Sop PDF

Ayder referral hospital Standard operational procedures 2015
MEKELLE UNIVERSITY
AYDER REFERRAL HOSPITAL
NURSING SERVICE
STANDARD OPERATING PROCEDURES (SOP)

MANNUAL
PREPARED BY: HAILAY TEKLU

HAREG G/MEDHIN
ETHIOPIA, TIGRAY, MEKELLE

December, 2008 E.c
Acknowledgement
We gratefully acknowledge Ayder referral hospital, department of nursing service for offered us such
an opportunity to undertaken this standard operational procedures manual. We would like thanks for
sr. Hareya G/medhin for given us reference materials and encourage us while preparing this SOP ma-
nual.
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LIST OF CONTENTS
Table of Contents
Acknowledgement ................................................................................................................................................... i
LIST OF CONTENTS .................................................................................................................................................. ii
LIST OF ACRONYMS AND ABBREVIATIONS ............................................................................................................. v
INTRODUCTION ...................................................................................................................................................... 1
1. VITAL SIGN .......................................................................................................................................................... 3
1.1 Assessing body temperature ......................................................................................................................... 3
1.2 Obtaining a pulse .......................................................................................................................................... 5
1.3 Assessing Respiration ................................................................................................................................... 6
1.4 Obtaining Blood pressure ............................................................................................................................. 7
1.5 Assess for orthostatic hypotension ............................................................................................................... 8
1.6 Blood glucose monitoring ............................................................................................................................. 8
2. PAIN MANAGEMENT ........................................................................................................................................ 11
3. MEDICATION ADMINISTRATION....................................................................................................................... 16
3.1 Oral medications ......................................................................................................................................... 16
3.2 Administering medication by metered –dose inhaler ................................................................................. 18
3.3 Administering Intradermal Injections ......................................................................................................... 19
3.4 Administering subcutaneous Injections ...................................................................................................... 20
3.5 Administering Intramuscular Injections ..................................................................................................... 21
3.6 Intravenous therapy .................................................................................................................................... 22
4. ASSISTING PATIENT IN VEIN CUT DOWN (VENSECTION).................................................................................. 26
5. ASSISSTING WITH CENTERAL VENOUS CATHETERIZATION .............................................................................. 28
6. OXYGEN ADMINISTRATION .............................................................................................................................. 30
6.1 Oxygen administration via face mask......................................................................................................... 31
6.2 Nasal Cannula (Nasal Prongs) or nasal catheter ......................................................................................... 32
7. CARE OF A PATIENT ON MECHANICAL VENTILATOR ........................................................................................ 34
8. ENDOTRACHEAL TUBE/TRACHEOSTOMY SUCTIONING ................................................................................... 36
9. TRACHEOSTOMY CARE ..................................................................................................................................... 38
10. WATER SEAL CHEST DRAINAGE SYSTEM ........................................................................................................ 41
11.ASSISSTING WITH THORACENTESIS ................................................................................................................. 44
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12. POSTURAL DRAINAGE ..................................................................................................................................... 46
13. ADMINISTERING CARDIOPULMONARY RESUSCITATION (CPR) ...................................................................... 48
14. PERFORMING DEFIBRILLATION....................................................................................................................... 51
14.1 Use of an Automated External Defibrillator............................................................................................. 51
14.2 Assisting with cardiac defibrillation ......................................................................................................... 52
14.3 Assisting with synchronized cardioversion .............................................................................................. 53
15. ASPIRATION OF THE PERICARDIAL SAC (Pericardiocentesis) ......................................................................... 55
16. OBTAINING AN ELECTROCARDIOGRAM (ECG) ............................................................................................... 57
17. NASOGASTRIC TUBE ....................................................................................................................................... 59
17.1. Nasogastric tube insertion ....................................................................................................................... 59
17.2 Administering Enteral Nutrition: Nasoenteric, Gastrostomy, or Jejunostomy Tube ............................. 62
17.3. Gastric Lavage ......................................................................................................................................... 64
18. COLOSTOMY CARE AND IRRIGATION ............................................................................................................. 66
18.1 colostomy irrigation.................................................................................................................................. 66
18.2 applying a fecal ostomy pouch ................................................................................................................. 67
19. ABDOMINAL TAPE (ABDOMINAL PARACENTESIS).......................................................................................... 69
20. ADMINISTERING ENEMA ................................................................................................................................ 70
20.1 cleansing enema........................................................................................................................................ 70
20.2 Retention enema ..................................................................................................................................... 72
20.3 Rectal washout.......................................................................................................................................... 73
20.4 Passing a Flatus Tube ............................................................................................................................... 74
21. ASSISSTING WITH GASTROINTESTINAL ENDOSCOPY ..................................................................................... 75
22. URINARY CATHETERIZATION .......................................................................................................................... 77
23. BLADDER IRRIGATION ..................................................................................................................................... 81
24. PERIOPERATIVE NURSING CARE ..................................................................................................................... 82
24.1 Preoperative care ...................................................................................................................................... 82
24.3 post operative care .................................................................................................................................... 83
25. WOUND CARE ................................................................................................................................................. 86
25.1 Determining surgical site infection (SSI) ................................................................................................. 86
25.2 Dressing of a Clean Wound ...................................................................................................................... 87
25.3 Dressing of Septic Wound ........................................................................................................................ 88
25.4 pressure ulcer ........................................................................................................................................... 89
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Preventing Pressure Ulcers ........................................................................................................................... 89
Providing Care for Clients with Pressure Ulcers ........................................................................................... 90
Stages of Pressure Ulcer ............................................................................................................................... 91
26. WOUND SUTURING ........................................................................................................................................ 93
26.1 Simple suture or everting interrupted suture .......................................................................................... 93
26.2 Simple running suture .......................................................................................................................... 94
26.3 Mattress suture .................................................................................................................................... 94
26.4 Subcuticular suture ............................................................................................................................... 95
27. ASSISTING WITH CAST .................................................................................................................................... 96
27.1 Assisting with Cast Application ............................................................................................................... 96
27.2 Care of the patient in cast ......................................................................................................................... 97
27.3 Removal of cast ........................................................................................................................................ 98
28. ASSISSTING WITH TRACTION APPLICATION ................................................................................................... 99
28.1 Care of a Patient in Skin Traction ............................................................................................................ 99
28.2 Care of a Patient in Skeletal Traction and Pin Site Care ........................................................................ 100
29. HELP PATIENTS WITH CRUTCH WALKING..................................................................................................... 103
30. ADMINISTERING BLOOD TRANSFUSSION ..................................................................................................... 105
31. ASSISSTING WITH BONE MARROW ASPIRATION ......................................................................................... 107
32. ASSISSTING WITH LUMBAR PUNCTURE........................................................................................................ 109
REFERENCE ......................................................................................................................................................... 111
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LIST OF ACRONYMS AND ABBREVIATIONS
ABG Arterial blood gas

ADL Activity in daily living
AED Automated external defibrillator
AP Apical pulse
COPD Chronic obstruction of pulmonary disease
CPR Cardio pulmonary resuscitation
CSF Cerebro spinal fluid
ECG Electro cardiogram
EID Electronic infusion device
ET Endotracheal tubes
ICS Intercostal space
IM Intramuscular
IV Intravenous
LA Left arm
MAR Medication administering record
MRN medical record number
NGT Nasogastric tube
NS Normal saline
OPD Outpatient department
PO Per oral
RA Right arm
SOP Standard operating procedure
TM Tympanic membrane
V/S Vital sign
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STANDARD OF OPERATING PROCEDURES (SOP)

INTRODUCTION
The concept and importance of the term standardization have been reported since the Industrial Revo-
lution with the process of replacement of human labor by machines. Standardization of production
processes aimed to obtain more uniform products with increased production and service quality. The
word standard means "what serves as basis or norm for evaluation" and is related to the results one
wishes to achieve. In the health area, it relates to care standards, which in turn are related to clients'
rights of receiving nursing care according to their needs.
Concern with the quality of healthcare service is not new and, when clients seek hospital services, they
aim to reestablish their health, solve problems and normalize dysfunctions. For clients to enjoy quality
services, a management system is needed which acknowledges their needs, establishes standards and
attempts to keep up these standards with a view to client satisfaction. Quality management can be use-
ful to nursing and contribute to the implementation of new methods and changes necessary for the im-
provement of care and both team and patient satisfaction. The best way to begin standardization is to
understand how the whole process occurs and, in this case, a systematic representation is required. An
example is the Standard Operating Procedure (SOP), which describes each critical and sequential step
one has to perform in a task in order to assure its expected result. In addition to its relation to the tech-
nique, standardization is a Greek word and refers to the "disposition with which we do things with the
help of a true rule".
Technical acts induce repetitive actions, which sometimes are performed by many different hands,
with similar results being guaranteed to a certain extent. Nonetheless, technical professionals are dif-
ferent beings, with different talents, feelings and knowledge and, although they act with regularity, due
to the work context, they do not always produce results that satisfy different people, despite the use of
the same means. In the nursing area, SOPs are contained in manuals aimed at clarifying doubts and
guiding the execution of actions and should be in agreement with the institution's guidelines and stan-
dards, be updated whenever necessary, according to scientific precepts that should be followed by all
(physicians, nurses and nursing auxiliaries) in a standardized manner.
Well-qualified nurses favor the rationalization of routines, standardization and safer procedures, effec-
tive participation in care planning and liberation of more time to interact with the patient. Therefore, it
is necessary to follow new trends and participate in the construction of alternatives that meet the chal-
lenges of improving the supply of quality care services. In addition, nurses should exert the role of
producers, implementers and supervisors of nursing care actions, contemplating a holistic view of the
patient and adopting their own reference framework.
The lack of standardized procedures, norms and routines, and the non-utilization of a nursing care me-
thod indicate lack of organization of the nursing service, due to different professional conducts. Thus,
standards are defined aiming to establish guidelines for the control and continuing improvement of
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quality. Standardized care refers to detailed guidelines that represent predictable care delivery, pre-
scribed for specific situations, which promotes improvement of organizations' processes and results.
Additionally, the implementation of systems for the development of nursing care, based on standards
and criteria, rests on the precept that care should transcend compliance of medical and administrative
orders and specifically meet patients' real needs through knowledge and a holistic perspective. Thus,
nursing standards define nurses' field of practice and provide guidance to their performance, plan
competences and educational demands.
Overall the objectives of this preparing SOP is: stepwise the existence of SOPs in Ayder referral hos-
pital units/wards; follow the SOP manual by nursing teams; identify the review and updating of this
material and establish standard committee at this institution.
 Steps in developing SOP’s

 Designate a responsible person/persons
 Research the evidence
 Literature
 Ask other hospitals
 Write the SOP in standard format
 Publish in a SOP Manual
 Educate
 SOP standard format
• Policy/Purpose: statement that defines what the policy is about and the reason for it
• Equipment: list necessary equipment to do the procedure
• Procedure: Outlines and describes each step
• Documentation: Defines how, where and how often the procedure should be docu-
mented.
• Sources/references
• Approval: Usually Matron or Policy and Procedure Committee
• other
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PROCEDURE - 01
VITAL SIGN
Definition: vital signs reflect the physiological status and provide information critical to evaluat-
ing homeostatic balance. The term “vital” is used because the information gathered is the clearest
indicator of overall health status. Vital sign include: temperature, pulse rate, respiratory rate and
blood pressure
Purposes:
 To obtain base line data about the patient condition
 To aid in diagnosing patient condition (diagnostic purpose)
 For therapeutic purpose so that to intervene accordingly
Scope: all wards, units, OPDs, emergencies, clinics
Equipment
 Vital sign tray  Pencil
 Stethoscope  Vital sign sheet
 Thermometer (glasses, electronic and  Cotton swab in bowel
tympanic)  Disposable gloves
 Watch  Dirty receiver kidney dish
 Red and blue pen
1.1 Assessing body temperature

Goal: Obtain baseline temperature data for comparing future measurements; screen for altera-
tions in temperature; evaluate temperature response to therapies.
Sites to Measure Temperature

Most common are:
 Oral
 Rectal
 Axillary
 Tympanic
 Assessing Oral Temperature With an Electronic Thermometer

Procedure
1. Perform hand hygiene.
2. Identify the patient.
3. Close door or bed curtains, and explain the procedure to the patient.
4. Remove electronic thermometer from the battery pack, and remove the temperature probe
from the recording unit, noting a digital display of temperature on the screen.
3
5. Place the disposable cover over the temperature probe and attach securely. Grasp the
base of the probe.
6. Insert the probe below the patient’s tongue and into the posterior sublingual pocket of the
mouth. Ask the patient to close his or her lips around the probe. Hold the probe, support-
ing it in place.
7. Wait for a beep (usually 10 to 20 seconds), which indicates the estimated temperature.
Watch to see if temperature continues to rise. When the temperature reading stops rising,
note the temperature displayed on the unit and remove the probe from the patient’s
mouth.
8. Hold the probe over a waste container, and displace the probe cover by pressing the probe
release button.
9. Return the probe to the storage place within the unit, and return the thermometer to the
battery pack. Cleanse according to agency policy.
10. Record temperature on vital sign documentation record, indicating “O” for oral site. Dis-
cuss findings with patient if appropriate.
 Assessing Rectal Temperature with an Electronic Thermometer

Procedure
o Perform hand hygiene.
o Identify the patient.
o Close door or bed curtains, and explain the procedure to the patient.
o Assist patient to Sims’ position with upper leg flexed. Expose only anal area.
o Remove rectal (red) electronic thermometer from battery pack, and extend the temperature
probe from the unit, noting a digital display of temperature on the screen.
o Securely attach the disposable cover over the temperature probe.
o Apply water-soluble lubricant liberally to thermometer probe tip.
o Separate patient’s buttock with one gloved hand until the anal sphincter is visible.
o Ask patient to take a deep, slow breath. Insert thermometer into anus in direction of umbi-
licus, 1 inch (2.5 cm) for a child and 1.5 inches (4 cm) for an adult. Do not force.
o Hold the probe in place until machine emits a beep, obtain reading.
o Follow steps 7 through 9 in Assessing Oral Temperature with an Electronic Thermometer.
o Document “R” for rectal site.
 Assessing Temperature Using a Tympanic Membrane Thermometer

Procedure
3. Close door or bed curtains, and explain the procedure to the patient.
4. Remove tympanic thermometer from recharging base, and check that the lens is clean.
Attach tympanic probe cover to sensor unit.
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5. Insert probe into ear canal, making sure the probe fits snugly. Avoid forcing the probe
too deeply into the ear. Pulling the pinna back, up, and out in an adult will straighten the
ear canal. Some manufacturers recommend moving the thermometer in a figure eight
pattern. Rotate the probe handle toward the jaw line.
6. Activate the thermometer, and note the temperature readout, which is usually displayed
within 2 seconds.
7. Eject sensor probe cover directly into waste container, cleanse according to agency poli-
cy, and return tympanic thermometer to base for storage or recharging. Store away from
temperature extremes.
8. Record temperature on vital sign documentation record.
9. Document “TM” for tympanic membrane site. Discuss findings with patient if appropri-
ate.
 Assessing Axillary Temperature With an Electronic Thermometer

Procedure
1. Assist patient to comfortable position, and remove clothing to expose axilla.
2. Place thermometer against middle of axilla; fold patient’s arm down and place across
chest, enclosing thermometer in axillary area.
3. Wait for a beep that indicates the estimated temperature. Watch to see if temperature con-
tinues to rise. When it stops, note the temperature displayed on the unit and remove the
probe from the patient’s axilla.
4. Follow steps 2 and 3 in Assessing Oral Temperature with an Electronic Thermometer.
Document “A” for axillary site.
1.2 Obtaining a pulse

Goal: Obtain a baseline measurement of heart rate and rhythm; evaluate the heart’s response to
various therapies and medications; peripheral pulse may be palpated to assess local blood flow to
an extremity or to monitor perfusion to an extremity following surgery or diagnostic procedures.
Procedure
3. Close door or bed curtains and explain the procedure to the patient.
 Obtaining a Radial Pulse

4. Position patient comfortably with forearm across chest or at side with wrist extended.
5. Place fingertips of your first two or three fingers along the groove at base of thumb, on pa-
tient’s wrist.
6. Press against radial artery to obliterate pulse, then gradually release pressure until you
feel pulsations; assess for regularity and strength.
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7. If pulse is not easily palpable, use Doppler.
 Apply conducting gel to end of probe or to radial site.
 Press “on” button and place probe against skin on pulse site. Reposition slightly, using
firm pressure, until you hear a pulsating sound.
8. If pulse is regular, count pulse for 30 seconds and then multiply by two. If pulse is irregu-
lar, count for 1 full minute. If irregular pulse is a new finding, assess apical radial rate.
Count the initial pulse as zero.
 Obtaining an Apical Pulse

1. Position patient in supine or sitting position with sternum and left chest exposed.
2. Warm diaphragm of stethoscope by holding it in the palm of your hand for 5 to 10
seconds.
3. Use an alcohol swab to clean the stethoscope and earpieces before using.
4. Locate apex of the patient’s heart by palpating the space between the fifth and sixth rib
(fifth intercostal space) and moving to the left midclavicular line.
5. Insert the earpieces of stethoscope into your ears, and place diaphragm over apex of pa-
tient’s heart.
6. Assess the heartbeat for regularity and dysrhythmias. If rhythm is regular, count the
heartbeat for 30 seconds and then multiply by two. Count for 1 full minute if the rhythm
is irregular. Count the initial pulse as zero.
7. Replace the patient’s gown and assist the patient to return to a comfortable position.
8. Share results of assessment with patient, if appropriate.
9. Document pulse on vital sign record or computerized record. Specify in the documenta-
tion that you obtained an apical pulse (e.g., “AP”)
1.3 Assessing Respiration

Goal: Assess respiratory status by evaluating rate and quality; evaluate the influence of medica-
tions and therapies on respiration.
Procedure
4. After or before assessment of pulse, keep your fingers resting on patient’s wrist and ob-
serve or feel the rising and falling of chest with respiration. If patient is asleep, you may
gently place your hand on the patient’s chest so you can feel chest movement. Do not
explain procedure to patient.
5. When you have observed one complete cycle of inspiration and expiration, and if respi-
ration is regular, look at second hand of your watch and count the number of complete
cycles in 1 full minute.
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6. If respirations are shallow and difficult to count, observe at the sternal notch.
Note depth and rhythm of respiratory cycle.
7. Discuss findings with patient and document respiratory rate, depth, rhythm, and charac-
ter.
1.4 Obtaining Blood pressure

Goal: Evaluate the patient’s hemodynamic status by obtaining information about cardiac output,
blood volume, peripheral vascular resistance, and arterial wall elasticity; obtain baseline mea-
surement of blood pressure; monitor the hemodynamic response to various therapies or disease
conditions; screen for hypertension.
Procedure
4. Clean stethoscope head with alcohol or approved cleaning solution.
5. Assist patient to a comfortable position with forearm supported at heart level and palm
up. Verify that you have a correctly sized blood pressure cuff.
6. Expose the upper arm completely. Palpate the brachial artery.
7. Wrap deflated cuff snugly around upper arm with center of bladder over brachial artery.
Lower border of cuff should be about 2 cm above the antecubital space (nearer the ante-
cubital space on an infant).
8. Palpate brachial or radial artery with fingertips. Close valve on pressure bulb and inflate
cuff until pulse disappears. Slowly release valve and note reading when pulse reappears.
9. Fully deflate cuff and wait 1 to 2 minutes.
10. Place stethoscope earpiece in ears. Repalpate the brachial artery, and place stethoscope
bell or diaphragm over site.
11. Close bulb valve by turning clockwise. Ensure gauge starts at zero. Pump bulb to inflate
cuff. Inflate cuff to 30 mm Hg above reading where brachial pulse disappeared.
12. Open valve on manometer, then slowly release valve so pressure drops about 2 to 3 mm
Hg per second.
13. Identify manometer reading when first clear Korotkoff sound is heard.
14. Continue to deflate, and note reading when sound muffles or dampens (fourth Ko-
rotkoff) and when it disappears (fifth Korotkoff).
15. Deflate cuff completely and remove from patient’s arm.
16. If cuff will be used on another patient, clean cuff according to agency requirements and
allow air-drying.
17. Record blood pressure. Record systolic (e.g. 130) and diastolic (e.g. 80) in the form
“130/80.” Abbreviate as “RA” or “LA” to indicate right or left arm measurement.
18. Assist patient to comfortable position and discuss findings with patient, if appropriate.
Assessing for orthostatic hypotension
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1.5 Assess for orthostatic hypotension

Goal: Assess the compensatory status of the cardiovascular and autonomic nervous systems to
changes in body position assess for fluid volume deficit; assess patient’s safety in getting up and
ambulating.
Procedure
4. Position patient supine with head of bed flat for 10 minutes.
5. Check and record supine blood pressure and pulse. Keep blood pressure cuff attached.
6. Assist patient to a sitting position at edge of bed with feel flat on the floor. Wait 2 to 4
minutes and check blood pressure and pulse rate.
Note: The waiting period is a convenient time to auscultate the patient’s lung fields.
7. Assist patient to standing position, then wait 2 to 4 minutes and check blood pressure and
pulse rate. Be alert to signs and symptoms of dizziness.
8. Assist the patient back to a comfortable position.
9. Record measurements and any symptoms that accompanied the postural change. Report
a drop of 25 mm Hg in systolic pressure or a drop of 10 mm Hg in diastolic pressure.
10. Discuss findings with patient, if appropriate.
1.6 Blood glucose monitoring

Definition: Blood glucose monitoring is a way of testing the concentration of glucose in the
blood.
Purpose
 To monitor blood glucose levels for patients who are at risk for hypoglycemia or hypergly-
cemia
 To monitor the effectiveness of insulin administration.
Scope: all wards, units, OPDs, emergencies, clinics and home
Equipment
 Antiseptic swab
 Cotton ball
 Lancet device, either self-activating or button activated
 Blood glucose meter (e.g., Accucheck , progidy)
 Blood glucose test strips appropriate for meter brand used
 Clean gloves
 Paper towel
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Procedure
1. Identify patient using two identifiers (i.e., name and birthday or name and account num-
ber) according to agency policy. Compare identifiers in MAR/medical record with infor-
mation on patient’s identification bracelet and/or have patient state name.
2. Perform hand hygiene. Instruct adult to perform hand hygiene, including forearm (if ap-
plicable) with soap and water. Rinse and dry.
3. Position patient comfortably in chair or in semi-Fowler’s position in bed.
4. Remove reagent strip from vial and tightly seal cap. Check code on test strip vial. Use on-
ly test strips recommended for glucose meter. Some newer meters do not require code
and/or have disk or drum with 10 or more test strips.
5. Insert strip into meter (refer to manufacturer directions). Do not bend strip. Meter turns on
automatically.
6. Remove unused reagent strip from meter and place on paper towel or clean, dry surface
with test pad facing up.
7. Meter displays code on screen that must match code from test strip vial. Press proper but-
ton on meter to confirm matching codes. Meter is ready for use.
8. Perform hand hygiene and apply clean gloves. Prepare single use lancet or multiple-use
lancet device. Remove cap from lancet device; insert new lancet. Some lancet devices
have disk or cylinder that rotates to new lancet.
a. Twist off protective cover on tip of lancet. Replace cap of lancet device.
b. Cock lancet device, adjusting for proper puncture depth.
9. Obtain blood sample.
a. Wipe patient’s finger or forearm lightly with antiseptic swab. Choose vascular area for
puncture site. In stable adults select lateral side of finger. Avoid central tip of finger,
which has denser nerve supply
b. Hold area to be punctured in dependent position. Do not milk or massage finger site.
c. Hold tip of lancet device against area of skin chosen for test site. Press release button
on device. Some devices allow you to see blood sample forming. Remove device.
d. With some devices a blood sample begins to appear. Otherwise gently squeeze or mas-
sage fingertip until round drop of blood forms.
10. Obtain test results.
a. Be sure that meter is still on. Bring test strip in meter to drop of blood. Blood will be
wicked on to test strip. Follow specific meter instructions to be sure that you obtain
adequate sample.
b. Blood glucose test result will appear on screen. Some devices “beep” when completed.
 Load test strip into meter
 Prick side of finger with lancet
 Gently squeeze puncture site until drop of blood forms
 Touch test strip to blood drop. Blood wicks into test strip
 Results appear on meter screen
9
11. Turn meter off. Some meters turn off automatically. Dispose of test strip, lancet, and
gloves in proper receptacles.
13. Discuss test results with patient and encourage questions and eventual participation in care
if this is a new diabetes mellitus diagnosis.
14. Document the procedure.
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PROCEDURE - 2
PAIN MANAGEMENT
Definition
Pain is an unpleasant feeling that is conveyed to the brain by sensory neurons. The discomfort si
gnals actual or potential injury to thebody.
Assessing pain
Procedure
1. Assess type of pain, and ask client to describe pain using his or her own words.
 Acute pain: short duration of a few seconds/minutes to 6 months.
 Chronic pain: prolonged, persistent pain, 6 months to years.
 Intractable pain: severe and constant, resistant to relief measures.
 Malignant pain: recurrent, acute episodes, which may include chronic pain and may last
longer than 6 months.
2. Assess location.
 Ask client to point to area of the body or verbalize location of pain.
 Ask if pain is superficial or deep.
 Ask if pain is diffuse or localized.
 Ask if pain radiates and where it goes.
3. Assess quality.
 Stabbing, knife-like.
 Throbbing.
 Cramping.
 Vise-like, suffocating.
 Searing or burning.
4. Assess intensity.
 Ask client to indicate intensity of pain using a pain scale; for example, a scale of 0–10.
Use the same pain scale comparing intensity before and after interventions.
 Ask client what measures have reduced the level of pain on the scale.
NUMERIC PAIN INTENSITY SCALE
0 4 5 6 7 8 9 10
1 2 3
No pain mild pain moderate pain severe pain worst pain
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5. Assess onset of pain and aggravating factors.

 What triggers the pain?
 How does movement affect pain?
 Does coughing affect pain?
 What is impact of emotion on pain?
 How does position or fatigue affect pain level?
6. Assess associated factors.
 Nausea and vomiting.
 Hypotension/hypertension.
 Profuse perspiration.
 Apprehension or anxiety.
 Respiratory and heart rate.
7. Assess alleviating factors.
 Position.
 Elevation of extremity.
 Techniques used at home for pain relief.
 What pain medications does client use?
8. Assess client’s behavioral responses to pain.
 No pain—relaxed, calm, and alert. (0)
 Mild pain—stressed, tense, occasional grimace or frown. (1–3)
 Moderate pain—stoicism, squirming, grimacing, more reassurance to comfort. (4–6)
 Severe pain—moaning, restless, muscle twitching, difficult to comfort. (7–9)
 Worst pain—crying, constant moaning, withdrawn, unable to comfort. (10)
9. What is the client’s level of sedation and is it safe to administer the next pain medication?
 Is the client awake and responsive? (1)
 Is the client frequently drowsy? (2)
 Is the client continually falling asleep, even in midsentence? (3)
 Is the client difficult to arouse? (4)
 Is the client somnolent—unable to arouse? (5)
10. By checking the level of sedation above, determine the level of response by number.
 Level 1 and 2—generally safe to administer the next pain medication.
 At level 3, it may be dangerous to administer the next pain medication.
 At levels 4 and 5, it would be dangerous to administer the next pain medication. Notify
physician.
11. When to reassess for follow-up pain medication administration.
 Post-op client—every 2 hr or until pain is controlled.
 Client experiencing pain—every 4 hr.
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12. After pain medication is given, the appropriate follow up time for reassessment is as fol-
lows:
 Injection—5–30 minutes.
 Oral medication—60–90 minutes.
 Sustained-release analgesic or transdermal patch—4 hr.
Assessing Pain in a Cognitively Impaired or Nonverbal Client
Procedure
13. Assess client’s level of understanding (i.e., Alzheimer’s client may still be able to answer questions
about pain he or she is experiencing).
14. Assess nonverbal cues if a verbal response is not elicited.
 Facial expressions
 General behavior
 Unusual movements, twisting or turning, restlessness, pacing, immobility
 Vocal sounds—moaning, crying, gasping, groaning
 Muscle contractions especially around the eyes.
15. Evaluate changes after pain relief intervention to determine whether further assessment is
indicated
Assessing Pain in Young Children
Procedure
16. Assess unidimensional indicators.

 Increase in heart rate.
 Elevation in blood pressure.
 Sweating
 Changes in skin color.
17. Assess multidimensional indicators.
 High-pitched cry
 Baby or child is inconsolable
 Awake continuously—not able to sleep
 Fussy
 Grunting sounds.
18. Assess behavioral responses.
 Facial movement
 Bulging of area between eyebrows
 Tightly closed eyes
 Rigid mouth and tongue
13
 Non pharmacological pain management
Purpose
 To relieve pain or prevent pain from escalating

 To decrease client’s anxiety that present and future pain relief will not be achieved
 To bring pain relief to a level acceptable to the client
Alleviating Pain through Touch (Massage)
Equipment
 Body lotion
 Massage oil
 Towel or drape
Procedure
1. Establish a quiet, private environment.

2. Determine whether client achieves more relief from pain with massage over painful area,
near painful area, or from foot rub, back rub, or hand rub.
3. Warm your hands by rubbing them together or rinsing in warm water.
4. Warm lotion to be used by holding closed bottle under warm running water.
5. Massage area of client’s choice with slow and steady motion.
6. Use deep pressure or light stroking motion, whichever is more comfortable for the client.
Using Relaxation Techniques
Equipment
 A printed relaxation technique (the nurse can read slowly until client learns technique)
 CD and disc or cassette recorder and tape
Procedure
1. Help client assume a comfortable position.

 If lying, place support under knees, lower legs, and under head. Be sure body is in good
alignment.
 If sitting, sit comfortably positioned with both feet on the floor, hands on knees, back
straight, and head balanced comfortably straight.
2. Instruct client to inhale deeply, hold breath for a moment, and then exhale deeply. Repeat
several times.
3. Give the following instructions to client, using a slow, soothing voice.
 Continue to breathe in and out slowly. Concentrate on my voice and follow my words.
 Find a point of tension in your body.
 As you identify the tension, tense the area up even more.
14
 Then relax the area, letting all the tensions drain out.
4. Continue with these instructions until the client has had time to relax all points of tension.
5. To end the process, instruct the client to open eyes slowly and say, “I feel relaxed and
awake.”
 Pharmacological pain management
Purpose
 To implement strategies to decrease pain

 To prevent pain from retarding recovery
 To prevent pain from causing undue fatigue
 To prevent pain from inhibiting moving, ambulating, turning, and coughing
 To provide a consistent level of pain control without unacceptable side effects
Administering Pain Medications
Equipment
 Pain-Assessment Scale
 Ordered pain medication
Procedure
1. Assess pain according to the parameters of pain assessment and select a pain tool based
on client’s preference.
 Verbal description scale.
 Numeric rating scale.
 FACES pain scale.
2. Check chart for any allergy to pain drug and physician’s orders for changes in pain medi-
cation.
3. Administer ordered pain medication or request change in dosing schedule of infusion,
PCA, etc.
4. Ensure analgesic is individualized to client, taking into account type of pain, intensity,
and potential for toxicity (age, renal impairment, peptic ulcer, etc.).
5. Record results and set schedule for follow-up reassessment
15
PROCEDURE - 3
MEDICATION ADMINISTRATION
3.1 Oral medications

Definition: is the administration of a tablet, a capsule, a solution or other liquid form of medica-
tion by mouth.
Purpose
 When local effects on GI tract are desired
 When prolonged systemic action is desired
Contra- indications
 For a patient with nausea & vomiting, unconscious patients.
 When digestive juices inactivate the effect of the drug.
 When there is inadequate absorption of the drug, which leads to inaccurate determination
of the drug absorbed.
 When the drug is irritating to the mucus membrane of the alimentary canal.
Scope: all wards, units, OPDs, emergency, clinics and at home
Equipment
 Tray
 Towel
 A cup with water
 Measuring spoon
 A Jug of water (boiled water)
 Chart and medication card
 Ordered medication
 Straw if necessary
 Device for crushing or splitting tablets
Procedure
1. Review physician’s orders for accuracy and completeness, including patient’s name, drug
name, dosage, route, and time and indications.
3. Arrange MAR next to medication supply.
4. Prepare medications for only one patient at a time. Check patient allergies before remov-
ing any medications.
5. Remove ordered medications from supply. Compare label on medication with the MAR
and check the 9 rights of medication administration. If a discrepancy exists, recheck the
patient’s chart and medication orders.
6. Calculate correct drug dosage if necessary.
7. Prepare selected medications.
16
a. Unit dosage: Place packaged medications directly into medicine cup or lay them on
tray without unwrapping them.
b. Medications from a multidose bottle: Pour tablets or capsules into the container lid,
and transfer them into medicine cup. Return any extra tablets to the bottle. Label all
unlabeled medications. Break only scored tablets, if necessary, using a pill cutter to
obtain proper dosage.
c. Medications from a bingo card: Snap the bubble containing the correct medication di-
rectly over the medication cup. Do not touch the medication.
d. Swallowing difficulty: If patient has trouble swallowing tablets, grind with mortar and
pestle or other drug crushing device until smooth. Mix powder in small amount of
pudding or applesauce. Do not crush enteric coated tablets or extended-release tablets.
Review physician’s orders for accuracy and completeness, including patient’s name,
drug name, dosage, route, and time and indications.
e. Liquid medications: Remove cap and place on counter top with the inside up. Hold
bottle so label is against palm of hand. Fill until bottom of meniscus (the surface of the
fluid that appears curved) is at desired dosage. Discard excess poured liquid from cup
into sink; do not pour it back into the bottle. Label medication.
8. Take medications directly to patient’s room. Keep medications in sight at all times.
9. Compare name on MAR with name on patient’s identification band using two separate
identifiers (e.g., name, MRN, birth date).
10. Complete any pre administration assessment (e.g., blood pressure, pulse) required for the
specific medication to be given.
11. Compare medication to MAR, and recheck the nine rights of medication administration. If
using unit-dose medication, unwrap the medication and place it in the cup before checking
the nine rights of the next medication.
12. Explain the medication’s purpose to the patient.
13. Assist patient to sitting position if necessary. Give the medication cup and glass of water
to the patient.
14. If patient cannot hold the medication cup, place it to the patient’s lips and introduce the
medication into his or her mouth. If a tablet or capsule falls on the floor, discard and re-
peat preparation.
15. Stay with patient until he or she swallows all medications. Look inside patient’s mouth if
the patient is cognitively impaired or has difficulty swallowing.
16. Dispose of soiled supplies, and wash hands.
17. Document time at which medication was administered and any pre administration assess-
ment in order data collected. Note the time that post administration assessments to assess
effectiveness are due for prn medications. If a medication has been held, note this (usually
by circling initials on the MAR in the applicable time slot) and give the reason the medi-
cation was not given.
17
Note
 Remember the 9 R's
 Right patient  Right documentation
 Right medication  Right to response
 Right route  Right to storage
 Right dose  Right to action
 Right time
3.2 Administering medication by metered –dose inhaler

Definition: A metered-dose inhaler is a small portable canister, encased in a plastic device,
which holds medication and delivers it in aerosol form, in exact doses, so that it can be inhaled
directly into the lungs.
Purpose
 To temporarily decrease the work of breathing
 To promote better ventilation
 To loosen secretions
 To deliver aerosolized medications
Scope: all wards, units, OPDs, emergency, clinics and at home

Equipments
 Inhaler device with medication canister
 Spacer device such as AeroChamber or InspirEase (optional)
 Facial tissues (optional)
 Stethoscope
 Medication administration record (MAR)
 Pulse oximeter (optional)
Procedure
1. Review physician’s order for type of medication, dosage and route, and assess patient al-
lergies (see Procedure 3.1, steps 1 through 6).
4. Assist the patient to sitting or standing position. Perform the second medication check of
nine rights.
5. Instruct the patient on assembly of medication canister, inhalation mouthpiece, and spac-
er device if needed. Instruct the patient to attach the medication canister to the inhaler
mouthpiece by inserting the metal stem into the long end of the mouthpiece. Teach pa-
tient to shake the canister and spacer several times.
18
6. Assist the patient to position the mouthpiece 1 to 2 inches from his or her open mouth. If
using a spacer, have patient place spacer’s mouthpiece into mouth, forming a secure seal.
Instruct the patient to breathe in slowly through the mouth. As the patient starts inhaling,
instruct the patient to press the canister down to release one dose of the medication.
7. Instruct the patient to hold his or her breath for 10 seconds (if possible) and then to ex-
hale slowly through pursed lips.
8. Wait at least 1 minute before administration of a second puff by MDI.
9. Wash hands and clean mouthpiece. If steroid medication was administered, have patient
rinse mouth.
10. Reassess ease of breathing, respiratory rate, accessory muscle use, and breathe sounds.
11. Document medication administration and patient status before and after administration.
Modification for using a spacer with a metered dose inhaler
12. Attach the spacer to the inhaler mouthpiece. Instruct the patient to exhale and then place
the mouthpiece in the mouth, closing his or her lips around the mouthpiece. Depress the
medication canister and have the patient inhale until the medication from the chamber is
gone. Advise the patient to take two or three short breaths to get all the medication from
the spacer.
3.3 Administering Intradermal Injections

Goal: Administer medication into the dermal tissue to screen for an allergic (antigen antibody)
dermal reaction, to screen for tuberculosis, or to administer local anesthesia.
Purpose
 For diagnostic purpose
 Fine test (mantoux test)
 Allergic reaction
 For therapeutic purpose
 Intradermal injection may also be given like in vaccination
Equipment
 Syringe & needle (sterile)
 Receiver
 Tuberculin syringe, 1 mL
 Medication ampule or vial
 Medication card or medication administration record (MAR)
 Disposable gloves
 Marking pen
 Disposing box
19
Procedure
1. Check medication order. See Procedure 3.1, steps 1 through 6.
2. Assemble needle and syringe.
3. Remove needle guard and withdraw medication from vial.
4. Identify patient by two identifiers (name, MRN, birth date), checking identification
bracelet.
5. Close door or bed curtains and explain the procedure to the patient, then educate patient
about medication.
6. Don gloves. Select injection site that is relatively hairless and free from tenderness,
swelling, scarring, and inflammation.
7. Remove needle guard. Hold syringe in dominant hand. Gently pull skin distal to in-
tended injection site taut with Non dominant hand.
8. Holding syringe from above, at a 10 to 15 degree angle (almost parallel to skin), gently
insert needle, bevel up, about 1/8 inch until dermis barely covers bevel.
9. Stabilize needle; inject medication slowly over 3 to 5 seconds while watching for a small
wheal or blister to appear.
10. Withdraw needle at the same angle at which it was inserted. Do not wipe or massage
site.
11. Do not recap needle. Dispose of syringe and needle in sharps container.
12. Record time and site of injection according to best protocol.
13. Instruct patient when to return for reading of response 15 to 60 minutes after injection
for allergy testing and usually 48 to 72 hours after injection for TST
3.4 Administering subcutaneous Injections

Goal: Ensure more rapid absorption and action of a drug than can be achieved orally; administer
drugs to patients who are unable to take oral medications (e.g., unconscious, nausea/
Vomiting, NPO status); administer medications that are not active by the oral route or are inacti-
vated by digestive enzymes (e.g., heparin, insulin)
Purpose:
 To obtain quicker absorption than oral administration
 When it is impossible to give medication orally
Equipment
 Tray
 Syringe appropriate for the medication being given
 Medication ampoule or vial
20
 Receiver
 Disposing box
Procedure
2. Check medication order. Assess allergies. See Procedure 3.1steps 1 through 6.
3. Assemble needle and syringe.
4. Remove needle guard and withdraw medication from container
5. Identify patient by two identifiers. Recheck nine rights.
about medication.
7. Don gloves.
8. Select an injection site that is free from tenderness, swelling, scarring, and inflammation.
9. Cleanse site with antiseptic swab, using a circular motion from center toward outside. Al-
low area to dry thoroughly.
10. Remove needle guard. Hold syringe in dominant hand. Place non dominant hand on ei-
ther side of injection site. Spread or bunch skin to stabilize site and identify subcutaneous
tissue.
11. Hold syringe between thumb and forefinger of dominant hand. Inject needle quickly at a
45 to 90 degree angle depending on the amount of subcutaneous tissue. Release bunched
skin.
12. Inject medication with slow, even pressure.
13. Remove needle quickly at the same angle at which it was inserted while supporting the
surrounding tissue with your non dominant hand. Apply gentle pressure to the site with
gauze square after the needle is withdrawn. Do not massage the site. Assist patient to a
position of comfort.
14. Do not recap needle. Activate the needle guard. Dispose of syringe and needle in sharps
container.
16. Document according to best protocol.
3.5 Administering Intramuscular Injections

Goal: Administer medication deeply into muscle tissue, without injury to the patient; administer
a medication that requires absorption and onset of action quicker than the oral route without irri-
tating the subcutaneous tissues.
Purpose
 To obtain quick action next to the intravenous route
 To avoid an irritation from the drug if given through other route
Equipment
 Safety syringe
 Antiseptic or alcohol swabs if necessary
 Medication ampoule or vial
21
Procedure
1. Check medication order. See Procedure 3.1, steps 1 through 6. Assemble needle and
syringe.
2. Prepare needle, syringe, and medication by following the appropriate steps
3. Assess for allergies. Identify patient by two identifiers. Recheck nine rights.
about medication.
5. Don gloves. Assist patient to a comfortable position, and expose only the area to be in-
jected.
6. Select appropriate injection site by inspecting muscle size and integrity. Consider volume
of medication to be injected.
7. Use anatomic landmarks to locate the exact injection site.
8. Cleanse the site with antiseptic swab, wiping from center of site and rotating outward.
9. Remove needle guard. Hold syringe between thumb and fore finger of dominant hand,
like a dart. Spread skin at the site with non dominant hand. Encourage the patient to relax
the muscle or use distraction techniques.
10. Insert needle quickly at a 90-degree angle to the patient’s skin surface.
11. Stabilize syringe barrel by grasping with non dominant hand. Slowly inject medication.
12. Withdraw needle while pressing antiseptic swab above site.
13. Apply gentle pressure at the site with dry gauze.
14. Do not recap needle. Activate needle guard. Dispose of equipment in sharps container.
16. Record medication and patient response.
3.6 Intravenous therapy

Definition: It is the administration of a large amount of fluids and drugs in solution form into the
system through a vein.
Purpose:
 To maintain or replace fluids for daily body fluid requirements
 To provide electrolytes to maintain or restore electrolyte balance
 To deliver glucose and nutrients for use as an energy source
 To deliver medication or blood products.
Sites for IV injection
o Dorsal Venous network o Ulnar vein
o Dorsal metacarpal o Baslic vein
o Cephalic Veins o Median cubital vein
o Radial vein o Greater saphenous vein
22
Equipment
 Tray  Receivers (2)
 Towel and rubber sheet  Treatment Chart,
 Sterile syringes with needle  Gloves
 Sterile forceps in a sterile container  Prescribed IV fluids
 Alcohol swabs  IV cannula
 File, Medication  IV stand
 Tourniquet  Plaster tape
Procedure
1. Verify the physician’s order for IV therapy including solution type, amount, additives, and
infusion rate.
2. Gather all equipment and bring it to the patient’s bedside.
4. Identify the patient using two separate identifiers.
6. Connect IV solution bag to the administration set, maintaining sterility of the equipment.
7. Compress the drip chamber until it is approximately half full. Open the flow clamp on the
tubing and allow the fluid to run through the tubing until all the air has been removed and
the entire length of the tubing is filled with solution; then close the flow clamp.
8. Attach the solution and tubing to the infusion control device according to the manufactur-
er’s instructions (if available). Apply label to the solution container
9. Place the patient in a comfortable, reclining position, leaving the arm in a dependent posi-
tion. Place a towel or protective pad under the extremity to be used. Inspect and palpate
the patient’s extremity to identify an appropriate vein. Select the puncture site.
10. Put on clean gloves and apply a tourniquet about 6 inches (15 cm) above the intended
puncture site.
11. Lightly palpate the vein with the index and middle fingers of your non dominant hand.
Stretch the skin to anchor the vein.
12. Clean the site using the antimicrobial agent. Work in a circular motion outward from the
site to a diameter of 2 to 4 inches (5 to 10 cm), and allow the agent to dry. Clip hair
around the intended insertion site for a distance of up to 2 inches. Do not shave or use de-
pilatory creams, which may injure the skin and increase risk of infection.
13. Grasp the device. Using the thumb of your non dominant hand, stretch the skin taut below
the puncture site. If using a vein in the hand, position the hand in a slightly flexed position
to keep the skin taut. Tell the patient that you are about to insert the device and that you
need him or her to remain still.
14. Hold the needle bevel up at a 15- to 30-degree angle, depending on estimated depth of the
vein, and enter the skin parallel to the vein. Decrease the angle of the needle until almost
23
parallel with the skin, and advance the device into the vein in one motion either from di-
rectly over the vein or from the side. You will feel a sense of release or a pop as you enter
the vein. Check for blood return and then advance the device, maintaining the device pa-
rallel to the skin until the hub is at the insertion site.
15. Hold finger pressure over end of catheter while removing needle stylet.
16. Remove the tourniquet quickly. While holding the hub with your non dominant hand, at-
tach the end of the infusion tubing to the device.
17. Secure the device with non allergenic tape.
18. Loop any IV tubing on the patient’s extremity and secure with tape.
19. Begin the infusion, setting the infusion pump to the prescribed rate of flow. Assess the
flow of the solution and infusion control device function. Inspect the site for signs of infil-
tration.
20. Dispose of all equipment and remove gloves. Perform hand hygiene.
21. Apply site protection device and secure as necessary.
22. Assist the patient to a comfortable position. Assess the patient’s tolerance of the proce-
dure.
23. Document the procedure, including the date and time of the venipuncture; device type and
length; location of insertion site and appearance; type and flow rate of the IV solution; pa-
tient’s response (including adverse reactions); patient teaching performed; and patient un-
derstands of the teaching.
24. Monitor infusion rate, condition of IV site, and patient complaints, initially approximately
30 minutes after beginning the infusion and then according to facility policy. Change
dressing, tubing, and solutions according to facility policy.
 Administering Medication into an Existing Intravenous Line

o Select injection port or “Y” site in IV tubing closest to the IV insertion site. Clean port
with antimicrobial swab.
o Uncap the syringe. Steady the port with your non dominant hand while inserting the
needleless device into center of injection port.
o Occlude the tubing by folding it between your fingers (or using clamp).
o Pull back on plunger to assess for blood return.
o Inject the medication slowly into the IV port at the prescribed rate. It is helpful to use a
watch to time the administration rate.
o If IV medication and IV solution in tubing are incompatible, flush line with normal saline
solution while occluding catheter above port. Administer medication at prescribed rate; re
flush with 10ml of sterile normal saline solution and release occlusion.
24
 Administering the Drug Into an Intermittent Infusion Device or Lock Device

1. Clean port with antimicrobial swab using friction.
2. Stabilize port with your non dominant hand and insert syringe with 1ml normal saline so-
lution into injection port.
3. Release the clamp on the extension tubing of the medication lock. Optional: Aspirate
gently and check for blood return.
4. Gently flush with normal saline by pushing slowly on the syringe plunger. Observe the
insertion site while inserting the saline. Remove the syringe.
5. Insert syringe with medication into injection port. Inject medication slowly at the pre-
scribed rate. Use watch to time administration rate. Remove syringe. Do not force the in-
jection if resistance is felt.
6. Insert syringe with 1 to 3ml of normal saline into injection port and gently flush the port
with saline. To gain positive pressure, clamp the IV tubing as you are still flushing the
last of the saline into the medication lock. Remove the syringe from the injection port.
7. Dispose of used syringes properly, remove gloves, and wash hands.
8. Document medication administration.
9. Evaluate and chart the patient’s response to medication therapy and document according
to agency policy.
25
PROCEDURE - 4
ASSISTING PATIENT IN VEIN CUT DOWN (VENSECTION)
Definition: It is dissection of a vein for inserting I.V cannula or needle.

Purpose
 When vein puncture is difficult.
 When prolonged, continuous infusion is needed.
 When a secured infusions is essential.
 When rapid infusion is important and when emergency situations combine these indica-
tions.
Scope: all wards, units, emergencies
Equipments
Sterile equipments:  Gauze(slit at one end)
 Dressing forceps(1)  Probe(1)
 Cotton balls in a galipot  Fine dissecting forceps(1)
 Solution for cleansing Clean equipments:
 surgical Gloves  Receiver for dirty swabs
 Hole sheet (fenestrated towel)  Draw and rubber sheet
 intravenous cannula or vein flow (2)  Local anesthesia
 Small , straight scissor(1)  Ordered fluid
 Small, curved scissor(1)  I.v stand
 Needle holder(1)  Antiseptic solution
 Round needle(1)  Stand light if available
 Cutting needle(2)  Adhesive tape(Plaster)
 Tissue forceps(1)  Dressing scissors(bandage scissors)
Common site of cut down vein
 femoral vein
 vein on the ankle
Procedure
1. Explain procedure to the patient
2. Hand washing
3. Bring equipment to the patient bed side
4. Shave the area if needed
5. Position the patient properly
6. The nurse will then open the set & pour the cleaning lotion into the galipot for the doctor
7. The doctor then will scrub his hand, put on gloves, clean & drape the area. He will then anes-
thetize the area & will insert the cannula.
8. The cannula is securely tied with silk and skin is closed
9. Attach catheter to previously prepared infusion set and close the wound.
26
10. Suture the incision and apply an antibiotic ointment
11. Apply a sterile dressing and tape the catheter in place.
12. The procedure must be documented (usually in Nursing Notes). Physician will specify when to
remove the skin sutures.
13. Outer tape should show catheter size, date and time of insertion, and inserter's initials
14. Remove all equipment, wash & send for sterilization
27
PROCEDURE - 5
ASSISSTING WITH CENTERAL VENOUS CATHETERIZATION
Definition: Central venous catheters are medically placed percutaneously through the chest wall into
the jugular or subclavian vein and are used for fluid or blood administration, obtaining blood speci-
mens, and administering medications and parenteral nutrition.
Purpose
 To assist the licensed practitioner with percutaneous central vascular catheter insertion
 To maintain patency of central vascular catheter
 To maintain the insertion site free of infection
 To monitor central venous pressure
Equipment
 Specific non tunneled catheter
 Routine IV setup (tubing and solution)
 Through-the-needle radiopaque central catheter
 Local anesthetic, syringes, and needles
 Sterile gloves, sterile gown, masks, drapes, and sutures
 Antimicrobial 2% chlorhexidine, gluconate swabs
 Intermittent infusion caps or positive pressure device
 Prefilled syringes with preservative-free normal saline
 Transparent semipermeable dressing Securement device
Procedure
1. Identify client using two descriptors and validate signed consent for catheter insertion.
2. Perform hand hygiene and explain procedure to client, including rationale for mask, positioning,
and Valsalva’s maneuver.
3. Place client in Trendelenburg position.
4. According to licensed practitioner’s preference, extend client’s neck and upper chest by placing
a rolled pillow or blanket between shoulder blades.
5. Place mask on client and turn client’s head away from side of vein puncture.
6. Maintain sterility while opening glove packet and sterile drape pack.
7. Open antimicrobial prep pads.
NOTE: New guidelines to prevent catheter-related bloodstream infection recommend
That licensed provider dons cap and sterile gown in addition to mask and sterile gloves.
8. Don mask and gloves and assist with central catheter insertion.
 Licensed provider dons mask, gown, and sterile gloves for this procedure.
 Licensed provider prepares the client’s skin, drapes area, and, using a sterile syringe and
needle, and draws up anesthetic to infiltrate the site.
 As licensed provider inserts catheter, client is instructed to perform Valsalva’s maneuver to
prevent air embolism.
28
 Instruct client to exhale against a closed glottisor to hum.
 If client is unable to do this, compress client’s abdomen.
NOTE: A 14-gauge needle is inserted into the subclavian vein, using the clavicle as a guide.
When blood returns in syringe, the syringe is removed from the needle and a wire is threaded
through the needle into the subclavian vein. The needle is removed and the catheter is fed over
the wire into the subclavian and brachiocephalic vein. The wire is removed when the tip of the
catheter rests in superior vena cava.
9. When catheterization is complete, insert injection cap, flush with 5 ml of normal saline, and
then heparinize with 3 mL of dilute heparin (according to agency policy).
10. Apply securement device to skin and place catheter in clamp.
11. Cover securement device and catheter with sterile transparent dressing (according to hospital
policy).
12. Label insertion site dressing with date, nurse’s initials, and time of insertion.
13. Obtain x-ray for validation of placement into superior vena cava before initiating infusion (un-
less emergency placement performed).
14. Monitor client’s vital signs.
29
PROCEDURE - 6
OXYGEN ADMINISTRATION
Definition: Oxygen administration is provision of oxygen for a patient with a serious respiratory prob-
lem by using oxygen administration methods
Purpose:
 Used primarily to reverse hypoxemia
 To provide and maintain a normal supply of oxygen for blood and tissues.
 To provide adequate transport of oxygen in the blood while decreasing the work of breathing
and reducing stress on the myocardium.
 Decrease work of the heart in clients with cardiac disease
 To relieve dyspnea
Indication:
 Respiratory failure
 Lung diseases and injury (COPD, Pneumonia, Bronchial asthma, Cystic fibrosis & Chest injury)
 Blood disorders such as anemia
 Cardiac insufficiency
 High metabolic demands
 Hypoxia
 Hypoxemia
 Asphyxia
 Gas poisoning
Scope: all wards, units, OPDs and emergency
Precautions
 A “no smoking” sign must be posted in the client’s room to prevent the risk of fire 3 meters
 The catheter tip and the cylinder itself must not be lubricated with Vaseline, oil.
 Never use alcohol on the patient’s skin while the oxygen is run.
 Never use an electrical facial shaver (razor) while the oxygen is in use.
 The cylinder must be handling carefully as the oxygen is under pressure
 The fine adjustment must always be closed when the main tap is turned on.
 Check that if there is obstacle in the patient airway before giving oxygen in order to prevent
patient from suffocation.
 Protect patient from asphyxiation by inspecting regularly the pressure gauge and flow
 Monitor the vital signs, and mental status.
 Transport oxygen cylinder always by the transport cart.
 Never deliver more than 2-3 liters of oxygen to patients with chronic lung disease, e.g. COPD
30
 Methods of oxygen administration
1. Face mask
2. Nasal catheter
3. Oxygen tent/hood
6.1 Oxygen administration via face mask
Purpose: used to administer higher concentration of oxygen.

Equipment
 A cylinder of oxygen.
 Face Mask of appropriate size
 Regulator (Gauge, Flow meter)
 Oxygen tube
 Humidifier with distil water
 Gauzes
 No smoking sign
 Equipments for V/S
 Receiver
 Chart
Procedure
2. Determine need for oxygen therapy
3. Check order for rate, device to be used and concentration.
4. Greet the patient and explain the procedure (if conscious) to the relatives (if unconscious).
5. Wash hands.
6. Assemble equipment to the bedside
7. Perform an assessment of vital signs, level of consciousness, lab. Values etc and record.
8. Assess risk factors for oxygen administration in patient and environment like – hypoxia drive in
patient and faulty electrical connection.
9. Post “No smoking” signs on patient’s door “oxygen in use” sign on the bed
10. Place the patient on fowlers position unless contraindicated
11. Check for patency of air ways
12. Set up oxygen equipment and humidifier:
a. Attach regulator to source. Set flow meter in “Off” position.
b. Open main tap while flow meter is closed then turn on fine adjustment to release small
amount of oxygen, to clean the inside of regulators
c. Read the gauges (or check the color in gauges) of the cylinder to determine the amount of
oxygen.
d. Fill humidifier with sterile water between the maximum and minimum mark on it.
e. Attach humidifier bottle to base of the flow meter.
f. Check the presence of bubbling in humidifier to confirm the flow of oxygen through.
g. Attach tubing and face mask to humidifier.
31
h. Adjust flow meter to prescribed level
13. Check the flow of oxygen through the tube and mask before applying to the patient (feel the in-
coming air with your cheek).
14. Clean the mouth if there is visible soiled
15. Apply mask to patient face from nose to down ward
16. Secure elastic band around patient head.
17. Apply gauze behind ears as well as scalp where elastic band passes.
18. Ensure that safety precautions are followed.
19. Inspect patient and equipment frequently for flow rate, clinical condition, level of water in hu-
midifier etc.
20. Wash hands
21. Remove the mask and dry the skin every 2-3 hours if oxygen is administered continuously
22. Document relevant data in patient record
6.2 Nasal Cannula (Nasal Prongs) or nasal catheter
Definition: A method by which oxygen is administered in low concentration through a cannula and
This is a disposable plastic device with two protruding prongs for insertion in to the nostril.
Purposes
 To administer low concentration of oxygen to patients
 To allow uninterrupted supply of oxygen during activities like eating, talking
 Light weight, comfortable, continuous use with meals and activity
Equipments
 Cylinder of oxygen.
 Nasal cannula
 Regulator (Gauge, Flow meter)
 Oxygen tube
 Humidifier with distil water
 Gauzes
 No smoking sign
 Equipments for V/S
 Receiver
Procedure
2. Determine need for oxygen therapy
3. Check order for rate, device to be used and concentration.
4. Greet the patient and explain the procedure (if conscious) to the relatives (if unconscious).
5. Wash hands.
7. Perform an assessment of vital signs, level of consciousness, lab. Values etc and record.
32
8. Assess risk factors for oxygen administration in patient and environment like – hypoxia drive in
patient and faulty electrical connection.
9. Post “No smoking” signs on patient’s door “oxygen in use” sign on the bed
10. Place the patient on fowlers position unless contraindicated
11. Check for patency of air ways
12. Set up oxygen equipment and humidifier:
a. Attach regulator to source. Set flow meter in “Off” position.
b. Open main tap while flow meter is closed then turn on fine adjustment to release small
amount of oxygen, to clean the inside of regulators
c. Read the gauges (or check the color in gauges) of the cylinder to determine the amount of
oxygen.
d. Fill humidifier with sterile water between the maximum and minimum mark on it.
e. Attach humidifier bottle to base of the flow meter.
f. Check the presence of bubbling in humidifier to confirm the flow of oxygen.
g. Attach tubing to humidifier and then to the nasal cannula
h. Adjust flow meter to prescribed level
13. Check the flow of oxygen through the tube before applying to the patient (feel the incoming air).
14. Place tips of cannula to patient’s nares and adjust straps around ear for snug. The elastic band
may be fixed behind head or under chin. If nasal catheter it should be lubricated preferably with
water and passed backward into pharynx till the tip of the catheter is opposite the uvula.
15. Pad tubing with gauze pads over ear and inspect skin behind ear periodically for irritation/break
down.
16. Ensure that safety precautions are followed.
17. Inspect patient and equipment frequently for flow rate, clinical condition, level of water in hu-
midifier etc.
18. Wash hands
19. Remove the mask and dry the skin every 8 hours if oxygen is administered continuously
20. Document relevant data in patient record
NB: A patient receiving oxygen by catheter requires special mouth and nose care since the cathete-
tends to irritate the mucous membrane.
33
PROCEDURE - 7
CARE OF A PATIENT ON MECHANICAL VENTILATOR
Definition: Mechanical ventilation is a modality of applying positive pressure for patients who are
unable to sustain the level of ventilation necessary to maintain the gas exchange functions oxygenation
and carbon dioxide elimination.
Purpose
 To achieve and maintain adequate pulmonary gas exchange (ventilation and oxygenation),
 To minimize the risk of lung injury,
 To reduce patient work of breathing (WOB), and
 To optimize patient comfort.
Indications:
 Absolute: respiratory failure
 Relative: - Failure of sufficient oxygenation
- Failure of sufficient CO2 removal
Scope: all ICUs, OR/recovery
Equipment
 Appropriate mechanical ventilator
 Oxygen source
 Pulse oximetry (SpO2) probe and monitor
 Capnography (EtCO2) window and monitor (if available)
 Stethoscope
 10-mL syringe
 Oral airway/bite block
 Manual resuscitation bag (bag-valve-mask) with oxygen connecting tubing and flowmeter
 Clean gloves
 Goggles (if splash risk exists)
 Suction equipment at bedside (in-line/individual catheters)
 Chlorhexidine solution and toothbrush for oral care
 Ventilator flow sheet to document ventilator changes and settings
Procedure
1. Perform hand hygiene; apply clean gloves. Apply mask, gown, and goggles if secretions are
projectile.
2. Identify patient using two identifiers (i.e., name and birthday or name and MRN) according to
agency policy.
3. Attach mechanical ventilator to ET or tracheostomy tube. Observe for proper functioning of
mechanical ventilator.
4. Verify that ET or tracheostomy tube is properly positioned during an inspiratory and expiratory
cycle by listening to both lungs and assessing chest wall symmetry.
5. Observe patient for synchronization with mechanical ventilation and response to therapy.
34
6. Monitor heart rate, blood pressure, respiratory rate, and cardiac rhythm.
7. Reassess and mark level of ET tube at lips or nares
8. Set up suction equipment, including oral suctioning
9. Reposition patient regularly to promote best oxygenation and ventilation. This position can be
high-Fowler’s, lateral, or even prone. Monitor SpO2 levels during and after positioning.
10. Collaborate with other health care provider frequently about status of patient, response to thera-
py, and ongoing monitoring.
 Monitor SpO2 continuously.
 Monitor EtCO2 continually and with serial ABG levels to detect possible over ventilation or
inadequate alveolar ventilation.
 Obtain ABG levels with changes in patient’s condition or ventilator changes.
11. Perform hourly safety checks on patient and ventilator system:
a. Make sure that patient can reach call light.
b. Check security of all ventilator connections; make sure that alarms are all turned on, in-
cluding both high- and low pressure alarms and volume alarms.
c. Verify that all ventilator settings are correct and correspond to orders
d. Check and refill humidifier as needed. Check corrugated tubing for condensation; drain
and appropriately discard liquid.
e. When present, observe temperature gauges on panel of mechanical ventilator, making sure
that gas is delivered at correct temperature. Desired temperature of inspired gas is 98.6° F
(37° C).
12. Perform mouth care at least 4 times per 24 hours. Use toothbrush and solution such as chlor-
hexidine, which is effective in reducing oral bacteria and risk for ventilator associated pneumo-
nia
13. Perform nursing activities to prevent hazards of immobility (e.g., help patient change position,
perform range-of-joint motion exercise, and encourage independence and activity as tolerated).
14. Keep patient informed on progress and plan for weaning from mechanical ventilator
15. Remove gloves and goggles; perform hand hygiene.
35
PROCEDURE - 8
ENDOTRACHEAL TUBE/TRACHEOSTOMY SUCTIONING
Definition: Endotracheal tube/tracheostomy suctioning is the process of applying a negative pressure

to the distal trachea by introducing a catheter to clear excess or abnormal secretions.
Purpose: The nurse performs Endotracheal and tracheostomy suctioning to:
 Maintain a patent airway.
 To improve oxygenation and reduce the work of breathing.
 To remove accumulated tracheo-bronchial secretions using sterile technique.
 Stimulate the cough reflex.
 Prevent infection and atelectasis.
Equipment:
 Sterile normal saline
 Suction machine
 Ambu bag connected to 100% O2
 Clear protective goggles/mask or face shield
 Sterile gloves for open suction
 Clean gloves for (in-line) closed suction
 Sterile catheter with intermittent suction
o French/size/ of suction catheter
 For infant from 5-8 fr
 For child from 8-10 fr
 For Adult from 12-16 fr
 Control port or In-line suction catheter
 Sterile solution container (or sterile kidney dish)
 Sthetescope
 Gauze/soft tissue
 Waste receiver
 Sterile or clean towel/water proof/
Procedures
2. Explain the procedure to the patient before beginning and offer reassurance during suctioning;
the patient may be apprehensive about choking and about an inability to communicate
3. Determine the need for suctioning.
4. Begin by carrying out hand hygiene.
5. Assess the client’s need for suctioning: inability to effectively clear the airway by coughing
and expectoration; coarse bubbling or gurgling noises with respiration.
36
7. Position the client in a high Fowler’s or semi- Fowler’s position and apply clean water proof
towel over the chest of the patient.
8. If the client is unconscious or otherwise unable to protect his or her airway, place in a side-
lying position.
9. Connect extension tubing to suction device if not already in place, and adjust suction control
If portable suction unit If wall unit suction machine
 For infant from 2-5 mmHg - For infant from 50-95 mmHg
 For child from 5-10 mmHg - For child from 95-110 mmHg
 For Adult from 10-15 mmHg - For Adult from 100-120 mmHg
10. Open packed sterile instrument and prepare on a sterile field.

11. Fill basin with sterile normal saline solution.
12. Ventilate the patient with manual resuscitation bag and high flow oxygen.
13. Put on sterile glove.
14. Pick up sterile suction catheter with gloved hand (Dominant hand) and connect to suction.
15. Hyper oxygenate the patient’s lungs for several deep breaths.
16. Insert suction catheter at least as far as the end of the tube without applying suction, just far
enough to stimulate the cough reflex
17. Apply suction while withdrawing and gently rotating the catheter 360° (no longer than 10 to 15
seconds, because hypoxia and dysrhythmias may develop, leading to cardiac arrest).
18. Re oxygenates and inflates the patient’s lungs for several breaths.
19. Repeat previous three steps until the airway is clear.
20. Rinse catheter in basin with sterile normal saline solution between suction attempts if neces-
sary.
21. Suction oropharyngeal cavity after completing tracheal suctioning.
22. Rinse suction tubing.
23. Discard catheter, gloves, and basin appropriately.
37
PROCEDURE - 9
TRACHEOSTOMY CARE
Definition: A tracheostomy is a 51- to 76-mm (2- to 3-inch) curved metal or plastic tube inserted into
a stoma through the neck and into the trachea to maintain a patent airway. It is placed in patients who
require long-term airway management because of airway obstruction, airway clearance needs, and
long-term intubation
Purpose
 To prevent infection
 To promote respiratory function.
 To maintain a patent airway
Indication
 When adventitious breath sounds are detected
 Whenever secretions are obviously present.
Equipment
 Sterile Tracheal dilator
 Sterile cotton-tip applicators
 Hydrogen peroxide solution
 Normal saline (0.9% sodium chloride solution )
 Sterile kidney dish (2)
 Sterile nylon brush
 Sterile precut 4 × 4 dressing gauze
 Sterile gauze for drying
 Sterile drapes/water proof pad
 Sterile glove
 Clean glove
 Suction kit and suction equipment
 Tracheostomy ties
 Ambo bag with 100% oxygen source
 Mouth care set
 Personal protective devices: gown, mask
 Waste receiver/Plastic bag/
 Chart
38
Procedure
1. Determine the need for suctioning, check physicians order.
2. Identify the patient
3. Explain the procedure to the patient if conscious otherwise for his/her relatives.
4. Wash hands.
6. Put on goggles, mask or face shield and gown and don sterile gloves
7. Position the client in a high Fowler’s or semi- Fowler’s position and apply clean water proof
towel over the chest of the patient; If the client is unconscious or unable to protect his or her
airway, place in a side-lying position.
8. Place plastic bag or disposal container within easy reach. Position in an area that does not re-
quire crossing over the sterile field or stoma to discard soiled items.
9. Prepare sterile equipments. Loosen the caps on the bottles of sterile saline and hydrogen pe-
roxide then pour in to each galipot (containers) to 1.25cm
10. Don clean glove then remove the soiled tracheostomy dressing. Note the amount, color, and
odor of any drainage around the stoma.
11. Gently loosen the inner cannula of the tracheostomy tube by twisting the outer ring counter-
clockwise; then withdraw the inner cannula in a smooth motion. Place the inner cannula into
the basin of peroxide.
12. Remove the gloves by pulling them over the discarded dressing, and discard the gloves and
dressing.
13. Put on the gloves using sterile gloving technique
14. Place the sterile drape on the patient’s chest, with its upper edge as near to the tracheostomy
tube as possible.
15. Using your sterile hand, pick up the cannula and pick up the nylon brush then scrub to re-
move any visible crusts or secretions from inside and outside the cannula
16. Place the cannula into the container of sterile saline. Agitate so that all surfaces are bathed in
saline.
17. Inspect the inner cannula again to be sure it is clean; then remove excess saline from the lu-
men by tapping the cannula against a sterile surface then place at dry sterile gauze.
18. Perform suctioning.
 The pressure of tracheostomy suctioning is similar with nasopharyngeal suctioning
 Give 1 full minute rest between each single suctioning
 Oxygenation with ambo bag must be given 3-5 times between each single suctioning
19. Using your sterile hand, pick up a sterile cotton swab and saturate the tip with hydrogen pe-
roxide. Swab the peristomal skin, including the area under the tracheostomy tube’s faceplate.
If you must touch the tracheostomy tube or the client, do so with your clean hand
20. Gently replace the inner cannula, following the curve of the tube. When fully inserted, lock
the inner cannula in place by rotating the external ring clockwise until it clicks into place.
39
21. Place a new precut sterile gauze dressing around the stoma, between the faceplate and the
skin.
22. Inspect the ties or strap securing the faceplate. If damp or soiled, carefully cut the ties (or loo-
sen the Velcro to remove a strap). Remove the ties or strap and inspect the underlying skin
for redness or breakdown. (Now no longer sterile procedure is needed)
23. To replace ties, cut a length of twill tape about as long as the circumference of the client’s
neck. Fold over one end to 1 inch and cut a small (1/2 inch) slit into the folded end.
 Thread the slit end of the tape through the eye of one side of the tracheostomy faceplate
from the underside of the faceplate. Thread the end of the tie through the cut slit and se-
cure it with a knot.
 Slip the tape under the client’s neck, keeping it smooth and flat against the skin.
 Bring the loose end of the tape around to the other side of the faceplate. Ask the client to
flex his or her neck and slip one of your fingers under the tape as you measure the desired
tightness of the tie.
 Fold the end of the tape and cut a slit as in step then tie the end. Trim off excess tape from
the end and knot the cut ends of the tape.
24. To replace a Velcro strap:
 Place new strap behind client’s neck and thread ends through faceplate eyelets. Adjust
tightness as above and secure Velcro.
25. Reconnect the patient to oxygen and reposition for comfort.
26. Discard soiled items in the appropriate container.
27. Remove and discard soiled gloves.
28. Wash hands.
29. Document the procedure, noting the appearance of the stomal site and any exudate.
40
PROCEDURE - 10
WATER SEAL CHEST DRAINAGE SYSTEM
Definition: A water sealed drainage bottle is a system set up that air or fluid does not enter into the
chest cavity (pleural cavity) from the outside, and air or fluid from it is drained.
Indication
 Pneumothorax
 Haemothorax
 Empyema
 Chest trauma
 Flail chest
 Lobectomy post-operatively
Types of water sealed drainage
1. One bottle system
2. Two bottle system
3. Three bottle system
Purpose:
 To re-establish expansion of the pleural space
 To remove the air or bloody fluid from pleural space and allow for expansion of the lung (or to
evacuate fluid & blood).
 To re-establish negative intra pulmonary and intrathoracic pressure or restoration of the normal
negative pressure in the pleural space.
Contraindications for chest tubes:
 Infection over insertion site
 Uncontrolled bleeding
Equipment
 Sterile gloves
 suture set (or sterile scissors and sterile forceps)
 Sterile Vaseline gauze
 Sterile glass tube
 Sterile water/saline (100c.c.)
 Suction machine with tube
 Dressing material
 Wide tape
 Local anaesthesia
 Drainage bottle and tube
 Vital sign equipment
 Labeling paper
 20-mL syringe, 21-gauge needle, and antiseptic swab
41
 Clean gloves
 Chest tube tray (all items are sterile): chest tube clamp, small sponge forceps
 Facemask/face shield
Procedures
1. Check consent form is signed
2. Identify the patient and explain the procedure
3. Check vital sign
4. Collect equipment after washing your hands
5. Assist patient to the upright position, have the patient sit upright in bed and lean forward resting
on the over bed table.
6. Set up water-seal system (or dry system with suction);
 Obtain chest drainage system. Remove wrappers and prepare to set up a two- or three-chamber
system.
 While maintaining sterility of drainage tubing, stand system upright and add sterile water or NS
to appropriate compartments.
 Two-chamber system (without suction): Add sterile solution to water-seal chamber (second
chamber), bringing fluid to required level as indicated.
 Three-chamber system (with suction): Add sterile solution to water-seal chamber (middle
chamber). Add amount of sterile solution prescribed by physician to suction control
(third chamber), usually 20 cm water pressure. Connect tubing from suction control
chamber to suction source. Tailor length of drainage tube to patient
 Dry suction system: Fill water-seal chamber with sterile solution. Adjust suction control
dial to prescribed level of suction; suction ranges from −10 to −40 cm of water pressure.
Suction control chamber vent is never occluded when suction is used.
NOTE: On a dry suction system, DO NOT obstruct positive-pressure relief valve. This
allows air to escape.
7. Set up waterless system.
 Remove sterile wrappers and prepare to set up.
 For two-chamber system (without suction), nothing is added or needs to be done to system.
 For three-chamber system (with suction), connect tubing from suction control chamber to
suction source.
 Instil 15 to 45 ml of sterile water or NS into diagnostic indicator injection port located on top
of system.
8. Secure all tubing connections with tape in double-spiral fashion using adhesive tape or use
zip ties (nylon cable) with a clamp . Check system for patency by:
 Clamping drainage tubing that will connect to patient’s chest tube.
 Connecting tubing from float ball chamber to suction source.
 Turning on suction to prescribed level.
9. Turn off suction source and unclamp drainage tubing before connecting patient to system. Make a
second check to be sure that drainage tubing is not excessively long. Suction source is turned on
again after patient is connected.
42
10. Administer premedication such as sedatives or analgesics as ordered.
11. Help chest tube insertion by providing needed equipment and local analgesic. physician will
anesthetize skin over insertion site, make a small skin incision, insert a clamped tube, suture it
in place, and apply occlusive dressing.
12. Attach drainage tube to chest tube; remove clamp. Turn on suction to prescribed level.
13. Tape or zip-tie all connections between chest tube and drainage tube.
14. Check systems for proper functioning. Physician will order a chest x-ray film.
15. After tube placement position patient:
 Use semi-Fowler’s or high-Fowler’s position to evacuate air (pneumothorax).
 Use high-Fowler’s position to drain fluid (hemothorax).
16. Check patency of air vents in system.
17. Adjust tubing to hang in straight line from chest tube to drainage chamber.
18. If a specimen needed take specimen, label it and send to the laboratory immediately
19. Dispose of sharps in proper container, dispose of used supplies.
20. Care of patient after chest tube insertion:
 Perform hand hygiene and apply clean gloves. Assess vital signs, oxygen saturation; skin
colour; breath sounds; rate, depth, and ease of respirations; and insertion site every 15
minutes for the first 2 hours, then at least every shift
 Monitor colour, consistency, and amount of chest tube drainage every 15 minutes for first 2
hours. Indicate level of drainage fluid, date, and time on write-on surface of chamber.
 Expect less than 100 ml/hr from a mediastinal tube immediately after surgery and no more
than 500 ml in first 24 hours.
 Expect between 100 and 300 ml in the first 3 hours after insertion of posterior chest
tube, with total of 500 to 1000 ml expected in first 24 hours. Drainage is grossly bloody
during first several hours after surgery and changes to serous.
 Expect little or no output from anterior chest tube that is inserted for a pneumothorax.
 Observe chest dressing for drainage.
 Palpate around tube for swelling and crepitus (subcutaneous emphysema) as noted by
crackling.
 Check tubing to ensure that it is free of kinks and dependent loops.
 Observe for fluctuation of drainage in tubing and water-seal chamber during inspiration and
expiration. Observe for clots or debris in tubing.
 Keep drainage system upright and below level of patient’s chest.
 Check for air leaks by monitoring bubbling in water-seal chamber: Intermittent bubbling
is normal during expiration when air is being evacuated from pleural cavity, but
continuous bubbling during both inspiration and expiration indicates leak in system
 Remove gloves and dispose of used soiled equipment in appropriate biohazard container.
Perform hand hygiene.
43
PROCEDURE - 11
ASSISSTING WITH THORACENTESIS
Definition: It is a surgical puncture of the chest wall to aspirate (withdraw) fluid or air from the pleur-
al cavity surrounding the lung.
Indication for thoracentesis
 Infection
 Empyema (pus)
 Suspicion of tumor
 Pneumothorax, haemothorax
Purpose:
 The purpose may be therapeutic or diagnostic purpose.
1. Therapeutic purpose:
 To remove fluid from the pleural cavity which causes pressure up on the chest organs or
 To remove air from the pleural cavity which inhibiting respiration.
2. Diagnostic purpose:
 To identify an infecting microorganism or the presence of malignant cells.
 A needle biopsy of the pleura may also be taken at the same time.
 Site
 7th or 8th or 9th ICS (posterior mid-axillary line: for fluid)
 2nd or 3rd ICS(anterior mid-clavicular line: for air)
 Method of aspiration
 aspirate with syringe or drain the fluid in to bottle or use suction
Equipments
Sterile set containing
 Sterile gloves  Sterile pressure dressing and tape
 gallipots
 dissecting forceps
 pair of artery forceps Clean set containing:
 swabs and gauze in a receiver  Receiver for used instruments
 fenestrated towel  Measuring jug
 syringe and needle for local anesthesia  Local anesthetia
 20 or 10 cc aspiration syringe and  Iodine solution
needle  Plaster
 2 glass tubes for specimen  Vacutainer
 receiver to collect fluid  Lab request
44
Procedure
2. Take vital signs, and complete a respiratory assessment.
3. Administer sedative as ordered.
4. Position client on edge of bed with arms crossed and resting on the over bed table.
Or Client can be placed in side-lying position on unaffected side if unable to sit up.
5. Provide adequate warmth and covering for client using bath blanket.
6. Place unwrapped sterile tray on bedside stand.
7. Open sterile gloves as indicated. Maintain sterile technique throughout procedure.
8. Assist physician as needed with skin preparation.
9. Done clean gloves. Instruct client not to cough, take a deep breath, or move during
placement of needle by the physician.
10. After insertion of needle into pleural space, observe client for pallor, dyspnea, tachycar-
dia, chest pain, or vertigo. Report these findings immediately to the physician.
11. Connect tubing to vacutainer, allowing fluid to be drawn from cavity.
NOTE: Blunt-tip, soft catheter-over-needle is used more often than a needle to prevent
pneumothorax.
12. Apply pressure dressing (as determined by policy) after fluid and needle is removed.
Remove gloves and perform hand hygiene.
13. Observe client every 5 minutes for half hour for pulmonary edema (blood-tinged spu-
tum), crepitus, cardiac distress (changes in respirations, pulse, or color), or a shift in the
mediastinum.
14. Place client on unaffected side with head elevated 30° for at least 1 hr.
15. Monitor vital signs and breathe sounds as with postoperative clients for 2 hr.
16. Observe dressing, change as needed. Drainage is a common occurrence after a tap.
17. Obtain chest x-ray after procedure to check for pneumothorax.
18. Record color, amount, consistency, and samples of fluid obtained.
19. Complete lab slips, and send specimen to lab.
45
PROCEDURE - 12
POSTURAL DRAINAGE
Definition: postural drainage is the gravitational clearance of secretions from specific bronchial
segments by using one or more of different positions. In this way the force of gravity and ciliary
activity of the small bronchial air ways will move secretion to the main bronchi and trachea.
Once the secretion has reached this point the patient should be able remove it by coughing.
Purpose:
 To improve the mobilization of bronchial secretions
 To facilitate removal of secretions by using gravity
Position for postural drainage
The nurse must know the part of the lung affected before performing postural drainage.
 Four important positions
 Put patient in prone position with pillow under the lower abdomen to help drain secre-
tion from the lower lobe of lung.
 Lie patient on the right side with pillow under the lower abdomen to help drain from left
lung segment.
 Lie patient on the back with a pillow under the buttocks to help drain from the anterior
portion of the chest.
 Lie patient on the left side with a pillow on the hips to drain from the right lung.
Equipment:
 Sputum cup
 Bed blocks
 Chair if needed
 Tissue paper3
 Jar for measuring
 Specimen bottle if needed
 Mouth care set
46
Procedure:
1. Loosen any tight clothing.
2. Explain purpose and method of procedure to gain fullest cooperation of patient
3. Position patient to the side affected and elevate the foot of the bed with the average
range of 10-30 inches.
4. The height of the foot of the bed will depend upon the affected area. The lower the af-
fected lobe is, the foot of the bed must be elevated.
5. Patient remains in this position 20 –30 minutes
6. Give sputum cup and tissue paper to the patient and secure him from falling by putting
pillow.
7. Encourage patient to expectorate secretions. This will be repeated every morning until
the lungs become clear
8. Assist client to slowly return to normal sitting position after coughing in dependent po-
sitions.
9. Determine pulse oximetry as necessary.
10. Auscultate chest areas for improved breath sounds.
11. Observe patient and record the color and amount of sputum.
12. Save the sputum, if it is needed for lab. test
13. Wash the sputum cup and return to the bedside table.
14. Offer oral hygiene after secretion expectoration.
47
PROCEDURE- 13
ADMINISTERING CARDIOPULMONARY RESUSCITATION (CPR)
Definition: CPR stands for cardiopulmonary resuscitation. It is an emergency life saving proce-
dure that is performed when a person's own breathing or heartbeats have stopped.
Purpose
 Initiating the chain of survival
 Performing prompt, high quality chest compressions for adults, child and infant victims
 To provide adequate oxygenation of lungs through mechanical support
 To support ventilation and circulation
 To reestablish a patent airway for client with foreign body
Equipment:
 Clean and sterile gloves, gown, protective eyewear
 Oxygen source
 Bag-mask device or resuscitation bag
 Oral airways
 Laryngoscope handle, and laryngoscope blades, straight and curved
 Endotracheal (ET) tubes, various sizes, Tape or commercial ET tube holder
 Backboard
 AED and/or manual defibrillator with AED/defibrillator pads
 IV cannula (sizes for adults and pediatrics)
 IV tubing and fluids (normal saline [NS] and 5% dextrose in water [D5W])
 Syringes
 Emergency medications
 Suction source and suction equipment
Scope: all wards, units, OPDs and emergency………
Procedure
1. Quickly approach client.
2. Check responsiveness. Tap shoulders/foot reflex for infant/. Shout, “Are you OK? To de-
termine responsiveness of client.
3. Call out or phone for help. Get AED.
4. Move victim to flat, firm surface and position yourself next to victim, left side near head
of victim. Left side is preferred when using AED.
Primary survey: use the CAB method
C (Circulation)
5. Check carotid pulse on adult or child; use brachial or femoral pulse in an infant. Palpate
for no more than 10 seconds.
6. Place victim on hard surface such as floor, ground, or backboard.
48
7. Victim must be flat. Logroll victim to flat, supine position using spine precautions if trau-
ma is suspected.
8. Place heel of hand in middle of chest. Place other hand on top of first with fingers inter-
laced. Use one hand for young children and two fingers/two thumb for infants.
9. Start chest compressions at 100/min with a depth of 2 inch (5cm) for adults and children, 1
and 1/2 inches (4cm) for infants.
10. Perform 5 cycles of compressions and breathes(30:2 ratio), for infants with one rescuer
30:2 ratio similar to adults and children, and with two rescuer 15:2 ratio (compressions
and breathes ratio)
A (Airway)
11. Apply clean gloves and face shield.
12. Open airway.
 Head tilt–chin lift (no trauma) or
 Jaw thrust (cervical trauma is suspected
B (Breathing)
13. Attempt to ventilate patient with slow breaths using one of these methods.
 Mouth-to-mouth using barrier device.
 Mouth-to-mask using pocket mask
 Bag-mask device
14. If available, insert oral airway.
15. Suction secretions if necessary or turn victim’s head to one side unless trauma is sus-
pected.
16. Reposition head and try ventilation again, if chest does not rise
D (Defibrillation)
17. If pulse is absent and AED is available, apply AED immediately as appropriate
 After one shock, resume CPR for 5 cycles and begin rhythm analysis and shock se-
quence again
18. If pulse is absent and an AED is unavailable, immediately initiate chest compres-
sions.
Secondary survey: Implementation
Analysis of cardiac rhythm
19. Attach manual defibrillator/monitor to patient using electrocardiogram (ECG) elec-
trodes, quick-look paddles with gel pads, or “hands-off ” defibrillation electrode to vi-
sualize cardiac rhythm
20. If cardiac rhythm is “shockable,” continue CPR and assist code team with manual defibril-
lation
 Turn on defibrillator and select proper energy level following agency policy and equip-
ment directions.
49
 Apply conductive gel or gel pads to patient’s chest where defibrillator paddles will be
placed. Some defibrillators use “hands-off pads” that are applied to patient’s chest and di-
rectly connect to manual defibrillator.
 Place paddles or pads on patient’s chest wall.
 Verify that no one is in physical contact with patient, bed, or any item contacting patient
during defibrillation. A warning must be called out before initiating charge
21. Establish IV access with large-bore IV needle (14- to 22-gauge) and begin infusion of
0.9% NS a If you cannot obtain peripheral IV access, physician may pursue central
venous access.
22. Help with procedures as needed
23. Continue CPR until relieved, until victim regains spontaneous pulse and respiration, res-
cuer is exhausted and unable to perform CPR effectively, or physician discontinues CPR.
24. If respirations are absent, help the code team with ET Intubation
 Have available laryngoscope handle, laryngoscope blades, curved and straight blades,
ET tubes, stylet, suction, and tape or ET tube holder. Ensure that light source on
laryngoscope is functional
25. Assist in confirmation of ET tube placement or advanced airway support by auscultating
lungs for bilateral breath sounds. Carbon dioxide (CO2) detector or esophageal detector
devices are used as secondary methods to confirm correct airway placement
50
PROCEDURE – 14
PERFORMING DEFIBRILLATION
14.1 Use of an Automated External Defibrillator

Definition: An automated external defibrillator is a portable device that checks the heart rhythm
and can send an electric shock to the heart to try to restore a normal rhythm. AED is used to treat
sudden cardiac arrest.
Purpose:
 To rapidly identify and provide early defibrillation to the victim of sudden cardiac arrest.
Equipment
 AED
 Pair of AED adhesive pads
Procedure
1. Assess patient for unresponsiveness, not breathing and Pulselessness
2. Activate code team in accordance with hospital policy and Procedure
3. Remove victim’s clothing on torso
4. Ensure chest is dry
5. Start chest compressions and continue until AED is attached to patient and verbal prompt
of device advises you “Do not touch the patient.”
6. Place AED next to patient near chest or head.
 If the AED is immediately available, attach it to patient as soon as possible. The faster
defibrillation is delivered, the better the survival rate
7. Turn on power
8. Attach the device. Place the first AED pad on the upper right sternal border directly be-
low the clavicle. Place the second AED pad lateral to the left nipple with the top of the
pad a few inches below the axilla. Ensure that cables are connected to the AED.
9. Do NOT touch patient when AED prompts you. Direct rescuers and bystanders to
avoid touching patient by announcing “Clear!” Allow the AED to analyze the rhythm.
Some devices require that an analysis button be pressed. The AED takes approximately
5 to 15 seconds to analyze the rhythm.
10. Before pressing the shock button, announce loudly to clear the victim and perform a vis-
ual check to ensure that no one is in contact with him or her.
11. Immediately begin chest compression after the shock and continue for 5 cycles or 2 mi-
nutes. Do NOT remove the pads.
12. Deliver two breaths using mouth-to-mouth with barrier device or mouth-to-mask device
or bag-mask device. Watch for chest rise and fall. Deliver 10-to-12 breaths/min
13. After 2 minutes of CPR, the AED will prompt you not to touch patient and will
resume analysis of patient’s rhythm.
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14. When shockable rhythm is not present, AED will signal “no shock indicated” or “no
shock advised.”
15. Check for presence of pulse—if none found, resume CPR, This cycle will continue
until patient regains a pulse or physician determines death.
14.2 Assisting with cardiac defibrillation

Definition: Defibrillation: is a direct unsynchronized electrical current delivered to the heart.
Purpose
 The counter shock depolarizes all the myocardial cells simultaneously terminates ventri-
cular tachyarrhythmia's allows the sinus node to resume control as pacemaker of the
heart.
Equipment
 Defibrillator with ECG recorder
 Defibrillator pads or conduction gel for paddles (do not use ultrasound gel)
 Emergency cart with:
 Airway
 Cardiac board
 Resuscitator bag
Procedure
1. Plug defibrillator into electric outlet.
2. Turn defibrillator power ON and allow to warm up.
3. Attach monitor/defibrillator.
4. Dry client’s chest if necessary (do not use alcohol).
5. Place conducting pads on client’s chest, pressing firmly for adhesion, or spread thin coat
of defibrillation electrode gel evenly over surface of paddles. One pad is placed below
right clavicle near sternum and second pad is placed to left of cardiac apex (below and to
the left of left nipple or at the fifth to sixth intercostal space at midaxillary line). Do not
place over broken skin.
6. Alternatively, apply “hands-free” defibrillation pads.
7. Insert electrodes connector into cable. Push firmly for proper connection.
8. Turn on ECG recorder.
9. Validate that client has shockable rhythm (pulseless VT or VF is present).
10. If non shockable rhythm is present (PEA, asystole), continue CPR for five cycles and ad-
minister fluids/medications before attempting defibrillation.
11. Be certain defibrillator is NOT in synchronized mode.
12. Set standard monophasic defibrillator to charge at 360 watt seconds; set biphasic de-
vice at 200 watt seconds.
13. Command all persons to move away from bed area and any equipment connected to client.
14. Stand away from bed area yourself.
15. Apply paddles with firm pressure.
52
16. Depress discharge buttons on paddles simultaneously to ensure appropriate discharge or
push “shock” button on defibrillator for hands-free pads—delivering ONE shock.
17. Immediately resume chest compressions. Do not delay for rhythm reanalysis or pulse
check.
18. Immediately resume CPR for five cycles.
NOTE: After advanced airway placed, breaths (8–10 per minute) are given along with uninter-
rupted chest compressions (100/min).
19. Analyze ECG. If sinus rhythm is established, check for pulse, vital signs, LOC.
20. Recharge defibrillator for second attempt at 360 watt seconds (monophasic) or 200 watt
seconds (biphasic) if shockable rhythm continues.
21. Deliver ONE shock, and then resume CPR immediately for five cycles.
22. Give epinephrine 1 mg IV/IO during CPR; repeat every 3–5 minutes or give Vasopressin
40 units IV/IO in place of first or second dose of epinephrine.
23. Repeat steps 19, 20, and 21.
24. May administer amiodarone (300 mg IV/IO) once, or lidocaine (1–1.5 mg/kg) once, then
0.5–0.75 mg/kg IV/IO, maximum three doses, or magnesium (1–2 g IV/IO) for polymor-
phic VT.
25. Repeat steps 19–22.
26. For asystole or pulseless electrical activity (PEA), continue CPR for five cycles, adminis-
ter vasopressors(see step 22). Consider treatable factors and correct.
27. Check the ECG for shockable rhythm, and repeat process starting with step 11 if present.
28. Continue CPR throughout entire resuscitation process.
29. Clean reusable equipment, discard used supplies, perform hand hygiene
14.3 Assisting with synchronized cardioversion

Definition: Is a direct synchronized electrical current delivered to the heart
Purpose
 depolarizes all the myocardial cells simultaneously terminate atrial or ventricular tachyarr-
hythmias
 allows the sinus node to resume control as pacemaker of the heart shock synchronized to
occur with the R-wave of each QRS complex
Equipment
 Defibrillator monitor with ECG recorder set to SYNCHRONIZATION mode
 Paddles—anteroposterior or anterolateral or hands-free pads
 Conductive gel or conductive pads
 Emergency cart with medications and supplies
Procedure
1. Validate client’s identity: Check Ident-A-Band and have client state name and birth date.
2. Remove any jewelry.
3. Remove transdermal medication patches.
53
4. Establish IV line, and administer fluids at “keep open” rate.
5. Administer oxygen if ordered.
6. Plug in defibrillator and turn power switch ON.
7. Turn synchronizers witch ON
8. Test synchronization by pushing manual synchronization button.
9. Disconnect all electric equipment from client except ECG monitor and cardioverter.
10. Administer sedative as ordered by physician (anesthetist/anesthesiologist may do this).
11. Charge defibrillator to level specified by physician. Note that designated charge is reached.
12. Place client in supine position.
13. Make sure client’s chest is dry.
14. Apply conductive gel to surface of paddles, or use “handsfree” defibrillator pads and place
on client’s chest.
 Anterio-lateral handheld paddles are placed as in defibrillation, one below the right cla-
vicle and the other placed to the left of the cardiac apex (below and to the left of the nip-
ple or at the 5thor 6th intercostal space at the midaxillary line).
 Apex-posterior self-adhesive defibrillation pads are placed over the left precordium and
posteriorly below the right or left scapula.
15. Observe ECG rhythm on monitor and start recording continuous printout using lead II to
display a large R wave.
16. Discontinue oxygen.
17. Ensure that synchronization indicator is superimposed on R wave of ECG.
18. Give command to “stand clear,” and stand clear yourself.
19. The physician depresses discharge buttons on paddles and keeps them depressed until car-
dioversion countershock is delivered. The shock may not occur instantly, since machine
waits until the next R wave in the ECG to discharge.
20. Observe postcardioversion rhythm.
21. Provide postcardioversion care.
 Support airway and ventilation, and oxygenate as needed.
 Obtain 12-lead ECG, and label it “postcardioversion.”
 Monitor heart rhythm continuously.
 Evaluate vital signs, ECG, level of consciousness, peripheral pulses, and neurologic sta-
tus, until stable, then routinely
 Keep client under observation for 12 to 24 hr.
22. Clean reusable equipment and discard used supplies.
23. Perform hand hygiene
54
PROCEDURE - 15
ASPIRATION OF THE PERICARDIAL SAC (Pericardiocentesis)
Definition: It is the aspiration of a fluid from the pericardium. The collection of fluid is due to
pericardial effusion.
Purpose
 To relieve symptoms caused by pressure
 for diagnosis
Scope: ICU units, OR, emergencies and cardiac center
Equipment
Sterile set containing:
 2 gallipots
 1 pair of dissecting forceps
 1 pair of artery forceps
 swabs and gauze in a receiver
 1 towel with a hole(fenestrated towel)
 1 hand towel
 Surgical gloves
 syringe and needle for local anesthesia
 1 rubber tube which fits the opening of the two way tap
 20 or 10 cc aspiration syringe and needle
 two way tap needle for aspiration
 2 glass tubes for specimen
 receiver to collect fluid
Clean set containing:
 Rubber & draw sheet
 Receiver for used instruments
 Measuring jug
 Local anesthetia
 Cleaning lotion as ether, tincture of iodine
 Plaster
 Lab request
 Soft tissue
55
Procedure
1. Bring the equipment to the bedside of the patient
3. Instruct patient not to cough or move while the needle is being inserted
4. Position and cover the patient. He may be in a sitting up position or may be lying on his
back
5. Screen the bed
6. Expose the patient’s chest
7. Open the sterile set and pour the cleansing solution into the galipots. The doctor then
will scrub his hands, put on gloves and clean the area.
8. Hold the anesthetic bottle for the doctor. He will then anaesthetize the area anesthetist
will insert the needle. The fluid will be aspirated ( the doctor will insert the needle either
into the left fifth intercostals space or into the posterior pleural cavity at the angle of the
left scapula)
9. During the procedure, the nurse watches for any change of pulse, respiration, color and
report immediately.
10. The puncture area should be covered either with dry dressing of collation dressing at the
end.
11. Record the color, amount and viscosity. If there is a specimen label and send it to the
lab.
12. Leave the patient for any changes. Vital signs should be cheated every 15 min. For the
1st hour and the depending on patient’s condition.
N.B.
 This procedure may be done in the ward or operation room depending on the policy of
the hospital
 Make sure the emergency tray and oxygen is of air into the chest cavity.
56
PROCEDURE - 16
OBTAINING AN ELECTROCARDIOGRAM (ECG)
Definition: An Electrocardiogram (EKG) is a method of measuring, displaying and recording

the electrical activities, or conduction system of the heart.
Purpose
 To assess the cardiac functions
 To diagnose cardiac rhythm disorders
 To diagnose cardiac diseases
 To detect electrolyte imbalance
 To evaluate effects of treatments
Equipment
 12-lead ECG machine
 ECG leads and electrodes (self-stick adhesive)
 Electrode gel (optional)
 Alcohol wipes
 Hair clippers (optional)
Procedure
ber) according to agency policy.
3. Remove or reposition patient’s clothing to expose only patient’s chest and arms. Keep
pelvis and thighs covered.
4. Place patient in supine position.
5. Instruct patient to lie still without talking (12-lead ECG only) and to not cross legs.
6. Clean and prepare skin; wipe sites with alcohol. It is often necessary to clip hair from
chest if large amounts are present.
7. Apply self-sticking electrode, being careful to use pressure on perimeter only, and attach
leads. (If self-sticking leads are not available, apply electrode paste to skin before attach-
ing leads.)
a. For 12-lead ECG:
1) Chest (precordial leads)
 V1—Fourth intercostal space (ICS) at right sternal border
 V2—Fourth ICS at left sternal border
 V3—Midway between V2 and V4
 V4—Fifth ICS at midclavicular line
 V5—Left anterior axillary line at level of V4 horizontally
 V6—Left midaxillary line at level of V4 horizontally
57
2) Extremities (limb leads): one lead on each extremity. Place on lower portion of each ex-
tremity, avoiding any bone prominences.
 aVr—Right wrist- red color
 aVl—Left wrist- yellow “
 aVf—Left ankle- green “
 aV7—Right ankle- black “
8. Turn on ECG machine, enter required demographic information into computer, and obtain
tracing.
a. Simultaneous 12-channel recording:
 Enter patient’s name and medical record number into ECG machine menu. Obtain
test tracing.
 Reposition leads as needed. Activate machine to obtain simultaneous tracing of all 12
leads. If patient experiences chest pain, document occurrence on ECG printout.
b. Three or five-lead recording:
After placing limb electrodes, apply electroconductive gel over V1 to V6 locations.
 Turn lead selector to lead “1,” turn on machine, and begin recording. If tracing is
clear, run sequential 6-second tracings for leads I, II, III, aVR, aVL, and aVF by turn-
ing lead selector to corresponding settings.
 Stop machine, position V electrode over V1 position, and run a 6-second tracing. Re-
peat sequentially by moving V electrode over V2, V3, V4, V5, and V6 positions.
c. For continuous interpretation/monitoring:
 Apply limb electrodes. Apply electroconductive gel over location for single chest lead
where designated by agency policy or as ordered.
 Maintain either two upper limb electrodes (3-lead), or four limb electrodes (5-lead).
9. Disconnect leads and wipe off excess electrode paste from chest. If serial tracings are ex-
pected, some cardiologists will have you mark where leads were placed to ensure subse-
quent tracings from same electrode sites.
10. Deliver ECG tracing to appropriate laboratory or health care provider. Provide any pre-
vious ECG tracings.
58
PROCEDURE – 17
NASOGASTRIC TUBE
17.1. Nasogastric tube insertion

Definition: Passing a tube through a nasal cavity down the nasopharynx and oesophagus in to
the stomach
Goal: Decompresses the stomach to relieve pressure and prevent vomiting; provides a means
for irrigating the stomach (lavage); provides access to gastric specimens for laboratory analysis;
provides a route for delivering liquid enteral feedings (gavage) in patients who can’t swallow or
ingest adequate calorie intake
Purpose
 To administer tube feeding and medication to clients unable to eat by mouth or swallow a
sufficient diet without aspirating food or fluids in to the lungs.
 To establish a means for suctioning stomach contents to prevent gastric distension, be-
fore and after surgery ,nausea and vomiting
 To remove stomach contents for laboratory analysis
 To decompress abdominal distension.
 To lavage (wash) the stomach in case of poisoning or overdose of medications
Indication
 Surgery  Unconscious
 Abdominal distension  Severe dehydration
 Poison  Diagnostic analysis
Equipment
 NGT (Ryle’s tube), plaster,  Rubber sheet and draw sheet
 Gauze  Mouth wash tray
 Water soluble lubricant  Tongue depressor
 Disposable glove  Flash light
 Glass of water  Basin with warm water or ice
 20 to 50 ml syringe  Denature cup
 Stethoscope  Safety pin and rubber band
 Blue litmus paper  Bath towel
 Spigot to close the tube  Normal saline
 Cotton applicator to clean nostril  Emesis basin( bowel)
 Waste receiver
59
Procedure
1. Explain the procedure to the patient
2. Wash hands and prepare equipments
3. Position:
 For conscious patient sitting or a semi-upright position and support the head on a pillow
It is often easier to swallow in this position and gravity helps the passage of the tube
 For unconscious patient lying in the left lateral position with the head slightly lower than
the body.
 For infants and young children, do not hyper extend or hyper flex the neck may occlude
air way.
4. Done examination glove
5. Drape plastic sheet and lower around patient’s neck.
6. Assess client’s necks
7. After hyperextend the head of the client observe the patent of the tissues of the nostrils, in-
cluding any irritations or abrasions by using a flash light and examine the nares for any ob-
structions or deformities by asking the client to breathe through one nostril while occluding
the other
a. Check that the nostrils are patent by asking the patient to sniff with one nostril closed
b. Repeat with the other nostril. If necessary cleanse the nostrils with water using cotton
wool on applicator.
8. Prepare the tube for insertion. If a rubber tube is being used, place it on ice this stiffens the
tub, facilitating insertion. If a plastic tube is being used, place it in warm water. This makes
the tube more flexible, facilitating insertion
9. Use the tube to mark off the distance from the tip of the client’s nose to the tip of the ear lobe
and then from the tip of the earlobe to the tip of the sternum. This distance varies among in-
dividuals. For infant and young children, measure then to the point midway between the
umbilicus and the xiphoid process. Mark this length with adhesive tape /ink if the tube does
not have markings.
10. Lubricate about 15-20 cm of the tube with a water soluble lubricant using a swab
11. Insert the rounded end of the tube in hyper extend the neck in to the cleanest nostril and slide
it backwards and in wards along the floor of the nose to the nasopharynx.
a. If any obstruction is felt, withdraw the tube and try again in a slightly different direction or
use the other nostril.
12. As the tube passes down in the nasopharynx, ask the patient to start swallowing and sipping
water this will close the glottis, enabling the tube to pass in to the oesophagus.
a. Slight pressure is sometimes necessary to pass tube but never forced against resistance,
because of the danger of injury
13. Advance the tube through the pharynx, as the patient swallow’s until the predetermined mark
has been reached.
60
 While inserting the tube observe for patient condition for Coils in the mouth by opening
the mouth by tongue depressor
 If Client gag, stop passing the tube momentarily with each wall insert 5 to 10 cm with
each swallow.
 If client continues to gag and the tube does not advance with each swallow, withdraw it
slightly.
 If the patient shows signs of distress like gasping or cyanosis, remove the tube immediate-
ly and try again the procedures.
14. Continue in advancing the tube until the mark on and the tube reach his/her nostril.
15. Taping a tube to the bridge of the nose
16. Check the position of the tube to confirm that it is in the stomach by:-
a. Ask patient to talk
b. Inspect posterior pharynx for presence of coiled tube
c. Introducing 10-20ml of air in to the stomach via the tube and check for a whooshing
sound using a stethoscope placed over the epigastrium.
d. Aspirating the contents of the stomach with a syringe. The aspirate turns blue litmus pa-
per to red, due to HCI.
e. Insert/immerse the tip of tube in the glass of water and if you see gentle and continuous
bubble that show you are in the lung.
f. Obtain x-ray film examination of chest and abdomen as ordered
17. Close the end of the tube with spigot
18. Secure the tube to the nostril and attach to forehead with adhesive tape. Ensure patient is
comfortable.
19. Assist the patient into position and comfort
20. Remove and clean the used equipment return it in to proper place
21. Wash hands and dry
22. Document relevant information.
61
17.2 Administering Enteral Nutrition: Nasoenteric, Gastrostomy, or Jejunostomy

Tube
Definition: Enteral nutrition, or tube feeding, is a method for providing nutrients to patients who
are not able to meet their nutritional requirements orally
Indications:
 It is used most of the time for the unconscious patient and for those who have laryngeal
operation or oral operation.
 Poor oral intake.
 Patients who are unable to swallow
Purpose
 For gastric feeding
 To provide nourishment to patients who cannot be feed through mouth
 For medication giving
Equipment
 Tray
 measuring jar
 warm water
 Naso- gastric tube insertion materials, if not inserted
 Narrow funnel or syringe, tubing and glass connector if funnel is used.
 Disposable feeding bag, tubing
 60-mL or larger catheter-tip syringe
 Stethoscope
 Enteral infusion pump for continuous feedings
 pH indicator strip (scale 0.0 to 11.0)
 Prescribed enteral formula or local prepared fluid diet
 Clean gloves
 napkin
 Receiver for used equipment and swabs.
Procedure
1. Introduce yourself and verify the client’s identity. Explain to the client what you are
going to do, why it is necessary, and how the client can cooperate.
2. Assess for food allergies, time of last feed, bowel sounds
3. Assist patient to fowler position
4. Perform hand hygiene and observe other appropriate infection control procedures.
5. Spread towel and mackintosh over patient’s chest.
6. If tube is not inserted, follow NGT insertion procedures
7. Puor feed into syringe barrel or funel and allow it to flowby gravity. Pinch tube whenever
necessary to stop when puoring.
62
8. If formula is used: Obtain formula to administer:

a. Verify correct formula and check expiration date; note condition of container
b. Provide formula at room temperature.
9. Prepare formula for administration:
a. Use aseptic technique when manipulating components of feeding system (e.g., for-
mula, administration set, connections)
b. Shake formula container well. Clean top of canned formula with alcohol swab before
opening it
c. For closed systems, connect administration tubing to container. If using open system,
pour formula from brick pack or can into administration bag
10. Open roller clamp and allow administration tubing to fill. Clamp off tubing with roller
clamp. Hang container on intravenous (IV) pole
11. Verify tube placement. Observe appearance of aspirate and note pH measure
12. Check gastric residual volume (GRV) before each feeding (for bolus and intermittent
feedings) and every 4 to 6 hours (for continuous feedings)
f. Draw up 10 to 30 ml air into syringe and connect to end of feeding tube.
g. Inject air into tube. Pull back slowly and aspirate total amount of gastric contents.
h. Return aspirated contents to stomach unless volume exceeds 250 ml
i. Do not administer feeding when a single GRV measurement exceeds 500 ml or when
two measurements taken 1 hour apart each exceed 250 ml
j. Flush feeding tube with 30 ml water.
13. Intermittent gravity drip:
a. Pinch proximal end of feeding tube and remove cap. Connect distal end of administra-
tion set tubing to feeding tube and release tubing.
b. Set rate by adjusting roller clamp on tubing or attach tubing to feeding pump. Allow
bag to empty gradually over 30 to 45 minutes. Label bag with tube-feeding type,
strength, and amount. Include date, time, and initials.
c. Change bag every 24 hours.
14. Continuous drip method:
a. Connect distal end of administration set tubing to feeding tube as in Step 10a
b. Thread tubing through feeding pump; set rate on pump and turn on
15. Flush tubing with 30 ml water every 4 hours during continuous feeding, before and after
an intermittent feeding. Have registered dietitian recommend total free water requirement
per day
16. After tube is cleared close end of feeding tube.
17. Dispose of supplies and perform hand hygiene.
63
17.3. Gastric Lavage

Definition: This is the irrigation or washing out of the stomach.
Purpose
 To remove alcoholic, narcotic or any other poisoning which has been swallowed.
 To cleanse the stomach before operation
 To relieve congestion, there by stimulating peristalsis: e.g Pyloric stenosis.
 For diagnostic purposes.
Equipment
 Clean trolley
 Bowl containing large esophageal tube in ice (cold ) water
 Metal or plastic funnel
 Large jug (5litres)
 Solution as per prescription (usually to care for acidic poisoning we use sodium
bicarbonate 2 teaspoon to 500 cc of water at a temperature of 370C -380C)
 Small jug to carry solution to the funnel.
 Bowl for gauze swab
 Cape or protective material to put around the patients neck
 Pail to receive returned fluid
 Mackintosh or paper to protect the floor beneath the pail
 Receiver for used esophageal tube
 Paper bag for waste material
 A Tray for mouth wash after lavage.
 A receiver containing mouth gag, tongue depressor, and tangue forceps if patient is
unconscious
 Mackintosh to protect bed linen
 Specimen bottle, if laboratory test is required
Procedure
1. Explain procedure to the patient and ask him/her to remove artificial denturres, if any.
2. Protect patient with cape or towel.
3. Protect bed line by spreading the mackintosh on the accessible side of the bed
4. Place mackintosh of paper under the pail to protect the floor.
5. Elevate head of the bed if patient is conscious and the condition permits. But if
unconscious, place in prone position with head over the edge of the bed or head lower
than the body.
6. Measure the tube from the tip of the nose up to the ear lobe and from the bridge of the
nose the end of the sternum 32-36cm.
7. Gently pass the tube over the tongue, slightly to one side of the midline towards the
pharynx. (If patient is unconscious mouth gag may be used)
64
8. Ask patient to swallow while inserting the tube and allow to breath in between
swallowing.
9. If air bubbles, cough and cyanosis are noticed the tube is with drawn and procedure
commenced again.
10. After inserting, place funnel end in a basin of water to check if the tube is in the air
passage.
11. Fill the small pint measure and pour gently until the funnel is empty then invert over the
pail.
12. Take specimen, if required, and continue the process until the returned fluid becomes
clear and the prescribed solution has been used.
13. Remove tube gently and give mouth wash.
14. Measure the amount of fluid retumed and record.
15. Report any abnormality e.g. blood stain or clots or pieces of the gut.
N.B: Record
 Time of treatement
 Amount and kind of solution used
 Nature of returned fluid
 Reaction of patient during and after procedure
65
PROCEDURE – 18
COLOSTOMY CARE AND IRRIGATION

Definition: Colostomy: is an opening created as a permanent or temporary diversion of the bo-
wel at the level of the colon
18.1 colostomy irrigation

Purpose: to empty the large colon of stool
Equipments
1. Tape, if gauze is used
2. Clean and surgical gloves
3. Fenestrated towel
4. Rubber and draw sheet
5. Kidney dish
6. Warm water and soap
7. Transfer forceps
8. Ostomy odor eliminator
9. Bedpan
10. Normal saline

Procedure
1. Wash hands.
2. Apply clean gloves.
3. Assemble irrigation kit: Attach cone or catheter to irrigation bag tubing.
4. Fill irrigation bag with 1000 cc tepid tap water
5. Open clamp and let water from the irrigation bag fill the tubing.
6. Hang bottom of irrigation bag at height of client’s shoulder, or 18 inches above the stoma
if client is supine.
7. Check direction of intestine by inserting a gloved finger into orifice of stoma.
8. Place irrigation sleeve over stoma and hold in place with belt
9. Spray inside of irrigation sleeve and bathroom with odor eliminator (usual dose is two
sprays).
10. Cuff end of irrigation sleeve and place into toilet bowl (if client is in bathroom) or bedpan
(if client is in bed or chair).
11. Lubricate the cone end of the irrigation tubing and insert into orifice of stoma through the
top opening of irrigation sleeve
12. Close top of irrigation sleeve over the tubing.
13. Slowly run water through tubing into colon
14. Remove cone after all water has emptied out of irrigation bag.
15. Close end of irrigation sleeve by attaching it to the top of the sleeve.
66
16. Encourage client to ambulate to facilitate emptying of remaining stool from colon.
17. Remove irrigation sleeve after 20–30 minutes or when stool is no longer emptying from
colon.
18. Cleanse stoma and skin with warm tap water. Pat to dry.
19. Place gauze pad over stoma to absorb mucus from stoma.
20. Secure gauze with hypoallergenic tape.
21. Remove gloves and wash hands.
18.2 applying a fecal ostomy pouch

Purpose:
 To contain drainage and odors for the comfort of the patient
 To protects the peristomal skin from excoriation
 To allows accurate assessment of output, especially in the postoperative period;
 To provides visualization of the stoma and sutures during the postoperative period.
Equipment
 One- or two-piece transparent ostomy pouch with adhesive wafer

 Warm water and mild soap
 Soft cloths
 Bath blanket
 Plastic bag for pouch disposal
 Tail closure or night adaptor for pouch
 Clean gloves
 Graduate or bedpan
 Measuring guide
 Tissues
 Ostomy scissors and dark marking pen
Procedure:
1. Perform hand hygiene and don gloves. The patient may perform the procedure without
gloves.
3. Close door or bed curtains and explain procedure to the patient.
4. Place a waterproof pad by stoma site.
5. Gently remove old appliance (and skin barrier if applicable) by pushing skin away from
appliance (do not pull appliance from skin); start at the top of the appliance. If disposable,
discard. If reusable, set aside for washing.
6. Use toilet tissue to remove excess stool. Wash skin thoroughly around stoma with skin
cleanser or soap and water.
67
7. Rinse skin thoroughly and blot dry.

8. Observe condition of peristomal skin, the stoma, and the sutures. Teach the patient to
make these observations daily.
9. Cover stoma with gauze while you prepare new appliance. Prepare appliance and/or skin
barrier: Measure stoma using a measurement guide, and trace stoma measurement on the
adhesive paper backing of appliance or barrier. Cut the opening 1⁄8 inch larger than trac-
ing.
10. If stoma is located in an abdominal crease or the skin is irregular, use a paste barrier to fill
the irregularity.
11. Apply protector as needed/desired. Allow protector to dry completely.
12. Apply protective skin barrier:
a. Peel paper backing off wafer, and center stoma in hole.
b. Place on abdomen, pressing lightly over all areas of the barrier to promote adhesion
with skin surfaces
68
PROCEDURE - 19
ABDOMINAL TAPE (ABDOMINAL PARACENTESIS)
Definition: abdominal tape or paracentecesis is the removal of fluid (ascitic fluid) from the peri-
toneal cavity.
Purpose
 For diagnostic purpose to obtain a specimen of fluid
 For therapeutic purpose – to relieve abdominal distention
Scope: all wards, units, OPDs, emergencies
Equipment
Sterile set containing:
 Towel with hole
 Hand towel
 Gloves, Swabs & gauze in a bowl.
 2 gallipots
 Syringe and needle for local anesthesia
 Dissecting forceps & artery forceps
 Small scalpel if needed.
N.B
 During and after the procedure watch patient carefully for signs of shock
 If the puncture is done on the side, lay the patient on the unaffected side at the end of the
procedure.
 Make sure that the abdominal binder is under the procedure.
Procedure
1. Place client in Fowler’s position on chair or on edge of bed with legs spread apart.
2. Drape client, and provide adequate warmth and covering with a bath blanket.
3. Obtain vital signs, and observe client for pallor and vertigo during procedure.
4. Position and open tray on over-bed table.
5. Open sterile gloves if needed.
6. Assist physician in preparing skin with antiseptic solution and topical anesthesia or as
needed.
7. Don clean gloves.
8. Physician inserts trocar needle, or cannula through small incision. Plastic tubing is at-
tached to cannula.
69
PROCEDRUE - 20
ADMINISTERING ENEMA
Definition: Introduction of solution in to the large intestine for removing faces and cleansing the
bowel. The term enema is associated with the cleansing enema, which is given for emptying the
rectum & the lower colon. However enemas also are used for other than cleansing purpose.
20.1 cleansing enema

Purpose:
 To relieve constipation or fecal ipaction and gas
 To prevent involentary escape of fecal matter during surgical procedure
 To promote visualization of the intestinal tract during radiographic or instrumental
examination.
Solution used
 Tap water, One tsp of table salt in 500 ml of tap water
 3 to 5 ml of concentrated soap solutions in 1000 ml of water
 Sodium phosphate
Contraindication
 Acute renal failure
 Appendicitis
 Intestinal obstruction
 Inflammation and infection of abdomen
Equipment:
 Disposable linen-saver pad
 Bath blanket
 Bedpan
 Clean gloves
 Water-soluble lubricant
 Paper towel
 Enema can
 Tubing and clamp
 Solutions as ordered
 Appropriate size rectal tube
 IV stand
 Mackintosh
70
Amount of solution for different age groups

Adult 750-1000 ml
School age 300-500ml
Toddler 250-300ml
The rectal tube should be appropriate: is measured in French scale
Age Size
Infants/small child 10-12 fr
Toddler 14-16 fr
School age child 16-18 fr
Adults 22-30 fr
Procedure
1. Assess status of patient normal bowel movement, mobility, external sphincter bowel pat-
tern.
2. Determine the level of consciousness and understanding of patient.
3. Introduce yourself and verify the client’s identity. Explain to the client what you are going
to do why it is necessary, and how the client can cooperate. Indicate that the client might
experience a feeling of fullness while the solution is being administered.
4. Perform hand hygiene and observe other appropriate infection control procedures.
5. Provide for client privacy.
6. Assist the adult client to a left lateral position, with the right leg as acutely flexed as poss-
ible and the linen-saver pad under the buttocks.
7. Cover the patient exposing only anal area, clearly visualizing anus.
8. Insert the enema tube.
 For clients in the left lateral position, lift the upper buttock.
 Insert the tube smoothly and slowly into the rectum, directing it toward the umbilicus.
 Insert the tube 7–10 cm (3–4 inches).
 If resistance is encountered at the internal sphincter, ask the client to take a deep breath,
and then run a small amount of solution through the tube.
 Never force tube or solution entry. If instilling a small amount of solution does not permit
the tube to be advanced, or the solution to flow freely, withdraw the tube. Check for any
stool that might have blocked the tube during insertion. If present, flush it and retry the
procedure. You may also perform a digital rectal examination, to determine if there is an
impaction or other mechanical blockage. If resistance persists, end the procedure and re-
port the resistance to the primary care provider and nurse in charge
9. Raise the solution container, and open the clamp to allow fluid flow
10. During most low enemas, hold or hang the solution container no higher than 30 cm (12
inches) above the rectum. During a high enema, hang the solution container approximately
45 cm (18 inches) above the rectum.
71
11. Administer the fluid slowly. If the client complains of fullness or pain, lower the contain-
er or use the clamp to stop the flow for 30 seconds, and then restart the flow at a slower
rate.
12. After all the solution has been instilled, or when the client cannot hold any more and feels
the desire to defecate, close the clamp, and remove the rectal tube from the anus. Place the
rectal tube in a disposable towel as you withdraw it.
13. Request that the client retain the solution for the appropriate amount of time—for exam-
ple, 5–10 minutes for a cleansing enema, or at least 30 minutes for a retention enema.
14. Assist the client to defecate a sitting position on the bedpan, commode, or toilet.
20.2 Retention enema

Purpose:
 To supply the body with fluid
 To give medication such as stimulants for absorption e.g. paraldehyde as a sedative.
 To soften impacted fecal matter.
 Is given slowly by means of a rectal tube
Equipment:-
 Commercially prepared disposable oil retention enema
Oil: Adult 150–200 mL, child 75–100 mL, 91°F
 Water-soluble lubricant
 Bedpan or commode
 Bed protector
 Skin care items (e.g., soap, water, towels)
 Clean glove
Procedure:
1. Explain steps of procedure to client.
2. Raise bed to HIGH position.
3. Perform hand hygiene and don gloves
4. Place bed protector on bed.
5. Expose anal opening, and gently insert rectal tube tip of container 3–4 in. Commercially
prepared enemas are prelubricated.
6. Squeeze contents slowly, and empty entire amount into rectum.
7. Keep container compressed and remove rectal tube gently.
8. Lower bed.
9. Discard equipment and gloves, following Standard Precautions. Perform hand hygiene.
10. Explain to client that oil should be retained for 30–60 minutes before it is expelled.
11. A cleansing enema may need to be given to remove oil and stimulate defecation.
12. Don gloves and provide hygienic care if needed.
13. Remove gloves, discard in appropriate container, and perform hand hygiene.
72
N.B
1. Most medicated retention enemas must be preceded by a cleansing enema & pt should rest
for half hour before giving retention enema.
2. A small catheter is to be used instead of a rectal tube.
3. If necessary, elevate foot of bed to help patient retain enema.
20.3 Rectal washout

Definition: Is the process of introducing large amount of fluid into large bowel for flushing pur-
pose and allow return or wash out fluid. Colon irrigation or colonic flush - Also called enteroly-
sis
Purpose:
 To prepare the pt for x-ray examination & sigmodoscopic
 To prepare the pt for rectum & colon operation to clean the rectum from mucus, blood &
debris before rectal operation.
Solution Used
 Normal saline
 Soda-bi-carbonate solution (to remove excess mucus)
 Tap water
Equipment
Tray containing:
 Large jug for the fluid
 Pint jug
 Funnel, tubing and glass connecting
 Rectal catheter & clamp
 Swabs & Vaseline
 Mackintosh & towel
 Bucket
 Screen
 Lotion Thermometer
 Pillow to rest the elbow on
Procedure:
2. Explain the purpose of procedure to patient thoroughly.
3. Prepare the solution ordered by the physician.
4. Bring equipment to bed side
5. Screen the bed & place the patient in the left lateral position with the buttocks on the edge
of the bed.
6. Place mackintosh & towel underneath the buttocks.
7. Check the temperature of the fluid & fill the small jug. Temperature should be about 38oc
or 100.4of
73
8. Lubricate the catheter.

9. Run the fluid through to expel air & then clamp it.
10. Expose the anal region separate the buttocks, with one hand & insert the rectal tube into
the rectum 8 – 10cms
11. Open the clamp & allow to run about 100cc of fluid in the bowel, then syphone back in to
the bucket.
12. Carry on the procedure until the fluid returned is clear.
13. Remove the catheter & leave the patient comfortable
14. The amount returned should be measured to ensure that none has been retained.
15. Record or chart the time, result & effect on the patient.
NB:
 The rectal wash out should not exceed for more than 2 hrs
 The rectal washout showed is finished one hour before examination or x-ray that is to give
time for the large intestine to absorb the rest of the fluid.
 Give cleansing enema half hour before the rectal washout.
20.4 Passing a Flatus Tube

Purpose
 To decrease flatulence (severe abdominal distention)
 Before giving a retention enema
Procedure
1. Place the patient in left. Lateral position
2. Lubricate the tube about 15 cm
3. Separate the rectum and insert 12-15 cm in to the rectum and tape it
4. Connect the free end to extra tubing by the glass connector
5. The end of the tube should reach the (tape H2O) solution in the bowel
6. The amount of air passed can be seen bubbling through the solution
7. Teach client to avoid substances that cause flatulent
8. Leave the rectal tube in place for a period or no longer than 20 minute – can affect the
ability to voluntarily control the sphincter if placement is prolonged
9. Reinsert the rectal tube every 2-3 hrs if the distention has been unrelieved or re accumu-
lates – allows gas to move in the direction of the rectum.
74
PROCEDURE - 21
ASSISSTING WITH GASTROINTESTINAL ENDOSCOPY
Definition: Endoscopy is the visualization of a body organ or cavity through a scope.

Purpose
 Allows for direct visualization of esophageal, gastric, duodenal and colon mucosa
through a lighted endoscope to detect abnormalities.
 To collect secretions and tissue specimens for further analysis
 To giving treatment
Scope: GI clinic
Equipment
 Protective equipment: Mask, gown, gloves, head cover, goggles for all health care per-
sonnel
 Endoscopy tray
 Fiberoptic endoscope and camera
 Solutions for biopsy specimens
 Local anesthetic spray
 Tracheal suction equipment
 Blood pressure equipment
 Sterile water-soluble jelly
 Sterile gloves for physician
 Emesis basin
 IV fluid and equipment for IV start (optional)
 Diazepam (Valium), midazolam (Versed), or other sedative for IV sedation (optional)
 Sedative reversal agents
 Carbon dioxide source to inflate colon (for lower GI procedures)
 Oxygen, resuscitative equipment, pulse oximeter/end-tidal CO2 Monitor
Procedure
ber) according to agency policy.
2. Perform hand hygiene and apply protective equipment.
3. Remove patient’s eyeglasses, dentures, or other dental appliances.
4. Take “Time-Out” to verify patient’s name, type of procedure scheduled, and procedure
site with patient and health care team.
5. Ensure that IV line is patent and administer IV sedation as Ordered
6. Help patient assume proper position for procedure and apply appropriate drape
a. Upper GI procedures: Assist patient in maintaining left lateral Sims’ position.
75
b. Lower GI procedures: Assist patient in maintaining left lateral decubitus position.

Drape patient for privacy.
7. Physician performs hand hygiene and puts on protective equipment.
Upper GI procedures:
a. Help physician spray nasopharynx and oropharynx with local anesthetic.
b. Administer atropine if ordered.
c. Position tip of suction cannula for easy access in patient’s mouth.
Lower GI procedures:
a. Prepare lubricant for fiberoptic endoscope.
8. Physician slowly passes endoscope into mouth or through anus to view esophagus, sto-
mach, colon, or rectum and advances to desired depth while visualizing lining of struc-
tures.
9. Physician insufflates air through endoscope into upper GI tract or carbon dioxide into
lower GI tract in case of colonoscopy.
10. Help patient throughout procedure:
a. Anticipate needs and promote comfort.
b. Tell patient what is happening as each portion of procedure is carried out (e.g., abdo-
minal cramping).
c. For upper GI procedures, suction if there are excessive oral secretions or vomitus.
11. Place tissue specimens in proper laboratory containers or on proper slides. Seal as
needed. Date, time, and initial all specimen containers before sending to laboratory.
12. Help patient return to comfortable position.
13. Help to dispose of equipment and perform hand hygiene
14. In recovery, after sedation resolves, inform patient not to eat or drink until gag reflex re-
turns.
76
PROCEDREU- 22
URINARY CATHETERIZATION
Definition: - Urinary catheterization is the placement of a tube through the urethra into the blad-
der to drain urine. This is an invasive procedure that requires a medical order and aseptic tech-
nique in institutional settings.
N.B. This is strictly a sterile procedure therefore the nurse should always follow aseptic tech-
nique.
Purpose
 In an obstruction due to the blockage of the urethra, therefore causing stricture
 To obtain a sterile specimen of urine for pathological examination
 To ensure that the bladder is empty before an abdominal or pelvic operation or abdominal
paracentesis.
 To keep an incontinence patient dry.
 To avoid contamination after an operation of the vagina and perineum.
 To empty the bladder before irrigation or instillation.
 To determine if residual urine is present in the bladder
 To relieve discomfort due to bladder distention
Types of Catheter
1. Straight (plain or Robinson) -Single lumen
2. Retention (Foleys, indwelling) -Double lumen or Triple lumen
 Catheter size depends on the size of the urethral canal
 8-10 Fr – children
 14-16 Fr – female adults
 18 Fr – adult male
Equipment
I. Sterile
 Kidney dish  Sterile drainage tubing and bag
 Gauze II. Clean
 Catheter  Waste receiver
 Water  Rubber sheet
 Gloves  Flash light
 Drapes  Screen
 Galipot  Measuring container for urine
 Towel  Device to secure catheter
 Anti septic Solution  Clean gloves, bed pans
 Syringe
 Specimen bottle
 Lubricant
77
Procedure
1. Identify patient using two identifiers (i.e., name and birthday)
2. Check patient’s plan of care for size and type of catheter (if this is a reinsertion). Use smal-
lest-size catheter possible.
3. Collect all required equipment
5. Provide privacy by closing room door and bedside curtain
6. Raise bed to appropriate working height.
7. Place waterproof pad under patient
8. Position patient:
 Female patient:
 Help to dorsal recumbent position (on back with knees flexed).
 Male patient:
 Position supine with legs extended and thighs slightly abducted.
9. Apply clean gloves. Wash perineal area with soap and water, rinse, and dry. Use gloves to
examine patient and identify urinary meatus. Remove and discard gloves
11. Put on sterile gloves. (Or apply sterile drape with ungloved hands when drape is packed as
first item. Touch only edges of drape. Then apply clean gloves.)
12. Create a sterile field
13. Drape perineum, keeping gloves sterile
14. Move tray closer to patient. Arrange remaining supplies on sterile field, maintaining sterili-
ty of gloves.
15. Clean urethral meatus:
 Female patient:
 Separate labia with fingers of non dominant hand (now contaminated) to fully expose
urethral meatus
 Maintain position of non dominant hand throughout procedure.
 Holding forceps in dominant hand, pick up one moistened cotton ball or pick up one
swab stick at a time. Clean labia and urinary meatus from clitoris toward anus. Use new
cotton ball or swab for each area that you clean. Clean by wiping far labial fold,
near labial fold, and directly over center of urethral meatus
o Male patient:
 With non dominant hand (now contaminated) retract foreskin (if uncircumcised) and
gently grasp penis at shaft just below glans. Hold shaft of penis at right angle to body.
This hand remains in this position for remainder of procedure
 Using uncontaminated dominant hand, clean the meatus with cotton balls/swab
sticks, using circular strokes, beginning at the meatus and working outward in a spiral
motion.
 Repeat cleansing three times using clean cotton ball/ swab stick each time
78
16. Pick up and hold catheter 7.5 to 10 cm (3 to 4 inches) from catheter tip with catheter
loosely coiled in palm of hand.
17. Insert catheter:
 Female patient:
 Ask patient to bear down gently and slowly insert catheter through urethral mea-
tus
 Advance catheter total of 5 to 7.5 cm (2 to 3 inches) or until urine flows out of cathe-
ter. When urine appears, advance catheter another 2.5 to 5 cm (1 to 2 inches). Do not
use force to insert catheter.
 Release labia and hold catheter securely with non dominant hand.
 Male patient:
 Lift penis to a position perpendicular (90 degrees) to patient’s body and apply gen-
tle upward traction
 Ask patient to bear down as if to void and slowly insert catheter through urethral
meatus.
 Advance catheter 17 to 22.5 cm (7 to 9 inches) or until urine flows out end of cathe-
ter.
 Stop advancing with a straight catheter. When urine appears in an indwelling ca-
theter, advance it to bifurcation (inflation and deflation ports exposed)
 Lower penis and hold catheter securely in non dominant hand.
18. Allow bladder to empty fully unless agency policy restricts maximum volume of
urine drained
19. Collect urine specimen as needed. Fill specimen container to 20 to 30 mL by holding end
of catheter over cup.
 Label and bag specimen according to agency policy. Label specimen in front of pa-
tient. Send to laboratory as soon as possible
22. Straight catheterization: When urine stops flowing, withdraw catheter slowly and
smoothly until removed
23. Inflate catheter balloon with amount of fluid designated by manufacturer.
 Continue to hold catheter with non dominant hand.
 With free dominant hand, connect prefilled syringe to injection port at end of catheter.
 Slowly inject total amount of solution
 After inflating catheter balloon, release catheter from non dominant hand. Gently pull
catheter until resistance is felt. Then advance catheter slightly.
 Connect drainage tubing to catheter if it is not already preconnected.
24. Secure indwelling catheter with catheter strap or other securement device. Leave enough
slack to allow leg movement.
79
 Female patient:
 Secure catheter tubing to inner thigh, allowing enough slack to prevent tension
 Male patient:
 Secure catheter tubing to upper thigh or lower abdomen (with penis directed toward
chest). Allow slack in catheter so movement does not create tension on catheter
 If retracted, replace foreskin over glans penis
25. Clip drainage tubing to edge of mattress. Position drainage bag lower than bladder by at-
taching to bed frame. Do not attach to side rails of bed
26. Check to make sure that there is no obstruction to urine flow. Coil excess tubing on bed
and fasten to bottom sheet with clip or other securement device.
27. Provide hygiene as needed. Help patient to comfortable position.
28. Dispose of supplies in appropriate receptacles.
29. Measure urine and record.
30. Remove gloves and perform hand hygiene
 Removal
Withdraw the solution or air from the balloon using a syringe and remove gently
80
PROCEDURE - 23
BLADDER IRRIGATION
Definition: It is washing out of bladder

Purpose:
 To remove blood clots from client’s bladder
 To ensure patency of drainage system
 To relieve bladder spasm discomfort
Equipment:
 Complete set of catheterization tray.
 Sterile funnel or 50/60cc syringe
 0.9% normal saline or sterile or boric lotion )
 Towel, Mackintosh, sterile swab, lubricant, receiver for urine,
 Catheter clamp and pail.
Procedure:-
1. Palpate client’s bladder to check for distention.
2. Open sterile irrigant container on overbed table. Maintain sterility
3. Don clean gloves.
4. Place an absorbent pad under connection of tubing and catheter
5. Insert irrigating syringe into catheter and attempt to aspirate any obstructing debris
6. Draw solution into the syringe
7. Attach syringe into catheter
8. Instill 30–50 mL of irrigant into catheter with a gentle pressure.
 Aspirate instilled solution.
 Continue to irrigate client’s bladder with 30–50 ml of irrigant until fluid returns are
clear
9. Withdraw syringe and put end of catheter into a large receiver which is placed on a sterile
towel over the mackintosh.
10. Wipe end of catheter with an antiseptic sponge and reconnect the catheter to the drainage
tube.
11. Tape catheter to inner thigh for a female and to abdomen for a male
12. Discard equipment and remove gloves.
13. Make sure client is clean and comfortable.
15. Measure amount of return. Subtract amount of irrigating solution used to irrigate.
16. Record net amount on client’s I&O record
81
PROCEDURE - 24
PERIOPERATIVE NURSING CARE
24.1 Preoperative care

Definition: Is the period of time from when the decision for surgical intervention is made to
when the patient is transferred to the operating room.
Purpose:
 To assist with monitoring the client’s progress through the operative experience
 To assist in identifying deviations from the client’s baseline data that may occur as a re-
sult of anxiety or stress of admission, preoperative events, diagnostic procedures, the sur-
gical trauma, postoperative complications, responses to and side effects of drugs
 To provide appropriate preoperative physical care to enable the client to have a safe
intraoperative and postoperative period
 To report client’s statements about allergies or chronic problems that could affect post-
operative nursing care
Equipment
 Thermometer
 Sphygmomanometer and stethoscope
 O2saturation probe
 Preoperative checklist
 Chart or computer for documenting findings
Procedure
1. Identify patient using two identifiers (i.e., name and birthday) and introduce yourself.
2. Ask about allergies to drugs, food, or latex
3. Orient patient to room or presurgical (holding) area. Surgeon obtains informed consent.
Act as patient advocate as needed; include considering any culturally sensitive issues.
Witness form if allowed by agency.
4. Assess for surgical risk: nutritional status, fluid and electrolyte balance, use of prescribed
medications, over the-counter complementary medications (i.e., herbs), and illicit drugs.
5. Assess for alcohol use and smoking habits.
6. Assess mental attitude; record any unusual stress or anxiety exhibited by the client.
7. Check medical record and review or complete preoperative checklist.
8. Provide preoperative teaching, including explanation of postoperative exercises, skin
preparation, pain control measures, and postoperative care in post anesthesia care unit
(PACU) phases I and II and nursing division.
9. Take and record vital signs and weight of client.
10. Maintain NPO status NPO 8 hours after regular meal before surgery in healthy
adult patients
11. Insert intravenous (IV) line and/or indwelling catheter if ordered.
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12. Provide for hygiene measures, ensuring patient privacy. Instruct patient to remove all
clothing, including undergarments, and apply disposable cap and hospital gown with
opening in back.
13. Instruct patient to remove hairpins; clips; wigs; hairpieces; jewelry, including rings
used in body piercing; and makeup (including nail polish and acrylic nails). Religious
medals may be pinned to gown if policy permits. Some agencies allow you to remove
acrylic nails or nail polish from only one finger if using a pulse oximeter. Clinical Deci-
sion Point Tape wedding rings that cannot be removed. Be careful not to create tourni-
quet effect with tape around finger.
14. Inventory all items and give to family member or significant other or have security put
valuables in a locked area. Have release form signed.
24.3 post operative care

Definition: Is the period of time that begins with the admission of the patient to PACU and ends
after a follow-up evaluation in the clinical setting or home.
Purpose:
 To ensure that the client experiences an uneventful postoperative course
 To provide safe, effective nursing care in the immediate postoperative period
 To ensure that postoperative pain is relieved promptly
 To be aware of the common postoperative drugs for pain control
Equipment
 Absorbent pads  Vital sign materials
 Warm blankets, Pillow  Nurses’ notes
 IV pole  Intake and output record
 Oxygen source, tubing, and equipment  Special equipment depending on type
 Incentive spirometer of surgery
 PEP device  Pulse oximeter
 Stethoscope  Sterile dressings
 Emesis basin and tissues
Procedure
1. Perform hand hygiene before each client contact.
2. Check two forms of client ID and introduce self to client.
3. Orient client to time, person, and place. Reorient as needed.
4. Assess for patent airway and level of consciousness; administer oxygen if ordered. Attach
pulse oximeter if ordered.
5. Assess for effects of anesthesia including general, regional, or local.
6. Take vital signs, including pain assessment: usual orders are every 15 minutes until stable;
then every half hour for 2 hr; every hour for 4 hr; then every 4 hr for 24–48 hr, or according
to hospital policy.
7. Check pulse oximetry every hour for 4 hr, then every 4 hr.
8. Check ETCO2 using capnography monitoring, if available.
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9. Check for nausea and vomiting.

10. Check IV site and patency frequently.
11. Observe, and record urine output, amount, and color.
12. Measure intake and output.
13. Observe skin color and moisture and nail beds.
14. Position client for comfort and maximum airway ventilation according to orders.
15. Turn every 2 hr and PRN.
16. Give back care at least every 4 hr.
17. Encourage coughing and deep breathing every 2 hr (may use spirometer or Tri-flow if or-
dered).
18. Keep client comfortable with medications.
19. Monitor for side effects of medications.
20. Check dressings and drainage tubes every 2–4 hr; if abnormal amount of drainage, check
more frequently. Empty drainage system when needed
21. Assess for signs and symptoms of Surgical Site infections (SSIs).
a. Superficial incisional:
 Purulent drainage with or without elevated white blood cell count
 Pain or tenderness at the site
 Localized swelling, heat, or redness
 Positive wound culture
b. Deep incisional:
 Purulent drainage
 Temperature above 100.4°F (38°C)
 Leukocytosis
 Localized pain or tenderness
c. Organ/space:
 Purulent drainage from a drain placed in an organ or space
 Positive culture from fluid or tissue in the organ or space
 Temperature above 100.4°F
 Leukocytosis
 Pain
 Abscess formation or other evidence of infection in the organ or space
22. Provide oral hygiene at least every 4 hr; if nasogastric tube or nasal oxygen is inserted, give
oral hygiene every 2 hr.
23. Bathe client when temperature can be maintained.
24. Keep client warm and avoid chilling, but do not increase temperature above normal. Use of
Bair Paws Warming System allows client to maintain warmth and provides comfort. Ex-
cessive perspiration causes fluid and electrolyte loss.
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25. Irrigate nasogastric tube every 4 hr and PRN, as ordered, with normal saline to keep patent
and to prevent electrolyte imbalance.
26. Maintain dietary intake: type of diet depends on type and extent of surgical procedure.
a. Minor surgical conditions: Client may drink or eat as soon as he or she is awake, de-
sires food or drink, and has gag reflex present.
b. Major surgical conditions: NPO until bowel sounds return. Clear liquid advanced to
full diet as tolerated.
27. Place client on bedpan 2–4 hr postoperatively if catheter not inserted.
28. Check physician’s orders when to begin the client’s postoperative activity. Most clients are
ambulated within first 24 hr.
29. Observe for signs and symptoms of possible postoperative complications, particularly
postoperative bleeding and infection.
30. Dangle or position client in chair as ordered.
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PROCEDURE - 25
WOUND CARE
Definition: A wound is any disruption in the skins intactness. It may be accidental or intentional
such as abrasion (rubbing off the skin’s surface); a puncture wound (stab wound); or laceration
(a wound with torn, ragged edges). A wound may be intentional, such as surgical incision (a
wound with clean edges).
25.1 Determining surgical site infection (SSI)

Procedure
1. Before surgery assess client for risk factors associated with surgical site infections (SSIs).
 Complete health history and physical assessment.
 Obtain information on all medications currently taking.
 Determine whether client is allergic to specific medications.
 Review lab values.
2. Determine whether client has a preexisting viral or bacterial infection.
 Clients who must undergo surgery even with existing infections must be monitored close-
ly postoperatively.
 Clients scheduled for routine surgery should be treated first and then rescheduled for sur-
gery once the infection is cleared.
3. Check that client does not have nasal bacterial colonization
4. Complete a nutritional assessment and review lab findings for serum albumin, prealbu-
min, serum transferring, and total lymphocyte levels.
5. Diabetic clients with elevated fasting serum glucose are at higher risk than other diabetic
clients for SSIs due to the high glucose levels.
6. Clients with chronic illnesses such as hypertension and other uncontrolled conditions are
at high risk for SSIs and must be monitored carefully after surgery. It is preferable to get
the conditions under control before surgery is considered.
7. Determine whether client was instructed to perform a preoperative skin cleansing at
home.
8. Check that client has not shaved the surgical site.
9. Check that the client has an antibiotic order for 1 hr before surgery or, if vancomycin is
ordered 2 hr before surgery.
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25.2 Dressing of a Clean Wound

Purpose
 To keep wound clean
 To prevent the wound from injury and contamination
 To keep in position drugs applied locally
 To keep edges of the wound together by immobilization
 To apply pressure
 To facilitate wound healing process
Equipment
 Pick up forceps in a container
 Sterile bowl or kidney dish
 Sterile cotton balls
 Sterile galipot
 Sterile gauze
 Three sterile forceps
 Rubber sheet with its cover
 Antiseptic solution as ordered
Technique
 Aseptic technique to prevent infection
Procedure:
2. Close door or bed curtains and explain the procedure to the patient and patient’s family.
3. Position patient comfortably. Expose only wound area.
4. Place rubber sheet and its cover under the affected side.
5. Ensure that an appropriate waste receptacle is within easy reach of work area.
6. Remove the outer layer of the dressing e.g. adhesive tape bandage.
7. Remove the inner layer of the dressing using the first sterile forceps (If dressing adheres
to wound, apply a small amount of sterile saline on the wound to loosen the dressing) and
discard both the soiled dressing and the forceps.
8. Take the second sterile forceps. Clean wound with gauze soaked in antiseptic solution,
starting from inside to the outside Cleanse around a closed incisional wound with small
circular strokes to gently remove adherent wound exudates.
9. Again use the second forceps to clean the skin around and remove adhesive with benzene
or ether.
10. Inspect the wound for bleeding, inflammation, drainage, and healing. Note any areas of
dehiscence (opening or gaping of wound edges).
11. Apply medication if any and Pick up sterile dressings by touching only the outer center of
the dressing, and apply one at a time over the wound.
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12. Secure the dressings with tape. Place tape over center of dressing and evenly apply pres-
sure to outward edges of dressings.
13. Remove gloves. Perform hand hygiene.
14. Document procedure.
25.3 Dressing of Septic Wound

Purpose:
 To facilitate wound healing process
 To absorb materials being discharge from the wound
 Apply pressure to the area
 Apply local medication
 Prevent pain, swelling and injury
Equipment
 Sterile galipot
 Sterile kidney dish
 Sterile gauze
 Sterile forceps 3
 Sterile test tube or slide
 Sterile cotton- tipped application
 Sterile pair of gloves, if needed, in case of gas gangrene rabies etc.
 Rubber sheet and its cover
 Local medication if ordered
 Receiver with strong disinfectant to immerse used instrument
 Scissors
 Benzene or ether
 Bandages or adhesive tape
 Bucket to put in soiled dressing
Procedure
2. Clean trolley o tray and assemble sterile equipment on one side and surgically clean
items on the other side. Make sure the tray or trolley is covered.
3. Drape patient and position comfortably.
4. Place rubber sheet and its cover under the affected part
5. First remove the outer layer of the dressing
6. Wear gloves if necessary. Use, forceps to remove the inner layer of the dressing smooth-
ly and discard there for caps.
7. Observe wound and check if there is drainage rubber or tube.
8. Take specimen for culture or slide if ordered (Do not cleanse wound with antiseptic be-
fore you obtain the specimen.)
9. Start cleaning wound from the cleanest part of the wound to the most contaminated part
using antiseptic solution.
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10. (H2O2 3% is commonly used for septic wound). Discard cotton ball used for cleaning
after each stroke over the wound.
11. Cleanse the skin around the wound to remove the plaster gum with benzene or ether
12. Drying the skin around the wound properly
13. Dress the wound and make sure that the wound is covered completely
14. Fix dressing in place with adhesive tape or bandages
15. Leave patient comfortable and tidy
16. Cleanse and return equipment to its proper places
17. Discard soiled dressings properly to prevent cross infection in the ward.
25.4 pressure ulcer
Definition: A localized injury to the skin and/or the underlying tissue, usually over a bony
prominence, as a result of pressure and/or shear.
Purpose
 To identify the stage of the ulcer
 To provide appropriate treatment for specific ulcer stage
 To promote healing of established ulcer
 To prevent new ulcer formation
 To prevent spread of pathogens from ulcerated area
Preventing Pressure Ulcers

Procedure
1. Inspect skin at least on admission and once a shift, particularly over bony prominences.
Heels and sacrum are most common areas for skin breakdown. Use Braden or Norton
scale for assessment. Document assessment findings
2. Individualize client’s bathing schedule. Daily baths are not essential
 Avoid hot bath water.
 Use mild cleansing agents to minimize dryness.
 Cleanse skin immediately if urine, fecal incontinence, or wound drainage seeps onto
skin.
 Provide humidity to prevent drying of skin.
 Use cream or thin layer of corn starch to protect skin.
3. Avoid massaging bony prominences.
 Keep bony prominences from direct contact with one another.
 Use pillow, foam wedges, or other positioning devices.
 Use elbow pads and heel elevators.
4. Promote adequate dietary intake of protein, calories, and nutrients. Protein should be
approximately 1.2 to 1.5 g/kg body weight daily.
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5. Ensure adequate fluid intake.

6. Reposition bedridden client every 1–2 hr.
 Do not position directly on trochanter.
 Do not turn more than 30° angle.
 Raise heels off bed by placing pillows under legs; allow heels to hang over edges.
 Use trapeze or turning sheet to reposition client.
7. Encourage mobility or range-of-motion exercises.
8. Minimize force and friction on skin when turning or moving client. Use turning sheets or
Hoyer lift.
9. Maintain head of bed at lowest degree of elevation consistent with medical problem; be-
low 30° if possible.
10. Place at-risk clients on pressure-reducing devices, in both bed and chair, such as foam,
static-air, alternating gel, water mattress, or air-fluidized mattress.
11. Place client on specialty bed or mattress if highly at risk for pressure ulcer formation or
has an ulcer.
12. Encourage chair-fast clients to shift position every 15 minutes
Providing Care for Clients with Pressure Ulcers

Procedure
1. Monitor client’s overall condition daily.
2. Differentiate type of ulcer, pressure versus nonpressure.
3. Determine stage of ulcer.
4. Monitor and assess ulcer characteristics daily:
 Observe dressing to determine whether dry, intact, and not leaking.
 Observe ulcer bed, if appropriate, and document findings.
5. Assess pain level of client and provide adequate pain relief.
6. Photograph ulcer according to facility policy.
7. Monitor progress toward healing and for potential complications.
 Measure pressure ulcer size weekly using a Pressure Ulcer Scale. Usual healing time is 2
to 4 weeks.
 If healing is not progressing or has not healed in usual time frame, reevaluate treatment
plan and client’s condition.
8. Maintain turning and positioning schedule to promote healing and prevent additional
ulcer formation.
9. Complete a nutritional assessment. Positive nitrogen balance and protein intake are ne-
cessary for healing.
10. Complete a psychosocial assessment to determine client’s adherence to pressure ulcer
treatment regimens.
90
11. Complete dressing change according to facility policy and type of dressing used. Follow
manufacturer’s guidelines for dressing change.
Table 1: Pressure Ulcer Risk Assessment Scales

Norton Scale
Physical Condition Mental Condition Activity Mobility Continence

Good 4 Alert 4 Walks 4 Full 4 Good 4
Fair 3 Apathetic 3 Walks with help 3 Slightly limited 3 Occasional incontinence 3
Poor 2 Confused 2 Sits in chair 2 Very limited 2 Frequent incontinence 2
Very poor 1 Stuporous 1 Remains in bed 1 Immobile 1 Urine and fecal incontinence 1
Total ____ Total ____ Total ____ Total ____ Total ____
Grand total = _____
A score of 14 or less indicates risk of pressure ulcer; a score under 12 indicates high risk
Braden Scale
Sensory Moisture Activity Mobility Nutrition Friction and

Perception Shear
No Rarely Walks No limitations 4 Excellent 4
Impairment 4 Moist 4 Frequently 4
Slightly Occasionally Walks Slightly limited 3 Adequate 3 No apparent
Limited 3 Moist 3 Occasionally 3 Problems 3
Very Very moist 2 Chair fast 2 Very limited 2 Probably Potential
Limited 2 Inadequate 2 Problem 2
Completely Constantly 1 Bedfast 1 Completely Very Problem 1
Limited 1 moist Immobile 1 Poor 1
Total ____ Total ____ Total ____ Total ____ Total ____ Total ____
Grand total = _____
Assign a score of 1 to 4 in each category. Total the score;

 no risk: 19–23;
 at risk: 15–18;
 moderate risk: 13–14;
 high risk: 10–12;
 Very high risk: 9 or below.
Stages of Pressure Ulcer

STAGE 1:- Nonblanchable erythema, redness that remains present over an area under pressure
30 minutes after pressure source is removed. Epidermis remains intact.
STAGE 2:- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink
wound bed, without slough.
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STAGE 3:- Full thickness tissue loss, subcutaneous fat may be visible, but Bone, tendon or
muscle are not exposed
STAGE 4:- Full thickness tissue loss with Exposed bone, tendon or muscle.
UNSTAGEABLE: - Full thickness tissue loss in which the base of the ulcer is covered by
slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound
bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true
depth, and therefore stage, cannot be determined.
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PROCEDURE – 26
WOUND SUTURING
Definition: the process of joining two surfaces or edges of a wound or surgical incision together
along a line by sewing.
Purpose
 To approximate wound edges until healing occurs
 To speed up healing of wound
 To minimize the chance of bleeding and infection
 For esthetic purpose
Sterile equipment
 Tray or trolley covered with a sterile  Dressing forceps
towel  Receiver
 Needle holder  Gauze
 Round needle (2)  Plaster
 Cutting needle (2)  Dressing scissors
 Silk, Cat- gut  Local anesthesia
 Tissue forceps  Needle & syringes
 Suture scissors  Gloves
 Cotton swabs in a galipots  Hole-towel(Fenestrated towel)
 Solution for cleaning
Procedure
1. Explain procedure to patient
2. Adjust light
3. Wash your hands
4. Clean the wound thoroughly
5. Wash your hands again
6. Put on sterile gloves
7. Drape the Wound with the hole sheet
8. Infiltrate the edges of the wound to be sutured with local anesthesia
26.1 Simple suture or everting interrupted suture
9. Insert the needle at a 90° angle to the skin within 1-2 mm of the wound edge and in the
superficial layer.
10. The needle should exit through the opposite side equidistant to the wound edge and di-
rectly opposite the initial insertion.
11. Oppose equal amounts of tissue on each side.
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12. Strive to Evert the edges and avoid tension on the skin, while approximating the wound
edges. Place all knots on the same side.
26.2 Simple running suture
9. This suture method entails similar technique to the simple suture without a knotted com-
pletion after each throw. Precision penetration and tissue opposition is required.
10. The speed of this technique is its hallmark; however, it is associated with excess tension
and strangulation at the suture line if too tight, which leads to compromised blood flow
to the skin edges.
11. Another variant is the simple locked running suture, which has the same advantages and
similar risks. The locked variant allows for greater accuracy in skin alignment.
12. Both styles are easy to remove. Additionally, the running sutures are more watertight.
26.3 Mattress suture

9. Vertical mattress sutures: can aid in everting the skin edges. Use this technique also for
attachments to a fascial layer.
10. The needle penetrates at 90° to the skin surface near the wound edge and can be placed in
deeper layers, either through the dermal or subdermal layers.
11. Exit the needle through the opposite wound edge at the same level, and then turn it to re-
penetrate that same edge but at a greater distance from the wound edge.
12. The final exit is through the opposing skin edge, again at a greater distance from the
wound edge than the original needle entrance site.
13. Place the knot at the surface. A knot placed under tension risks a stitch mark.
14. The horizontal mattress sutures: can be used to oppose skin of different thickness.
15. With this stitch, the entrance and exit sites for the needle are at the same distance from
the wound edge.
16. Half-buried mattress sutures are useful at corners. On one side, an intradermal component
exists, in which the surface is not penetrated.
17. Place the knot at the skin surface on the opposing edge of the wound.
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26.4 Subcuticular suture
9, Sutures can be placed intradermally in either a simple or running fashion.
10. Place the needle horizontally in the dermis, 1-2 mm from the wound edge.
11. Do not pass the needle through the skin surface.
12. The knot is buried in the simple suture, and the technique allows for minimization of ten-
sion on the wound edge.
13. In a continuous subcuticular stitch, the suture ends can be taped to the skin surface with-
out knotting.
14. Approximate the edges of the fascia with the help of the tissue forceps and using the
round needle and cat- gut. Suture the fascia layer first.
15. Using the cutting needle and silk, suture the outer layer of skin approximating the edges
with the help of the tissue forceps.
16. Clean with iodine and cover with sterile gauze.
17. Remove the hole- Sheet
18. Make patient comfortable
19. Remove all equipment, wash & return to its proper place or send for sterilization.
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PROCEDRUE- 27
ASSISTING WITH CAST
27.1 Assisting with Cast Application

Definition: A cast immobilizes an injured extremity to protect it from further injury, provides
alignment of a fracture by holding the bone fragments in reduction and alignment during the
healing process, and promotes comfort.
Purpose
 To prevent or correct deformity
Scope: surgical wards, units, surgical OPDs, OR and emergency
Equipment
 Plaster rolls (sizes include 2-, 3-, 4-, and 6-inch rolls) or cast materials such as fiberglass,
casting tape, or plastic, depending
 Padding material (felt, stockinet, Webril, or gore lining)
 Plastic-lined bucket or basin filled three-fourths full with warm water
 Clean gloves, apron, or protective cover
 Cart, chair, and fracture table
 Scissors
 Paper or plastic sheets
 Cast cutter (if old cast is to be removed)
 Clean cast saw blades
Procedure
1. Identify patient using two identifiers (i.e., name and birthday or name and account number)
2. Administer analgesic before cast application: oral (PO), 30 to 40 minutes before; intramus-
cular (IM), 20 to 30 minutes before; intravenous (IV)
3. Perform hand hygiene and apply clean gloves.
4. Help health care provider, patient and injured extremity as desired, depending on type of
cast to be used and area to be casted.
5. Prepare skin that will be enclosed in cast.
6. Explain that patient may experience warmth during cast application process.
7. Assist with application of padding material around body part to be casted. Apply minimum
of four layers of padding. Avoid wrinkles or uneven thickness.
8. Hold body part or parts to be casted or assist with preparation of cast materials.
 Plaster cast: Mark end of roll by folding one corner of material under itself. With your
thumb under outer edge, submerge plaster roll under water in casting bucket or plastic
basin until bubbles stop; squeeze slightly and hand roll to person applying cast.
 Synthetic cast: Submerge cast roll in lukewarm water for 10 to 15 seconds. Squeeze to
remove excess water. You can use a water bottle to apply water to casting material.
9. Continue to hold body part(s) as necessary as cast is applied or supply additional rolls of
casting tape as needed.
96
10. Hold body part while casting tape is applied and molded. Synthetic tape is applied with
slight tension. When wrapping is complete, gently compress with hands.
11. Provide walking heel, cast brace, bar, or other cast stabilization material as requested by
health care provider.
12. Using scissors, trim cast around fingers, toes, or thumb as necessary.
13. Remove and dispose of gloves and other disposable equipment into appropriate receptacle.
Perform hand hygiene.
14. Using palms of hands to support casted areas, help patient with transfer to stretcher or
wheelchair for return to nursing unit
15. Inform patient to notify care provider of any alteration in sensation, numbness, tingling,
burning, pain on passive motion, or inability to move fingers or toes in affected extremity
27.2 Care of the patient in cast

Purpose:
 To promote comfort, prevent pressure sores and other complications as deformity,
thrombosis, embolic, constipation etc.
 To improve general health of the patient and speed up recovery.
Scope: surgical wards, units, OPDs and emergency
Equipment:-
 Fracture board of the appropriate size
 Firm matters and bed cradle
 Sand age, 2 – 3
 A bed with trapeze, if available
 Mackintosh
Procedure
1. The bed should be prepared before hand with a board under the mattress, if needed,
2. Immediately after the completion of cast application and parts of the extremity on which
the cast is applied should be observed for symptoms such as pain, pallor discoloration,
tingling sensation, numbness, coldness or inability to move report immediately of any of
these signs are noticed
3. Put mackintosh under the part where the cast is, to protect the bed linen until it dries.
4. Keep the bed linen away from the wet plaster until it dries. Put the bed cradle to lift the
weight off the bed linen.
N.B.
 Be informed about the condition of the patient and the type of cast applied
 If cast is applied around the trunk or hip, turn patient frequently to allow even drying
of the cast and to prevent fatigue of the patient.
 Elevation of the part may help to control selling
 Heat should never be applied to the cast in attempt to dry it quickly as it can crack
and cause burning
97
27.3 Removal of cast

Purpose:
Cast is removed when
 Fracture is healed
 Cast is too tight
Scope: surgical wards, units, OPDs and emergency
Equipment
 Electrical shears (cutter) or plaster shears or cutter
 Metal strip, if available
 Water and soap
 Towel
 Oil or lanolin
 Mackintosh
 Waste basket
 Dressing scissors
 Plaster knife
Procedure:
1. Explain procedure to patient’
2. Make a mark with a plaster knife
3. Use the electric shears, the placer shears or cutter and push it gently into the cast follow-
ing the knife mark.
4. Cut the last layer with dressing scissors
5. Wash the skin with water and soap
6. Dry it with a towel
7. Apply oil or lanolin
8. Remove clean and return used equipment to its proper place.
9. Discard the removed cast
10. Record
N.B
 Be careful not to cut the skin under the cast while cutting it.
 Electric shears should be used by skilled personnel only.
 Help the patient to understand that he may experience pain and stiffness until he his reha-
bilitate
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PROCEDRUE - 28
ASSISSTING WITH TRACTION APPLICATION
Definition: Traction is the application of a force to stretch certain parts of the body in a specific
direction.
Purpose
 To regain normal length and alignment of involved bone.
 To reduce and immobilize a fractured bone.
 To relieve or eliminate muscle spasms.
 To relieve pressure on nerves, especially spinal.
 To prevent or reduce skeletal deformities or muscle contractures.
 Controls pain.
 Reduces fracture.
 Maintain reduction.
28.1 Care of a Patient in Skin Traction

Equipment
 Overhead frame for attachment of traction
 Traction bar
 Cross clamp and pulley
 Buck’s extension boot or moleskin and elastic bandages
 1- to 7-lb weights
 Spreader bar
Procedure
1. Identify patient using two identifiers (i.e., name and birthday or name and MRN) accord-
ing to agency policy
2. Prepare patient by discussing procedure.
3. Administer analgesic for acute pain and a muscle relaxant for spasms in advance of trac-
tion application.
5. Buck’s extension: Position patient supine and nearly flat with no more than 30 degrees of
elevation, with affected leg halfway between edge and middle of bed.
6. Apply clean gloves and wash affected extremity gently and pat dry. Do not shave extrem-
ity.
7. Apply foam boot, moleskin, or elastic bandages to affected extremity, proceeding from
distal to proximal. For Buck’s extension:
a. Before placing foam boot, wrap leg in soft roll. Ensure that boot fits snugly.
b. Seat heel properly in traction boot. Do not pad at heel.
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c. Do not apply traction boot over sequential pneumatic compression devices. Instead
use foot pumps.
8. Attach weight to boot gradually and gently at end of bed. Health care provider determines
exact amount of weight to be applied and position to be maintained.
9. Inspect traction equipment, making sure that:
 Knots are secure.
 Ropes are in pulleys and not frayed.
 Weights are hanging freely, not caught on bed or resting on floor.
 Bed linens and bedclothes are not interfering with traction equipment.
 Check the four P’s of traction maintenance: pounds, pressure, pull, and pulleys.
10 Before health care provider leaves, assess patient’s position and ask about additional
permissible positions for patient and bed.
a. Buck’s extension: Patient is primarily on back but may be allowed to turn to unaf-
fected side for brief periods (10 to 15 minutes).
b. Dunlop’s traction: Patient must lie on back. Bed may be tilted on low shock blocks
toward side opposite traction. Head of bed is kept flat. Tilting uses body for some
counter traction.
c. Russell’s traction: Patient lies on back; head of bed may be elevated 30 to 45 de-
grees, depending on injury
11 Release and reapply traction and provide skin care according to health care provider’s
order. Traction boot is removed every 4 to 8 hours.
12 Remove and dispose of gloves. Perform hand hygiene. Gather unused materials and re-
turn to storage areas.
28.2 Care of a Patient in Skeletal Traction and Pin Site Care

Equipment
Balanced-Suspension Skeletal Traction
 Ropes, pulleys, weights, weight holders
 Thomas splint
 Pearson attachment with sheepskin padding
 Footplate
 Trapeze bar
 Clean gloves
Halo Traction
 Halo ring with four pins
 Molded vest jacket
 Vertical metal bars connecting ring to jacket
 Tracheostomy tray (for emergency resuscitation)
 Allen wrench (allows removal of screws for resuscitation)
100
Pin-site Care
 Sterile cotton-tipped applicators
 Prescribed cleaning agent. Preferred agent chlorhexidine, 2mg/ml solution, or 0.9% so-
dium chloride solution
 Split 2 × 2-inch gauze barrier (optional)
 Topical antibiotic ointment
 Clean gloves
Procedure
1. Identify patient using two identifiers (i.e., name and birthday or name and MRN) according
to agency policy). Discuss procedure with patient.
3. Initial traction setup:
 Apply clean gloves and position patient per physician’s order. Support limb at joint
above and below fracture to be placed in traction. Do not move distal parts unnecessari-
ly. Patient will likely be placed in supine position with head of bed slightly elevated.
 Physician wears sterile gloves and gown while cleaning skin over pin sites and inject-
ing local anesthetic.
 Assist (usually by holding spreader bar, splint, or Pearson attachment) while health care
provider continues to use drill to insert number of pins needed for traction. Support area
of joints not at injury site. Do not move distal portion unnecessarily.
 Once traction setup is applied, attach weights and gently lower until rope is taut.
 Inspect traction setup; ensure that:
o Knots are secure and footplate is in place.
o Ropes and pulleys are not frayed.
o Weights are hanging freely, not caught on bed or resting on floor.
o Bedclothes are not interfering with traction apparatus.
4. Provide pin-site care according to agency policy or Physician’s order.
 Apply clean gloves and remove gauze dressings from around pins and discard in ap-
propriate receptacle.
 Inspect pin sites for redness, edema, or purulent drainage.
 Prepare supplies.
 Apply clean gloves and clean each pin site with prescribed cleaning solution by placing
tip of moistened sterile applicator close to pin and cleaning away from insertion site.
Dispose of applicator. Use new sterile applicator for each swipe.
 Repeat process for each pin site.
 Using sterile applicator, apply small amount of topical antibiotic ointment to pin site
 Cover with sterile 2×2-inch split gauze dressing or leave site open to air (see physician
order or according to agency policy).
5. Provide routine traction care.
101
o Inspect skin (bony prominences, heels, elbows, sacrum, and areas under appliances)
for signs of pressure. Use pressure relief devices as appropriate. Try to reposition any
areas under pressure if possible. Do not massage areas of pressure if there is tender-
ness, reactive hyperemia (increase in blood flow), or areas of skin breakdown.
6. Provide non pharmacologic and pharmacologic pain relief as indicated.
7. Encourage use of unaffected extremities for ADLs and active and passive exercises. En-
courage use of trapeze bar for repositioning.
8. For elimination, provide a fracture pan if needed.
9. Raise appropriate number of side rails as needed.
10. Remove and dispose of gloves if used, gather equipment and supplies, and return to proper
storage places.
102
PROCEDURE - 29
HELP PATIENTS WITH CRUTCH WALKING
Crutches: - A wooden or metal vertical prop that helps support a disabled person while he or she
is walking. Crutches extend from the walking surface to either the armpit or the arm.
Purpose
 To Increase patient’s level of activity after musculoskeletal injury
 To assist patient to walk safely with crutches using the least amount of energy.
Assessment
 Assess physical ability to use crutches and strength of the client’s arm back, and leg mus-
cle.
 Observe client’s ability to balance self.
 Note any unilateral or unusual weakness or dizziness.
 Assess which gait is appropriate for client.
 Assess client’s understanding of crutch-waking technique
Purpose:
 To improve clients ability to ambulate He/ She has lower extremity injury
 To increase muscle strength
 To increase feeling of well being
 To promote joint mobility
Equipment
 Properly fitted crutches
 Regular, hard soled street shoes
 Safety belt, if needed
Procedure
A. Four-Point Gait
1. Explain the rationale for the procedure to the client
 The gait is rather slow but very stable
 The gait can be performed when the client can move
2. Patient stands erect, face forward in tripod position.
3. Patient places crutch tips 6 inches in front of feet and 6 inches to side of each foot.
4. Demonstrate the crutch foot sequence to the client.
 Move the right crutch
 Move the left foot
 Move the left crutch
 Move the right foot
5. Help the client practice the gait. Be ready to help with balance if necessary.
6. Assess client’s progress, and correct mistakes as they occur.
103
B. Three-Point Gait
Equipment: Similar with Four Gaits
Procedure
2. Explain the rationale of the procedure
 The gait can be performed when the client can bear little or no weight on one leg or
when the client has only one leg.
 This gait is fairly rapid and requires strong appear extremities and good balance.
2. Demonstrate the crutch-foot sequence to the client.
 Two crutches support the weaker extremities
 Balance weight on the crutches
 Move both crutches and affected leg forward
 Move unaffected leg forward
3. Assess the client’s progress, and correct any mistakes as they occur.
4. Remain with client until crutch safety is ensured.
C. Two point gait
Procedure
1. Explain the procedure to the client.
 This procedure is a rapid version of the four point gait
 This gait requires more balance than the four gait
2. Demonstrate the crutch-foot sequence to the client.
 Advance the right foot and left crutch simultaneously
 Advance the left foot and the right crutch simultaneously
3. Help the client practice the gait.
4. Assess the client’s progress, and correct any mistakes as they occur.
D. Teaching Swing-To-Gait and Swing through Gait
Equipment
 Properly fitted crutches
 Regular, hard soled street shoes
Procedure
1. Explain the rationale for the procedure the client.
 These gaits are usually performed when the client’s lower extremities are paralyzed.
 The client may use braces.
2. Demonstrate the crutch-foot sequences to the client
 Move both crutches forward
 Swing to gait: left and swing the body to the crutches
 Swing through gait: left and swing the body past the crutches
 Bring crutches informed of the body and repeat.
3. Help client practice the gait
4. Assess the client’s progress and correct any mistakes as they occur.
104
PROCEDURE – 30
ADMINISTERING BLOOD TRANSFUSSION
Definition: blood transfusion is generally the process of receiving blood products in to one’s cir-
culation intravenously and used for various medical conditions to replace lost components of the
blood.
Goal: Replace blood volume or blood components lost through trauma, surgery, or a disease
process; prevent complications from transfusing incompatible blood products.
Purpose
 To counteract severe hemorrhage and replace the blood loss.
 To prevent circulatory failure in operation where blood loss is considerable
 In severe burns to make up for blood lost by burning but only after plasma and electrolytes
have been replaced.
 For treatment of severe anemia due to cancer, marrow aplasia and similar conditions.
 To provide clotting factors normally present in blood, which may be absent as a result of
disease.
Equipment
 Prescribed blood product
 Blood giving set
 Sterile syringes and needle
 Alcohol swabs
 Tourniquet, Arm splint
 Adhesive tape
 Receiver for dirty swabs
 I.V pole (stand)
 Patient's chart.
 Vital sign equipments
 Gloves
 Pressure bag
Procedure
2. Identify the patient using two separate identifiers.
4. Ensure informed consent has been signed by provider and patient. Teach patient what to
report in the event of an adverse reaction, such as chills, back pain, headache, nausea or
vomiting, rapid heart rate, rapid breathing, or skin rash.
5. Administer premedication’s, such as diphenhydramine, if ordered.
105
6. Obtain patient’s vital signs, including temperature.

7. With another RN, a physician, or other licensed staff member at the patient’s bedside, veri-
fy the blood component and the patient’s identity by comparing the laboratory blood record
with the following:
 The patient’s name and identification number, both verbally and against patient’s iden-
tification band
 The blood unit number on the blood bag label
 The blood ABO group and Rh factor on the blood bag label
 The type of blood component and the expiration date on the blood label.
8. Inspect blood product for integrity of bag and appearance of component (clots, cloudiness,
abnormal color). Note expiration date and time on the transfusion report.
9. Wash your hands. Put on clean gloves.
10. Open Y-type blood administration set, and clamp both rollers completely.
11. Spike blood component unit bag port. Prime drip chamber and tubing with blood compo-
nent.
12. Spike 0.9% NaCl container with second spike. Keep roller clamp shut.
13. Remove primary IV tubing from catheter hub, and cover end with sterile protector.
14. Attach blood administration tubing to catheter hub, and secure with tape. The IV should be
started into an 18- or 19-gauge catheter.
15. Open clamp to blood component. Open roller clamp below drip chamber and begin transfu-
sion. Program EID to infuse blood slowly for first 15 minutes.
16. Observe and document patient’s condition during first 15 minutes, assessing for chilling,
back pain, headache, nausea or vomiting, tachycardia, hypotension, tachypnea, fluid over-
load, or skin rash. (Note: If any adverse reactions occur, close clamp to blood, open clamp
to 0.9% NaCl, and notify physician immediately. Follow agency policy for laboratory noti-
fication and obtaining blood and urine specimens.)
17. If no adverse reactions occur after 15 minutes, reprogram EID to increase infusion accord-
ing to physician’s orders. A unit of RBCs is usually administered over 2 to 4 hours. Ob-
serve the patient for signs and symptoms of transfusion reaction at least every 30 minutes
throughout the transfusion. Obtain vital signs when observations warrant. Document obser-
vations, including the absence of any signs of transfusion reaction, in the medical record.
18. When blood transfusion is complete, clamp roller to blood and open roller to 0.9% NaCl.
Infuse until tubing is clear (usually no more than 50 ml of normal saline).
19. Obtain and document vital signs.
20. If second blood component unit is to be transfused, slow 0.9% NaCl to keep vein open until
next unit is available. Follow verification procedure and vital sign monitoring for each unit.
21. If transfusion orders are complete, disconnect the blood administration tubing from the IV
catheter hub. Reconnect the primary IV solution and tubing and adjust to desired rate.
22. Wash hands and document procedure.
106
PROCEDURE - 31
ASSISSTING WITH BONE MARROW ASPIRATION
Definition: - it is a puncture made into a flat bone obtains a specimen or red bone marrow.
Purpose: To get a specimen of red bone marrow for the Diagnose of blood diseases especially
for plastic anemia and leukemia.
Site of puncture:
 The sternum bone, therefore called sterna puncture, iliac crest.
Equipment:
 Sterile set containing  sterile test tube, watch glass, slides
 Sterile towel with hole  Clean Equipment:
 Hand towel  Sodium oxalate solution
 Gloves  Rubber sheet and towel to protect the
 Swabs gauze in receiver bed
 Dressing forceps  Antiseptic lotion as tincture of iodine
 Syringe and needle for local anesthe- ether, benzene or alcohol.
sia  Local anesthetic
 Sterna puncture needle with style  Receiver for used instruments
 10ml syringe and adapter if needed  Plaster and scissors.
Procedure
1. Identify client using two forms of identification and explain purpose of procedure.
2. Explain procedure.
3. Client will experience discomfort or pressure when needle is inserted.
4. Obtain consent
5. Obtain tray and provide any additional equipment needed, such as specimen container.
6. Assess coagulation studies and report unusual findings to physician.
7. Premedicate client with prescribed drugs.
8. Position client in supine position if sternum or anterior iliac crest is the biopsy site or
prone if posterior iliac crest is the biopsy site. Place a sandbag under iliac crest area if
physician requires.
9. Open tray on over-bed table.
10. Assist physician as needed.
11. Physician injects local anesthetic at site.
NOTE: A large-bore needle containing a stylus is inserted into bone, about 3 mm deep.
Stylus is removed and 10-mL syringe is attached to needle. About 0.5 to 2 ml of bone
107
marrow is removed as specimen, spread on slides, and sprayed with preservative. Re-
mainder is placed in green or lavender top tube.
12. Perform hand hygiene and don sterile gloves.
13. Apply direct pressure for 5–15 minutes after removal of needle.
14. Cover puncture site with sterile pressure dressing. Icepack may be applied to help control
bleeding.
15. Remove gloves and perform hand hygiene.
16. Monitor vital signs, and observe puncture site for drainage, edema, or pain, as with sur-
gical
17. Position the client for comfort.
18. Properly label specimens and send to laboratory.
19. Evaluate client for signs of hemorrhage, shock, or infection.
108
PROCEDURE - 32
ASSISSTING WITH LUMBAR PUNCTURE
Definition: - It is the insertion of a needle into the subarachinoid space for diagnostic or thera-
peutic purposes.
Purpose:
1. To remove cerebro-spinal fluid for diagnostic purpose.
2. To measure the pressure or the cerebro-spinal fluid & to relieve intracranial pressure.
3. To inject drugs as streptomycin, spinal anesthesia, radio-opaque oil for amyelogram.
 Site of Puncture
 Between the 3rd and 4th or 4th and 5th lumbar vertebrae into the subarachnoid space.
Equipment:
 Sterile set containing:
 Gallipots
 Towel with hole
 Sterile Gloves
 Dissecting forceps & artery forceps
 2 Lumbar puncture needles
 A measure for the fluid to be collected
 A short length of rubber tubing to be attached to the needle
 Needle and Syringe for local anesthesia
 Two test tubes for specimen
 Clean Equipment:
 Manometer for measuring the pressure of C.S.F.
 Local anesthetic
 Skin cleansing lotion (ether, spirit, iodine etc)
 Rubber sheet & towel
 Plaster & scissors
 Receiver for used instruments
 Long tubing enough to be attached to the cannula & guide the fluid to the pail
109
Procedure
1. Identify client using two forms of identification and explain that a lumbar puncture (LP) is
used for diagnosis.
2. Explain procedure - a hollow core needle is placed in the subarachnoid space at L3–4 or
L4–5 to facilitate measuring CSF pressure and obtaining fluid for testing.
3. Obtain history of client’s complaints, including known allergies and current medications.
4. Obtain consent.
5. Instruct client to empty bowel and bladder.
7. Obtain tray and any additional equipment needed, such as sterile gloves, bath blanket.
8. Position client in lateral recumbent position with back at the edge of the examining table.
Cover with bath blanket, exposing only client’s back.
9. Open sterile tray if requested by physician. Pour antiseptic solution into sterile medicine
cup if needed.
10. Instruct client to pull knees up to abdomen and flex chin on chest. Assist client to maintain
position, by nurse standing in front of the client, reaching across to support client behind
neck and knees.
11. Place pillows between knees.
12. Assist client in relaxation exercises or instruct in deep, slow breathing through the mouth.
13. Explain that he or she must remain still without movement during test.
14. Assist physician with the Queckenstedt’s test when requested. After opening pressure is
obtained, apply compression to neck veins with your fingers.
15. Don clean gloves and assist physician as directed. Assisting With Lumbar Puncture
16. Label cerebrospinal fluid samples with number on each specimen container.
17. After removal of needle, apply Band-Aid to puncture site.
18. Remove gloves and perform hand hygiene.
19. Fill out lab slips for appropriate test (i.e., cell count, serology).
20. Instruct client to lie flat for 4–24 hr, Encourage fluids if not contraindicated by client’s
condition
21. Observe for spinal fluid leak from puncture site.
22. Check for headaches or alterations in neurologic status.
23. Document cerebrospinal fluid (CSF) characteristics, including color and clarity. Record
opening pressure.
110
REFERENCE
1. Clinical nursing skills and techniques- perry, anne griffin(SRG), 8E

2. Procedure Checklists for Fundamentals of Nursing human health and function, 7E(2013)
3. Clinical nursing skills – smith, Sandra F (SRG) 8E
4. Fundamentals of nursing standards and practice, 8E
5. Basic clinical nursing, Hawassa university
111

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Ayder referral hospital Standard operational procedures 2015

STANDARD OPERATING PROCEDURES (SOP)

PREPARED BY: HAILAY TEKLU

ETHIOPIA, TIGRAY, MEKELLE

LIST OF ACRONYMS AND ABBREVIATIONS

ABG Arterial blood gas

STANDARD OF OPERATING PROCEDURES (SOP)

 Steps in developing SOP’s

1.1 Assessing body temperature

Sites to Measure Temperature

 Assessing Oral Temperature With an Electronic Thermometer

 Assessing Rectal Temperature with an Electronic Thermometer

 Assessing Temperature Using a Tympanic Membrane Thermometer

 Assessing Axillary Temperature With an Electronic Thermometer

1.2 Obtaining a pulse

 Obtaining a Radial Pulse

 Obtaining an Apical Pulse

1.3 Assessing Respiration

1.4 Obtaining Blood pressure

1.5 Assess for orthostatic hypotension

1.6 Blood glucose monitoring

NUMERIC PAIN INTENSITY SCALE

No pain mild pain moderate pain severe pain worst pain

5. Assess onset of pain and aggravating factors.

Assessing Pain in a Cognitively Impaired or Nonverbal Client

Assessing Pain in Young Children

16. Assess unidimensional indicators.

 To relieve pain or prevent pain from escalating

1. Establish a quiet, private environment.

Using Relaxation Techniques

1. Help client assume a comfortable position.

 To implement strategies to decrease pain

3.1 Oral medications

3.2 Administering medication by metered –dose inhaler

Scope: all wards, units, OPDs, emergency, clinics and at home

3.3 Administering Intradermal Injections

3.4 Administering subcutaneous Injections

3.5 Administering Intramuscular Injections

3.6 Intravenous therapy

 Administering Medication into an Existing Intravenous Line

 Administering the Drug Into an Intermittent Infusion Device or Lock Device

ASSISTING PATIENT IN VEIN CUT DOWN (VENSECTION)

Definition: It is dissection of a vein for inserting I.V cannula or needle.

ASSISSTING WITH CENTERAL VENOUS CATHETERIZATION

6.1 Oxygen administration via face mask

Purpose: used to administer higher concentration of oxygen.

6.2 Nasal Cannula (Nasal Prongs) or nasal catheter

CARE OF A PATIENT ON MECHANICAL VENTILATOR

ENDOTRACHEAL TUBE/TRACHEOSTOMY SUCTIONING

Definition: Endotracheal tube/tracheostomy suctioning is the process of applying a negative pressure

10. Open packed sterile instrument and prepare on a sterile field.

WATER SEAL CHEST DRAINAGE SYSTEM

ASSISSTING WITH THORACENTESIS

ADMINISTERING CARDIOPULMONARY RESUSCITATION (CPR)

14.1 Use of an Automated External Defibrillator

14.2 Assisting with cardiac defibrillation

14.3 Assisting with synchronized cardioversion