a comfortable position that allows for easy
wound access.
8. Drape Pt, exposing only wound area, and place a waterproof
pad under the Pt to protect bed linens.
9. Prepare a sterile or clean field and add all supplies.
10. Don a gown, protective eyewear, and sterile or clean procedure
gloves.
11. Irrigate the wound with 10 to 30 mL of 0.9% saline solution or
other prescribed solution using a 30-mL syringe and direct
flow of irrigant from clean end toward dirty end of wound.
12. Clean and dry area around wound with sterile gauze and
apply a skin protectant around wound edges if available.
13. Remove soiled gloves and don new clean gloves for procedure.
14. Away from wound, cut dressing to appropriate size to fill
wound cavity and rub cut edges to remove debris.
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Wound Therapy—Negative Pressure (continued)
15. Gently place dressing into wound cavity without overlapping onto intact skin; do not overfill or pack into deep
crevices; note number of dressing pieces if more than one
is used.
16. Apply liquid skin preparation to periwound area if needed.
17. Lightly apply a transparent, occlusive film dressing that
extends 1 to 2 inches beyond wound margins.
Do not press down or compress dressing.
Do not pull, stretch, or wrinkle dressing.
Do not apply a dressing all the way around an extremity.
18. Pinch up center of film dressing and cut at least a 2 cm round
hole for suction track tubing apparatus.
19. Place track adhesive and suction device directly over hole in
dressing and gently apply pressure to secure.
20. Connect suction track tubing to canister tubing and open
clamps; ensure that canister is attached to a vacuum pump
that provides either continuous or intermittent negative
pressure.
21. Turn on power to pump and set to prescribed therapy settings,
usually in the range of –5 to –125 mmHg as prescribed.
22. Listen for audible leaks and observe dressing collapse or
wrinkle as pressure is applied to wound bed.
23. Change canister at least once a week or when it is filled.
24. Note start date on canister, on Pt dressing, and in Pt’s medical
record.
25. Dressing should be changed every 48 to 72 hours to prevent
tissue growth into dressing.
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Index
A
abbreviations, 18
do-not-use list, 17
abdomen
diagnosis of pain in, 82
postpartum assessment,
130
See also gastrointestinal
system
abducens nerve, 55
abrasions, 173
abscess, 173
acetaminophen, 14
acid–base imbalance, 10
causes of, 11
acoustic nerve, 55
acronyms, 18
activated coagulation time
(ACT), 12
activated partial thromboplastin
time (aPTT), 12, 13
acute pain, 128
advance directives/DNR, 53
air trapping, 142
airway(s)
aspiration precautions, 29
maneuver for opening, 24
nasal and oral, 25
suctioning, 154–155
albumin, 5
aldolase (ALD), 6
alkaline phosphatase, 6
Allen test, 37
amikacin, 15
amiodarone, 14
ammonia, 6
anaphylactic reaction (blood
transfusion), 36
anion gap, 6
antibiotics, therapeutic levels, 15
anticoagulants, injection of, 91
antiembolic devices, 26–27
APGAR score, 117
apical-radial pulse (pulse
deficit), 28
apneustic respiration, 142
arterial blood gases, 9, 37
aspartate aminotransferase
(AST), 6, 11
assessment overview, 2–3
assistive devices, 30
atrial fibrillation (A-fib), 66
atrial flutter, 66
atrioventricular (AV) blocks,
67–68
automated external defibrillator
(AED), 56
AVPU scale, 116
B
Babinski sign, 3
bag-valve-mask (BVM), 125
balance assessment, 116
bilirubin, 6
bladder irrigation, continuous
(CBI), 31
bladder scanner, 32
bleeding time, 12
blood administration, 33–34
transfusion reaction, 35–36
blood chemistry values, 5–9
blood gas analysis
arterial, 9
specimen collection, 37
venous, 10
blood products, 34
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INDEX
blood specimen
arterial blood gases, 37
fingerstick blood glucose, 37
venous sample, 39
blood urea nitrogen, 6
blood volume, 13
body positioning, 41
bradypnea, 142
breast
postpartum assessment/
breastfeeding, 131–132
self-examination, 42
buccal administration, 105
C
C-A-B (compression-airwaybreathing), 44
calcitonin, 6
calcium, 6
ionized, 7
canes, 30
capillary refill, 47
carbamazepine, 14
carbon dioxide (CO2), 7
cardiac arrest, 44
cardiac auscultation sites, 48
cardiac markers, 11
cardiopulmonary resuscitation
(CPR), 45–46
BLS cardiac arrest
guidelines, 44
components of, 43
cardiovascular system,
assessment, 3, 47–48
cerebrospinal fluid (CSF), 12
chest tubes, 49–50
Cheyne-Stokes respiration, 142
chloride, 7
chocking, 51–52
chronic pain, 128
coagulation, 12
codes, 53
cold therapy, 54
coma. See Glasgow coma scale
condom catheter, 163
contusion, 173
Coombs’ test, 119
cortisol, 7
crackles, 143
cranial nerves, assessment, 55
creatine kinase (CK), 7, 11
creatinine, 7
crushing wounds, 173
crutches, 30
cysts and spores, specimen
collection, 153
D
D-dimer, 13
deep venous thrombosis, 48
defibrillation
with automated external
defibrillator, 56
manual, 57
dialysis, peritoneal, 58
digoxin, 14
disseminated intravascular
coagulopathy panel, 13
do-not-resusitate (DNR)
orders, 53
dorsal recombent position, 41
dressings, 59–60
dysphagia, 29
E
ear drops, 105
ear irrigation, 61
edema grading, 73
electric pump cooling
device, 54
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183
electrocardiogram (ECG)
assessment, 62–64
lead placement, 65
sample rhythms, 66–72
enemas, 74
erythrocyte sedimentation rate
(ESR), 14
eye(s)
drops/ointments, 105
irrigation, 75
protection, 151
F
face mask, simple, 124
facial nerve, 55
fall(s)
prevention of, 76
risk assessment, 77
febrile reaction (blood
transfusion), 36
fecal impaction, 78
ferritin, 7
fetal monitoring, 79–81
fibrinogen, 12
fingerstick blood glucose
(FSBG), 37
FLACC pain scale, 126
folate, 7
Fowler’s position, 41
G
gastrointestinal system,
assessment, 3, 82–83
genitourinary system,
assessment, 3
gentamicin, 15
Glasgow coma scale (GCS), 84
glossopharyngeal nerve, 55
gloves, removing, 151
glucose, 7
guaiac test, 153
H
hand hygiene, 151
head and neck, assessment, 2
head-tilt, chin-lift maneuver,
45, 46
heart rate
fetal, 79
newborn, 119
heat therapy, 85
hematocrit, 13
hematology, 13–14
hemocult test, 153
hemoglobin, 13
hemolytic reaction (blood
transfusion), 36
Hemovac drain, 177
heparin, 19
injection of, 91
high-density lipoprotein
(HDL), 7
Homans’ sign, 48
humidified (O2) systems, 125
hyperventilation, 142
hypoglossal nerve, 55
I
ice bag/pack, 54
incentive spirometer (IS), 85
incision, 173
indwelling catheter, 164–165
removal of, 166
infants/newborns
chocking guidelines, 52
CPR, 43, 44, 46
Glasgow coma scale, 84
vital signs, 119
inhalation of medications, 106
injections
angle of, 87
anticoagulant alert, 91
insulin alert, 91
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INDEX
intradermal, 88
intramuscular, 88
intramuscular landmarks, 89
intramuscular Z-track
method, 90
subcutaneous sites, 92
insulin, 19
injection of, 91
mixing techniques, 95–96
types of, 93–94
intake and output (I&O), 97
intermediate IV piggyback
(IVPB), 103
international normalized ratio
(INR), 12
intradermal injections, 88
angle of, 87
intramuscular injections, 88
angle of, 87
landmarks, 89
Z-track method, 90
intravenous (IV) administration
access, 98
continuous infusion, 102
drops per minute, 22
intermediate piggyback, 103
push medications, 101
troubleshooting, 99–100
volume per hour, 22
iron binding capacity, total
(TIBC), 7
irrigation
bladder (CBI), 31
ear, 61
eye, 75
wound, 178
J
Jackson Pratt drain, 177
jaw-thrust maneuver, 45
K
Kussmaul respiration, 142
L
labor
stages of, 104
true vs. false, 104
laceration, 173
lactate dehydrogenase (LDH),
8, 11
lateral position, 41
leukocytes (WBCs), 13
Levine technique, 174
lidocaine, 14
linens, 151
lithium, 14
lithotomy position, 41
low-density lipoprotein (LDL), 7
lung sounds, 143
auscultation of, 1423
M
magnesium (Mg++), 8
measurement, units of
common equivalents, 4
standard-to-metric
conversions, 23
standard-to-metric formulas, 4
medication administration, 21,
105–110
alerts, 18–19
intramuscular, 87–90
intravenous, 98–103
six rights of, 19, 21
subcutaneous, 87, 92
medication(s)
common calculations, 22
errors, 16, 19–21
preparation of, 111
therapeutic levels, 14–15
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mental status assessment, 115
metabolic acidosis, 10
metabolic alkalosis, 10
metric conversions, 23
musculoskeletal system,
assessment, 3, 112
myoglobin, 11
N
nasal cannula, 124
nasogastric (NG) tube, 113–114
nasogastric administration, 107
nasopharyngeal airway (NPA), 25
suctioning, 154
neurologic system, assessment,
3, 115–116
newborn assessment, 118–119
APGAR score, 117
nitroprusside, 14
non-rebreather mask, 124
O
occult blood, 153
oculomotor nerve, 55
olfactory nerve, 55
optic nerve, 55
oral administration (PO), 107
oral care, 120
oropharyngeal airway (OPA), 25
suctioning, 154
osmolality, 8
ostomy care, 121–123
ova and parasites, specimen
collection, 153
oxygen administration, 124–125
P
pacemaker rhythm, 69
pain
acute vs. chronic, 128
at IV site, 100
postpartum assessment,
131
referred, 128
pain assessment
FLACC scale, 126
OPQRST, 126
patient-controlled analgesia
(PCA), 129
penetrating wounds, 173
Penrose drain, 177
personal protective equipment
(PPE), 151
pH
urine, 15
venous blood gas, 10
phenobarbital, 14
phenytoin, 14
phosphorus, 8
PKU (phenylketonuria), 119
plasminogen, 13
platelets, 14
postpartum assessment,
130–132
postprocedure guidelines, 1
potassium (K+), 7
premature atrial complex
(PAC), 69
premature junctional complex
(PJC), 69
premature ventricular complex
(PVC), 70
preprocedure guidelines, 1
pressure ulcers, staging, 172
procainamide, 15
prone position, 41
propranolol, 15
prostate-specific antigen
(PSA), 8
protein, total, 8
prothrombin time (PT), 13
pulse check, 45, 46
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INDEX
pulse deficit, 28
pulse oximetry, 133
pulse-strength grading
scale, 46
puncture wounds, 173
pyruvate kinase, 8
Q
quinidine, 15
R
rales, 143
range of motion exercises,
134–136
rectal administration (PR),
107–108
red blood cells (RBCs), 13
reflexes, deep tendon, 115
refuse, 151
respiratory acidosis, 10
respiratory alkalosis, 10
respiratory system, assessment,
3, 141–143
restraints
adverse events related to, 146
alternatives to, 144
laws pertaining to, 144–145
reasons for using, 145
safety guidelines, 145
types of, 144
rhonchi, 143
S
salicylate, 15
SBAR communication
technique, 147
seizure precautions, 148–149
SGOT. See aspartate
aminotransferase
sharps, 151
Sim’s position (left lateral), 41
sinus bradycardia, 71
sinus tachycardia, 71
skin, assessment, 2
sodium (Na+), 8
specimen collection
blood gas analysis, 37
fingerstick blood glucose, 37
order of draw for Vacutainer
tubes, 40
stool, 153
urine, 167–168
venous sample, 39
spinal accessory nerve, 55
sputum culture, 150
standard precautions, 151–152
staple removal, 156
stool specimen collection, 153
stridor, 143
subcutaneous injections
angle of, 87
sites of, 92
sublingual administration
(SL), 108
SUDEP (sudden unexpected
death in epilepsy), 149
supine position, 41
suture removal, 156
symbols, 18
T
tachypnea, 142
temperature
newborn, 119
standard-to-metric
conversion, 23
testicular self-examination
(TSE), 157
theophylline, 15
throat culture, 150
thrombin time, 13
thyroglobulin, 9
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thyroid-stimulating hormone
(TSH), 9
thyroxine (T4), 9
tobramycin, 15
topical administration, 108–109
tracheostomy care, 158–159
transdermal patch, 109
transfusion reaction, 35–36
transmission-based
precautions, 152
transmucosal administration,
105
transtracheal oxygenation, 125
Trendelenburg position, 41
tri-iodothyronine (T3), 9
trigeminal nerve, 55
triglycerides, 9
trochlear nerve, 55
troponin, 11
tube feeding, 160
complications, 161
tube placements, 161
tunnel wounds, 173
U
ulcers. See pressure ulcers,
staging
urea nitrogen, 9
uric acid, 9
urinalysis, 5, 15–16
urinary catheter, 163–166
urine, specimen collection,
167–168
uterus, postpartum assessment,
130, 131
V
Vacutainer tubes, order of draw
for, 40
vaginal administration (PV),
109–110
vagus nerve, 55
vancomycin, 15
venous blood gas, 10
ventilated patient
in respiratory distress,
169–170
suctioning, 154
ventricular fibrillation (VF), 72
ventricular tachycardia (VT), 72
Venturi mask (Ventimask),
124
vital signs
assessment, 2
newborns, 119
W
walkers, 30
wheezes, 143
wounds
assessment of, 171–173
culturing of, 174
drainage of, 175–177
irrigation of, 178
negative pressure therapy,
178
types of, 173
Z
Z-track method (IM injection), 90
zigzag technique, 174
INDEX