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Sterile Technique and Wound Care: A Checklist for Nursing Students, Summaries of Nursing

A detailed checklist for nursing students on the proper techniques for setting up a sterile field, preparing and assessing a wound, and removing an indwelling urinary catheter. It emphasizes the importance of hand hygiene, privacy, and maintaining asepsis throughout the process.

Typology: Summaries

2021/2022

Uploaded on 09/27/2022

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Physical AssessmentPass Off
Student: ____________________________ Instructor: __________________________
General Observations: Vital Signs Mental Status Measurements (done in advance)
Vision: Snellen or Rosenbaum (done in advance and reported to lab instructor @ pass-off) 2 points
Skin: (done throughout exam) inspect lesion/nevi/scars temperature turgor
Head: scalp hair nodules
Face: facial movements/ CN VII facial sensations/CN V palpate muscles/CN V temporal arteries
Eyes: eyebrows/eyelashes/eye lids conjunctiva
corneal light reflex pupils equal response direct/consensual to light & accommodation EOMs
Ears: external inspect/palpate otoscope hearing: whisper Weber & Rinne
Nose: patency (& CN I) internal mucosa & nasal septum tenderness palpate or percuss sinuses
Mouth: lips oral mucosa teeth & gums tongue m/l tongue movement/CNXII
“ah”/soft palate/uvula /CN X tonsils/palatine arches gag reflex/CN X
Neck: lymph nodes trachea m/l ROM strength against resistance/CNXI
shrug shoulders/CNXI carotid arteries
Thorax/posterior: inspection symmetry chest expansion percuss percuss CVA tenderness auscultate
RML: auscultate Anterior: auscultate (examiner requests deep breaths in & out through mouth before auscultating )
Cardiovascular: pulsations/heaves/lifts PMI auscultate: sitting, diaphragm & bell supine, diaphragm & bell)
Abdomen: inspect auscultate BS/bruits percuss (4 quads, liver) light palpate (tenderness)
deep palpation (masses, liver, spleen) (examiner requests knees flexed before palpation )
Upper Ext: Inspect: arms/hands/fingers nail plate angle/curvature Palpate: capillary refill handgrip Pulses: radial brachial
Lower Ext:: Inspect: legs/feet/toes/nails Palpate: capillary refill edema Pedal Pulses: dorsalis pedis posterior tibial
Muscle strength: upper extremities lower extremities
Sensory: light touch location/vibration sharp/dull proprioception
Coordination: rapid alternating movements heel to shin
Reflexes: biceps & triceps knee jerk & achilles plantar
ROM: upper extremities (shoulders, elbow, wrist, hands, fingers) lower extremities (hips, knees, ankles, feet, toes) spine
Ambulation/Gait/Balance: gait Romberg
Spine: inspection palpation (points from Skin-Spine = 1 point/square, total 85 points) sub-total _____/87
Professional dress yes no
hand hygiene: yes no
Equipment yes no
& Pass-off form: yes no
(1/2 point for each)
Explains procedures to client: always usually (2 points) sometimes
(1 point)
Organized & follows general order: always usually (skips back x1-2) (2 points) sometimes (skips back 3)
(1 point) >3
(0 points)
Refers to 3X5 card: end of exam only rarely (once during exam & once @ end) (2 points) occasionally (2-3 during exam)
(minus 1)
often (>3 during exam)
(minus 2 points)
Performs skills/techniques correctly: always usually (1 incorrect) (3 points) sometimes (2 techniques incorrect)
(1 point)
3 techniques incorrect
(0 points)
Complete in ≤ 40 minutes (2 points) Required excessive time >40 minutes (0 points)
start time___________ completion time______________
Comments/suggestions: Final Score _____/100
=completed
= not completed
= skipped back
to complete
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Physical Assessment—Pass Off

Student: ____________________________ Instructor: __________________________

General Observations: Vital Signs Mental Status Measurements  (done in advance)

Vision : Snellen or Rosenbaum (done in advance and reported to lab instructor @ pass-off) 2 points

Skin: (done throughout exam) inspect lesion/nevi/scars temperature turgor

Head : scalp hair nodules

Face : facial movements/ CN VII  facial sensations/CN V palpate muscles/CN V temporal arteries

Eyes : eyebrows/eyelashes/eye lids conjunctiva

corneal light reflex pupils equal response direct/consensual to light & accommodation EOMs 

Ears : external inspect/palpate otoscope hearing : whisper Weber & Rinne

Nose : patency (& CN I)  internal mucosa & nasal septum tenderness palpate or percuss sinuses

Mouth : lips oral mucosa teeth & gums tongue m/l  tongue movement/CNXII

“ah”/soft palate/uvula /CN X tonsils/palatine arches gag reflex/CN X

Neck : lymph nodes trachea m/l ROM strength against resistance/CNXI 

shrug shoulders/CNXI  carotid arteries

Thorax/posterior : inspection symmetry chest expansion percuss percuss CVA tenderness auscultate

RML: auscultate  Anterior : auscultate (examiner requests deep breaths in & out through mouth before auscultating )

Cardiovascular : pulsations/heaves/lifts PMI auscultate: sitting, diaphragm & bell supine, diaphragm & bell)

Abdomen : inspect auscultate BS/bruits percuss (4 quads, liver)  light palpate (tenderness) 

deep palpation (masses, liver, spleen) (examiner requests knees flexed before palpation )

Upper Ext: Inspect: arms/hands/fingers  nail plate angle/curvature  Palpate: capillary refill  handgrip  Pulses : radial  brachial

Lower Ext: : Inspect: legs/feet/toes/nails Palpate: capillary refill edema Pedal Pulses : dorsalis pedis posterior tibial

Muscle strength : upper extremities  lower extremities 

Sensory: light touch  location/vibration  sharp/dull  proprioception 

Coordination : rapid alternating movements heel to shin

Reflexes : biceps & triceps  knee jerk & achilles  plantar 

ROM : upper extremities (shoulders, elbow, wrist, hands, fingers)  lower extremities (hips, knees, ankles, feet, toes)  spine 

Ambulation/Gait/Balance : gait Romberg

Spine : inspection palpation (points from Skin-Spine = 1 point/square, total 85 points) sub-t otal _____/

Professional dress yes  no  hand hygiene : yes no  Equipment yes no  & Pass-off form : yes no  (1/2 point for each)

Explains procedures to client : always usually (2 points) sometimes  (1 point)

Organized & follows general order : always usually (skips back x1-2)  (2 points) sometimes (skips back 3)  (1 point) >3  (0 points)

Refers to 3X5 card : end of exam only  rarely (once during exam & once @ end)  (2 points) occasionally (2-3 during exam)  (minus 1)

often (>3 during exam)  (minus 2 points)

Performs skills/techniques correctly : always usually (1 incorrect)  (3 points) sometimes (2 techniques incorrect)  (1 point)

≥ 3 techniques incorrect  (0 points)

Complete in ≤ 40 minutes (2 points) Required excessive time >40 minutes (0 points) 

start time___________ completion time______________

Comments/suggestions: Final Score _____/

= completed

= not completed

= skipped back

to complete

Nasal Cannula  1-6 LPM  25-45% oxygen  Does not deliver humidified air Simple Mask  6-12 LPM  35-60% oxygen Non-rebreather Mask  10-15 LPM  Up to 90% oxygen Venturi Mask  Blue : 2 LPM, 24% oxygen  Yellow: 4 LPM, 28% oxygen  White: 6 LPM, 31% oxygen  Green: 8 LPM, 35% oxygen  Pink: 10 LPM, 40% oxygen  Orange: 12 LPM, 50% oxygen

(colors may vary by manufacturer – read the attachment )

N 295 Skills Lab: 9 Steps of Medication Administration

Compare Chart to MAR

Usually at the start of the shift the RN will sit down with

the chart to look at the actual orders and the patient’s

allergies and be sure that these match the MAR. The

order is the highest level of data and the most accurate,

sometimes errors in transcription occur when someone

types up the MAR. If there is a discrepancy that cannot

be resolved by looking back to the original order then

the provider must be called to clarify. In our lab we

won’t do this step because of time constraints.

Calculation & Information

Nurses should have a working knowledge of all the drugs

they administer. Often a quick check in the drug guide is

needed. It is important to know if the ordered dose falls

within the usual dose parameters, the side effects of the

drug, and any special things that need to be assessed

before administering the drug. The drug guide has a

special section on administration that lets nurses know if

a pill can be crushed, if one medication can be mixed

with another, if the medication can be taken with meals

etc. Nurses need to be especially careful when doing

calculations. It is never a bad idea to have another nurse

double check the calculation.

Gather Supplies

Thinking ahead about what supplies you will need saves

a lot of time and steps. Before gathering your supplies

perform hand hygiene. Be sure you have everything you

need and then as always, perform hand hygiene on the

way into the room. Medications are often prepared in

the patient room and that is how we will practice. Some

facilities are set up so that nurses prepare medications at

a nurses station and then bring them to the room.

Studies on medication errors have found that any time

there is an extra transport of medication there is a

chance for error. It is preferred to keep medications

locked in the patient room when possible.

Med OK

A quick inspection to be sure the medication is suitable

for injection involves three things. First, a general look at

the solution. Be sure it is the appropriate color and there

are no precipitates. Next, be sure the medication is not

expired. Expiration dates often include just the year and

month. Finally, a multi dose vial must be dated, timed,

and initialed as it is opened. In our lab you are only

allowed to inject from a vial that was opened on the

same day

5 of the Rights

Even though you have already read the medication name and even though you have already calculated the dose there comes a time when you have to “do the rights” and double check everything from the MAR to the medication. The MAR must have all of this information, so if you start with the patient name and then go to the line of the med you want to give and just read everything, you won’t miss a thing. It is important when looking at the drug to go to the highest level of information possible. For example, if the drug is in a bag, don’t count as correct the information on the bag if that information is also on the drug label. Or, when giving an inhaler, actually take out the canister and look at the name of the drug on the inside, not just the name printed on the label. Stock OTC medications will not have all of the same information as the Rx meds. For example, a bottle of vitamin C used by the whole floor won’t have your patient’s name on it. In these cases you do the rights you can.

Prepare Injection

If you swab the vial before you do the rights then it

should be dry by now. Don’t forget to roll the vial to mix

NPH insulin. Draw up the dose and get the air bubbles

out. Don’t forget to check the dose with another RN if

needed. Different facilities have different policies. Many

acute care settings require a double check with insulin

and lovenox. If you need to waste any narcotic it must be

wasted in front of another nurse and co-signed with the

other nurse. Be sure you re-cap by scooping the lid with

only one hand to take the syringe over to the bedside.

Prepare Patient

Explain to your patient what you are going to do. If you

are giving insulin, tell them what the blood sugar was

and how many units will be given. If you are giving a pain

medication verify the pain level. Assist the client to a

comfortable position. Look at the arm band and note the

allergies. Have the patient state their name and date of

birth and be sure this matches BOTH the arm band that

you are reading as well as the MAR

Administer Injection

Wear gloves if needed. Find your site and inject as

appropriate according to the injection method. Be sure

to dart in quickly to decrease pain and avoid movement

while the syringe is in the skin. Be sure to hold the

syringe in place for 5-10 seconds before withdrawing it

(immunizations are the exception). As soon as you

withdraw the needle think “safety first” and deploy the

safety, if a sharps container is immediately available then

drop it in; if not you can set the syringe aside. If you

need a bandaid use it. Help your patient to a

comfortable position and ask how they did. Remove

gloves and do hand hygiene.

Documentation (the 6th^ right)

Chart what you did. Remember some principles of

charting include: begin each entry with date and time,

use black pen, write neatly, if you don’t go to the end of

a line you started then draw a line through to the end so

more can’t be added later, if you make a mistake draw a

line through it and initial it, always end with your full

signature and title (SN-BYU), be sure the patients name

is on every page you chart on, always document patient

outcomes (e.g. “patient tolerated with minimal

discomfort” or “tolerated well” or “verbalizes

understanding of need to ask for prn pain med as pain

increases.”

Injections: Finding Your Site & Equipment

Site Finding the right site

Needle

Gauge

Needle

Length

Insertion

Angle

Max Fluid Notes

ID Intradermal Inner forearm, hairless site with light pigment and free of vessels or lesions. About 3 fingers down from inner crease of elbow is a good place. TB syringe 25 to 27 TB syringe ¼ to 5/

degrees Very small 0.1 mL Don’t put air in vial before drawing up. Stretch skin, administer bevel up. Should see needle tip through skin. Inject very slowly. No aspirating Should feel resistance and see bleb appear. If bleb doesn’t appear must do again. (this is not like a double dose) Read TB test at 48 – 72 hours Only count as positive areas of induration (thick or raised), not redness. Positive if > 15 mm for pts. with no risk; if. 10 mm for High Risk (recent immigrants, inj drug users, lab personnel, children <4, or children exposed to high risk adults), or if > 5mm for immunosuppressed (HIV, Organ transplants) or have evidence of previous TB infection on X-ray) IM Intramuscular Deltoid Lateral upper arm. Place 4 fingers across the deltoid muscle with first finger on the acromion process. This will give you a top border of about 2 inches below the acromion process. The lower border is the top of the axillae. 23 or 25 1 to 1.5 inch (may go down to ½ or 5/ inch for very thin) 90 degrees No more than 1 mL Find site. Swab. Pull skin laterally approx 2.5 to 3.5 cm with ulnar side of hand to z-track. Dart needle in quickly up to hub. Continue holding skin pulled aside. Aspirate , if no blood inject slowly. Wait 5-10 seconds. Withdraw needle & deploy safety with one hand. Release z-track. Band-Aid, dispose of sharp. For immunizations ( no aspiration, no z-track, no wait before withdrawal) IM Intramuscular ventrogluteal Pt. lies on side or back, flexing the knee and hip. If upper knee bends down towards the bed it is easier to find the Trochanter. Place heel of hand over greater Trochanter using right hand for left hip. Wrist should be perpendicular to the femur. Point thumb toward groin, Middle finger extends back along the iliac crest towards the buttock. The index finger points towards the anterior superior iliac spine. The index finger, the middle finger and the iliac crest form a V-shaped triangle. Feel for a thick muscle area in the middle. The injection site is in the center of the triangle 21 or 22 1.5 inch if obese 3 inch 90 degrees 2 - 3 mL Children & older adults no more than 2 mL infants no more than 0.5 mL Same as above: Note z-track is used especially for medications that are very irritating to the tissue or may stain the tissue. Some people advocate z-tracking all medications. The only medication that should not be z- tracked is immunizations. Immunizations are to be given quickly. The CDC has determined that if some small amount of immunizations went IV vs. IM it would not be a problem, so no need to aspirate either. Immunizations are often given to wiggly children. IM Intramuscular Vastus Lateralis Pt. sit or lay on back. Use middle third of the muscle. Inject between the midline of the anterior leg and the midline of the lateral leg. Palpate the muscle mass 21 or 22 1 to 1.5inch 90 degrees 2 - 3 mL Same as above SQ Subcutaneous Posterior Upper Arm Pt. can sit or lay down. Back of arm in the middle, grasp the fleshy part. 27 to 25 Ga (insulin is # 26 - 31 gauge) ½ to 5/8 inch Can select by pinching tissue at site and select needle that is half the width of the skin fold 45 to 90 degrees 0.5 to 1 mL Pinch or spread skin at site. Inject needle quickly and firmly at 45 to 90-degree angle. Then release skin before injecting if pinched. General rule: if you can grasp 2 inches of tissue, insert the angle at 90 degrees, if you can grasp one inch insert at 45 degrees. You can be sure muscle is not in your pinch by asking pt. to flex and extend the elbow. If muscle is in your pinch you will feel it and need to try again. Do NOT need to aspirate. Inject and wait 5-10 seconds before withdrawing needle. SQ Subcutaneous Abdomen At least 2 inches away from umbilicus. Not into any vessels or lesions. 27 to 25 Ga 90 degrees 0.5 to 1 mL Same as above: It is preferred that Lovenox be injected in abdomen only. If using pre-filled syringe for Lovenox do not expel air bubble before administering and hold the pinch. Updated 3/4/13 Deborah Himes

 Check arm band o Note allergies o Have client state name and birthday o Compare name and birthday to MAR

  • Assist patient to comfortable position
    • 1 patient not positioned well
    • 0.5 doesn’t check pain level with patient
  • Put on gloves (if desired or policy)
  • Find injection site (state out loud how you are finding it for pass off)
  • Swab site
  • Administer injection  Use correct angle of insertion for injection type  Aspirate for IM (except immunization)  No aspiration for SQ  Release the pinch for SQ  Minimal movement of needle while in tissue  Don’t let go of z-track while in the muscle (no z-track for immunization)  Hold before withdrawing needle (except for immunization)
  • Immediately deploy safety on needle  One handed is best; ok to use two as long as both stay behind the needle at all times; if administering with carpuject immediately empties into sharps container.
  • Apply pressure with gauze if needed (If you do not have gloves on, do not put your finger right over gauze to soak up blood. The blood goes through the gauze.)
  • Apply band-aid if needed
  • Help patient back to comfortable position/ assess how patient did (tolerate ok?)
  • Discard syringe in sharps container
  • Remove gloves (if on)
  • Hand hygiene Administer Injection 15 - 4 doesn’t display correct site selection (notes out loud landmarks and distances – ok to need to be asked to state out loud) - 2 doesn’t pinch or spread skin for SQ injection - 2 doesn’t release pinched or spread skin after needle inserted on SQ - 2 doesn’t use correct angle of insertion - 2 doesn’t position bevel up (or needs reminding) on intradermal - 2 doesn’t prep site with alcohol prep (or needs reminding) - 2 doesn’t use a smooth quick darting action or go all the way to the hub - 2 doesn’t aspirate on IM injection (except immunization) - 2 does aspirate on a SQ injection - 2 doesn’t hold z-track until needle removed if z-track is ordered - 2 too much needle movement while in tissue - 2 injects too rapidly or too slowly (about 1 mL/ 10 sec) - 2 doesn’t hold in place for 5-10 seconds after injection (except immunization) - 2 doesn’t immediately protect sharp - 2 uses a risky 2 handed method to protect sharp - 2 doesn’t put sharp in sharp’s container - 2 doesn’t perform hand hygiene after procedure - 1 doesn’t check on how the patient is doing Your 15 minutes of time ends here. The next section “documentation” is done independently. The TA will go on to observe the next student at this point. Documentation (nurses notes)
  • Writing is in black pen, neat and legible
  • Notes: Date, Time, Pt Name, Drug name, dose (in mg or units NOT in mL), route, location of injection site.
  • Notes patient outcome (toleration/ understanding)
  • Student signature and title
  • No empty lines
  • No “do not use” items (“u” for units; trailing zeros (5.0); naked decimals (.25)
  • Notes glucose level for insulin & pain level/ location for pain meds.
  • Any errors that occur are corrected with a single line through the mistake and initial
  • Documents narcotic use in the narcotic book with countersigned waste if needed. (this is done at the time of preparing the injection, the score is down here though) Documentation (the 6th^ right) On Nurses Notes On pass off his will be free text documentation on nurse’s notes. This won’t be simply putting initials in a box on the MAR… 3 - 0.5 not in black pen - 0.5 not neat and legible - 0.5 empty part of lines that have been used - 1 missing patient name - 1 missing date - 1 missing time - 1 missing drug name - 1 missing dose (in mg or units NOT in mL) - 1 missing route (IM, subcutaneous, ID) - 1 missing location of injection site - 0.5 missing patient outcome (toleration or understanding) - 1 missing student signature or title - 0.5 corrections are scribbled out or not initialed with a single line - 0.5 pain med does not have notation of pain level - 0.5 insulin does not have notation of glucose level - 0.5 a “do not use” item was used: (“u” for units; trailing zeros (5.0); naked decimals (.25) - 1 doesn’t document in narcotic book at all - 1 documents in mL in narcotic book instead of mg - 1 doesn’t sign narcotic waste with second RN - 1 doesn’t fill out MAR completely/ correctly. Completes Pass-off in 15 min (time of TA observation)
    • Start Time: __________ Finish Time: ____________ Total Time: Timely Pass Off 3 - 1 for every minute over 15 min (scenario is considered finished with injection) documentation does not count in time.)

Staple together the documentation/ critical thinking questions/

the narcotic sheet if there is one, the MAR and the scratch paper

Total of 40 ______

Sterile Dressing Change: Student Name ____________________________ Start Time: __________ Finish Time: Step By Step Appropriate Actions Dressing Change Category Pts Point Deductions & Notes

  • Compare orders & allergies to MAR
  • Be sure not allergic to any substances in the dressing change (irrigant, latex, tape etc.) Review Orders & Allergies
  • Hand Hygiene at nurses station and gather supplies  Sterile Gloves 4x4 tub 4x  Sterile Saline Red Bag Sterile q-tips (2)  ABD dressing 30 mL syringe Angiocath  Tape black pen PPE (if needed) Gather Supplies & Bring to Room 2 (-1) no hand hygiene before gathering supplies (-1) skips items and has to go back Hand Hygiene upon room entry Hand Hygiene 1 (-1) no hand hygiene upon room entry Assesses readiness/ pain & explains to patient what is going to happen and what is needed from the patient. Assess & Explain to client 1 (-.5) doesn’t check on pain or for readiness (-.5) doesn’t explain what is expected from patient Have patient state name and DOB, compare to MAR or order Right Patient 1 (-1) doesn’t double identify patient or doesn’t look at wrist band and order Don PPE (needs gown & gloves, as well as mask & goggles (or face shield) Don PPE 1 (-1) all PPE needed not put on, or put on in wrong order (gown, mask, goggles, gloves) Pull curtain/ close door Position client with pillows (will need to be propped for direction of irrigation flow) Place Chux to protect linen from irrigation Position Bedside tray & trash can in good position for working with sterile field  Think about where on the tray things should be positioned (e.g. do you want your wet stuff dripping across the dry stuff on your way to packing the wound?) Position disposable red biohazard bag (cuff the edges) Set up for dressing change 1 (-.5) misses any of the things to the left – up to max of 1 point off (-.5) Leaves trash can in a position where will not be able to drop things in freely without turning back on field or dropping hand below field) Remove tape (pull parallel to skin) Remove Secondary dressing (taking note of what was removed and drainage present) Remove packing (taking note of how much packing was removed and drainage color, odor, amount) Put folded dressing in bag Remove old dressing & note drainage 2 (-1) contaminates other areas with soiled dressings (-1) doesn’t note drainage on the old dressing Assess wound edges for blanching and thickness Use q-tip to check depth, width, length Assess for false base, tunneling or undermining State out loud what you are looking at (wound base, edges, surrounding skin) Remove gloves and perform hand hygiene Assess wound 3 (-1) skips length, width or depth (out loud) (-1) doesn’t probe for false base, tunneling or undermining (out loud) (-1) doesn’t assess wound base, edges and surrounding skin (out loud) (-1) doesn’t perform hand hygiene after removing old dressing Getting ready to set up sterile field. Will need to prepare anything that cannot be touched with sterile gloves. Specific order setting these things up is not important. Be sure things such as bedside tray and trash can are in final position. Be sure there is a measuring tape out/ in place for wound assessment.  Lays out tape  Opens 4x4 tub  Pours in sterile solution o Checks solution type/ expiration (out loud) o Palms the label & Pours off a bit into trash (keeping above waist level) o Does not contaminate the lid Open sterile gloves and use the glove wrapper to create a sterile field. Drops onto the field:  Syringe & angiocath, Q-tips & 4x4s  ABD drsg. (may leave off field, since applying with clean hands later) Lays out supplies/ begin sterile field set up that is done with clean hands 5 (-1) Bedside tray left in a position where will have to turn back to sterile field during dressing change. (-1) Doesn’t note out loud the name of the sterile solution (-1) doesn’t note out loud the expiration date and date opened on the solution. (Any breeches of sterile field in this section to be addressed in “Sterile Technique” section below.) Confidently dons sterile gloves without touching outside and preserving glove wrapper as sterile field Place things where they will be convenient to use and safely away from edges. Don Sterile Gloves & Arrange sterile field 1 (-1) awkward or slow with donning sterile gloves (Any breeches in sterile technique marked below) Set up syringe with catheter and irrigate directly into wound/ not across skin first Should drain from least contaminated to most (inside of wound to out) Irrigate Wound 2 (-1) Doesn’t protect needle immediately after taking angiocath off (-1) Irrigant goes across skin before going into wound Clean base of wound from center outward with wrung out gauze. Use new gauze to clean surrounding skin, from wound margins outward Clean Wound 2 (-1) doesn’t clean from base of wound out (-1) doesn’t clean outward on skin Pack wound with wrung out gauze (should be moist, not sopping; should not go over dry intact skin) Secondary dressing 4 x 4 s (2) Apply New Dressing 3 (-1) any granulation tissue is still showing (won’t be moist) (-1) wound is packed too tightly (tissue will be compressed) (-1) moist gauze over intact skin (will macerate the intact skin)

Foley Removal & Insertion: Student Name ____________________________ Total Time: __________

Step By Step Appropriate Actions Dressing Change Category Pts Point Deductions & Notes

  • Look at orders for order to insert catheter and FR
  • Compare to MAR
  • Check Allergies If allergic to latex, check for latex in products to be used. If allergic to betadine (mannequins can never have betadine, it stains them so they are “allergic”) Review Orders 1 (-.5) doesn’t look at orders for insertion order (-.5) doesn’t double check allergies
  • Hand Hygiene at nurses station and gather supplies  Foley Insertion Kit  An extra pack of sterile gloves if needed  Syringe for removal  Washcloth or Towel for removal  Towel or bath blanket for draping patient legs  PPE (if needed)  Identify patient (look @ wrist band, pt states name, DOB- compare to order or MAR) Gather Supplies & Bring to Room 1 (-.5) no hand hygiene before gathering supplies (-.5) skips items and has to go back (-.5) doesn’t assure is the right patient Hand Hygiene upon room entry Hand Hygiene 1 (-1) no hand hygiene upon room entry Assesses readiness & explains to patient what is going to happen and what is needed from the patient. Explain to client 1 (-1) doesn’t explain procedure to patient Pull curtain/ close door Position Bedside tray, garbage can, bag for linen close by Don clean gloves Empty urine from foley bag if needed Raise Bed & Position/drape client (side rail down on working side, chux underneath, drape) Remove tape or leg band, place towel (if tape, can be good to remove the tape before donning gloves) Note on the port # of mL that should be in balloon (out loud), withdraw solution from catheter balloon with syringe Give warning about to remove the catheter Pull out smoothly and quickly, catch end of catheter with towel Discard bag & tubing in trash Remove Gloves Hand Hygiene Remove indwelling catheter 8 (-1) does not ensure privacy (-1) does not position supplies within reach of where they will be needed (-1) does not measure and empty urine before removal (-1) does not apply clean gloves for removal (-1) does not raise bed to good working level (-1) does not position pt well (chux, drape, legs) (-3) attempts to pull out catheter without removing sterile water (-1) does not double check appropriate number of mL have been removed (-1) does not give patient warning that catheter is about to be pulled, eg:“ok this will sting a little, take a deep breath, 1,2,3” (-1) sets bag and tubing anywhere else other than trash (-1) touches things in room (self, linens, side rails) with contaminated gloves (-1) doesn’t do hand hygiene after glove removal Cuff outer bag of cath kit and place within reach of work area for disposal of used supplies Open cath kit, pulling first corner away from self Place sterile underpad Apply Sterile Gloves Organize supplies on the tray:, remove plastic from catheter, attach syringe to balloon port, moisten cotton balls with antiseptic solution, lubricate catheter tip (1- 2 inches women, 5-7 inches men) Apply fenestrated drape if desired Set up Sterile Field for inserting new catheter 8 (-1) bag for trash not placed well ( greater chance of contaminating hands while discarding supplies) (-1) awkward or slow donning of sterile gloves. (-1) lays out supplies in a way that catheter is not secure and tends to flip out of the package (-1) does not adequately lubricate the catheter tip (-1) does not put antiseptic solution on cotton balls. (-1) forgets to attach syringe to balloon port tightly before beginning cleaning. (-1) holds catheter too far back so that tip flops around increasing risk of contamination (Any breeches of sterile field in this section to be addressed in “Sterile Technique” section below.) Clean Urethra  Men: meatus out / Women meatus out and front to back o Maintains position of non-dominant hand holding skin throughout procedure Insert Catheter  Hold catheter in sterile hand 3-4 inches from the tip (holding too far back allows the catheter to be floppy)  Control catheter tubing by coiling into dominant hand  Insert catheter into meatus watching for urine to come into the catheter tube.  Advance catheter 1-2 inches further after urine in tube Insert new catheter 10 (-2) cleans meatus with gauze that has already gone across other skin. (-1) allows non-dominant hand to lose hold of skin while cleaning. (-1) does not secure catheter tubing in dominant hand so that it won’t flop around while inserting. (-2) does not advance catheter 1-2 inches past first sign of urine in tube (-1) syringe pops off while inflating balloon (-1) does not hold catheter securely while filling balloon (-1) does not fill balloon to appropriate # of mL (-1) does not remove gloves before touching leg/ bag/ side rail (-1) does not do hand hygiene after removing gloves

o Men usually 7-9 inches (up to hub)/ Women usually 2-3 inches total Fill Balloon with Sterile water  Hold catheter securely with non-dominant hand while inflating balloon. (catheter will start to slip out if not secured)  Correct number of mL listed on balloon port – puts in this much sterile water  Stop filling if pain voiced, deflate and insert further before attempting fill again  Once balloon is inflated to proper mL/ gently pull back until resistance is met  If male patient with foreskin, replace foreskin  Remove gloves & perform hand hygiene Insert new catheter (cont.) (Any breeches of sterile field in this section to be addressed in “Sterile Technique” section below.) Attach tubing to leg with leg band or tape Place bag on bed frame below level of the bladder (never on side rail)Position patient for comfort Put patient in comfortable/ safe position Assess how patient did/ is doing Clean up Finish Up 2 (-.5) leaves bed in high position (-.5) doesn’t put pt back in comfortable position (-.5) leaves pt sitting in a wet chux (-.5) doesn’t ask pt how they did (-.5) leaves supplies/ trash around (-1) places bag on side rail (vs. bed frame) (-.5) doesn’t attach tubing to leg

Sterile Technique – write in misses in boxes to right…

Students can lose up to 20 points on sterile technique. May have three free “strikes” before they start to count at 1 point each. For a strike to be “free” the student has to catch it his or herself, and has to tell what he or she would do to correct the situation. Free Strikes (student must catch the mistake themselves for it to be free):

 Forgets to do a “clean set-up” technique before applying sterile gloves  Tears a packet setting up field  Something rolls, or flips off the field or past the one inch margin  Sterile gloves become contaminated  Reaches across sterile field  Drops hands below waist  Turns back on sterile field  Contaminates field with water One Point off Strikes (anything student doesn’t catch or beyond the three):  Patient Name is on page  Each entry is marked with Date and Time  Each entry is signed with student name and title  Calls to provider list what nurse told provider (situation, background, assessment, recommendations) and orders/ instructions received.  Telephone Orders are signed: provider name & title/ nurse name & title  Names event: “Change indwelling urinary catheter,” or, “removal of indwelling urinary catheter,” or “insertion of indwelling urine catheter”  RC removal comments on volume, color and character of urine emptied (eg: 220 mL urine, pale, yellow, with sediment/ or/ 150 mL urine, pink with blood clots/ or/ 160 mL urine, dark amber, clear), volume of solution removed from balloon and patient toleration of procedure  RC insertion comments on FR of catheter, number of mL to fill balloon, sterile technique used, return of urine (amount/ color/ character) patient toleration.  Writing is in black pen, neat and legible  No empty ends of lines that were started (draw line to end)  Errors corrected with a single line and initial Document 5 Take 0.5 points for any single item missing to the left, with a max of up to one point for any single bullet point. Students should know how to chart both nurse’s notes and prescriber orders. EXAMPLE CHARTING: NURSES NOTES: 2/3/ 12 0100: removal of RC: Emptied 200 mL clear yellow urine in bag. Withdrew 5 mL solution from balloon. Removed RC without difficulty. Pt tolerated well with some mild stinging. John Whitaker SN BYU ------------------------------------------------------------------------- 2/3/12 0800: telephoned Dr. Saunders, notified patient has not voided since RC removed 6 hours ago, pt c/o full bladder sensation, bladder is full and tender to palpation, pt has tried voiding with running warm water over perineum, no results. Suspect urinary retention and requested order for new RC placement. Dr. Saunders ordered new 14 FR urinary catheter placed. Sally Stevens SN BYU----------------------------------------------------------------------------- 2/3/12 0830: Insertion 14 FR urinary catheter via sterile technique. Filled balloon with 10 mL sterile water. 250 mL of pink urine with small 2-3 mm clots out immediately. Pt reports bladder feels “much better.” Bladder not distended or tender to palpation anymore. Tolerated with mild discomfort. Sally Stevens SN BYU ----------------------------------------------- ORDERS: 2/3/12 08:00 Insert foley catheter 14 fr. TO: Dr Saunders/ Sally Stevens SN-BYU---------------

Completes Pass-off in 15 min Timely Pass Off^^3 (-^1 )^ for every minute over 15 min (timer^ starts when does hand hygiene at

bedside, is considered finished when balloon is filled)

Updated 3/26/2012 – Deborah Himes Total of 40 ______

Notes for GI Lab

Enemas that work by

stretching the colon:

Enema that work by

irritating the colon:

Enema that work by

lubricating the colon:

Tap Water Enema

 Hypotonic – water is pulled into interstitial space

 Infused volume stretches bowel and stimulates

defecation

 DO NOT REPEAT d/t risk of water toxicity

 Retain as long as able

Normal Saline

 Isotonic

 The volume stimulates peristalsis

 No risk of excess fluid absorption

Hypertonic Solutions (e.g. Fleets)

 Pull fluid from interstitial space

 Colon fills with fluid – distention promotes

defecation.

 Usually only need 4-6 ounces

Soap Suds Enema

 Only pure castile soap is

safe

 Harsh soaps/ detergents

can cause serious bowel

inflammation

Oil Retention Enema

 Feces absorb the oil &

become softer

 Client should retain for

several hours if possible

Adult Adolescent Child

Enema Volume 750 to 1000 mL 500 to 750 mL 300 to 500 mL

Insert lubricated

rectal tube

3-4 inches 3-4 inches 2-3 inches

Baseline Hospital Assessment

Vital Signs : HR, BP, O2 sats., RR, Temp.,

Neuro : Observations of mental alertness (RASS score); orientation (self, time,

place, circumstances); pain (location, absent, present, rating 0-10 or

FLACC score); numbness, bilateral grip (coordinated, strong/weak);

Glasgow Coma Scale, mood/affect (within normal limits (WNL), anxious,

dysphoric, hopeless, angry, crying)); Cognitive function (alert/cooperative,

confused, agitated, hallucinations, combative, delusions, non-

cooperative); moves all extremities equally (MAE equally), no alteration in

sensation/ strength, refer to neuro-flow sheet, limitations/assistance

needed; P upils E qual and R ound; R eactive to L ight and A ccommodation

(PERRLA)

Skin : Warm/dry, cool, cold, jaundice, diaphoretic, turgor; breakdown: presence

of lesions/incision/scar(s); check for pressure ulcers (especially coccyx

and heels); distribution of hair follicles, skin pigmentation, edema (yes/no,

site)

CV : Heart sounds (S1, S2 – lub/dub, S3 - Kentucky, S4 - Tennessee), pulse

rate and rhythm, PR interval(normal .12-.20s), QRS interval(normal .06-

.10), characteristics; pulses (radial, ulnar, dorsalis pedis, tibial, poplitial,

femoral), D= doppled, 1=palpable-weak, 2=palpable-strong, 3=bounding);

nailbeds: pink, dusky, cyanotic, capillary refill (<3 secs., >3 secs.);

pacemaker (internal/external, preset rate);compression boots (SCD’s);

DVT prophylaxis; Homan’s sign(when appropriate);

Resp : Respiratory rate; pattern (regular, unlabored, labored, abdominal,

grunting, assists vent); breath sounds (clear, coarse, crackles, wheezing

I/E): cough (productive/non-productive); secretions: thin, thick, small,

moderate, large, clear, cloudy, white, tan, yellow, pink-tinged, bloody);

oxygen (if required chart L/min and type of delivery); chest tube

assessment; sleep apnea; tobacco assessment;

GI : Watch, ascultate, palpate, percuss, Bowel sounds in 4 quadrants (normal,

absent, hyperactive, hypoactive); passing flatus; abdomen: soft/firm, flat,

round, distended; date of last BM plus characteristics; NG/DHT (small

bowel feeding tube) tube, which nostril, taped at ____ cm; mode of suction

(continuous/intermittent) amount and characteristics (brown, green,

yellow, clear, black, bloody, other) of the output; stoma (pink, dusky,

black); diet (NPO, clear liquids, full liquids, healthy, fluid restrictions,

enteral/parenteral, solutions given); inspection of oral mucosa (moist/dry;

teeth inspection/abscess/structure; thrush), PPI prophylaxis (if

appropriate),

GU : urine: clear, cloudy, amber, yellow, pink/bloody; Foley/Condom to gravity

(size measured in French), voids with urinal;

Wound : Location of wound; presence of swelling, drainage (serous,

serosanguineous, sanguineous, purulent), redness, pain, size, wound care

provided, prevention steps taken (pillows, PREVALON boots, pressure

redistributing bed, repositioning Q 2 hrs etc.)

Dressing : Location; dry/intact; reinforced; edges approximated, edges reddened;

drainage: bright red/dark red/yellow/serous/ serosanguineous/

sanguineous, purulent, green/foul smelling; amount of drainage (in ml);

drains (Hemovac, J-P drain, T-tube, etc.); date/time/initials of the last

dressing change,

IV : Location; date in; patent; site checked (s/s inflammation (redness,

swelling, pain, tenderness) or infiltration (pallor, swelling, coolness, pain));

infusion pump, solution infusing at ml/hr; Date/time/initials.

The “FISH” and the “X” diagram

Na| Cl| BUN| Glucose

K| CO2| Creatinine| Glucose

HGB

WBC X Platelets

Hematocrit

Glasgow Coma Scale

Pitting Edema Classification: 1+= 2 mm, 2+= 4 mm, 3+= 6 mm, 4+= 8 mm,

Drainage: Serous (clear, watery plasma), Purulent (thick, yellow, green, tan),

serosanguineous (pale, red, watery, mixture of clear and red fluid),

Sanguineous (bright red, indicates active bleeding).

Temperature Conversion

Celsius Fahrenheit

PRESSURE ULCER STAGES

Suspected Deep Tissue Injury:

Purple or maroon localized area of discolored intact skin or blood-filled blister

due to damage of underlying soft tissue from pressure and/or shear.

Further description:

Deep tissue injury may be difficult to detect in individuals with dark skin tones.

Evolution may include a thin blister over a dark wound bed. The wound may

further evolve and become covered by thin eschar. Evolution may be rapid

exposing additional layers of tissue even with optimal treatment.

Stage I:

Intact skin with non-blanchable redness of a localized area usually over a bony

prominence. Darkly pigmented skin may not have visible blanching; its color

may differ from the surrounding area. (think of tomato)

Further description:

The area may be painful, firm, soft, warmer or cooler as compared to adjacent

tissue. Stage I may be difficult to detect in individuals with dark skin tones. May

indicate "at risk" persons.

Stage II:

Partial thickness loss of dermis presenting as a shallow open ulcer with a red

pink wound bed, without slough. May also present as an intact or

open/ruptured serum-filled blister. (think of peeled potato)

Further description:

Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage

should not be used to describe skin tears, tape burns, perineal dermatitis,

maceration or excoriation.

Stage III:

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or

muscle are not exposed. Slough may be present but does not obscure the

depth of tissue loss. May include undermining and tunneling. (bite of an apple)

Further description:

The depth of a stage III pressure ulcer varies by anatomical location. The

Naso-gastric (NG) Pass-off Rubric Student Name______________________________________ Date ____________________ Section______________

NG Tube Placement Points possible Points earned

Wash Hands 2

Identify patient 2

Prepare supplies 2

Explain procedure to pt. 1

Position bed in high Fowler's position 1

Place towel, chux, etc. on pt's chest 1

Place emesis basin within reach 1

Don clean gloves 1

Remove nasal cannula from nostril and place in mouth 1

Select nostril with greatest air flow 1

Determine length of tube to be inserted 1

Lubricate tube 1

Insert tube through nose to back of throat 1

Have pt. tilt head forward, instruct pt. to sip water with straw and continue to insert

tube as he swallows

Verify placement 2

Anchor tube to nose and to gown 2

Replace nasal cannula back in nostrils 1

Connect tube to low intermittent suction 1

Return HOB to semi-fowlers position, no lower than 30 degrees 1

Return bed to lowest position to the floor 1

Total Points 25

Helpful Hints for Feeding Tubes

Checking Residuals (Q 4-6 hrs for continuous feeding/before each intermittent feeding)

1 Hand Hygiene

2 Explain procedure to pt.

3 Make sure bed is in semi-fowlers position

4 Pause feeding pump for 15 min (if applicable)

5 Apply gloves

6 Gather supplies (60 ml catheter tip syringe, emesis basin or other clean container, chux)

7 Draw up 30 ml of air into syringe

8 Flush feeding tube with 30 ml air

9 Slowly draw back residual

10 If residual is WNL replace residual and restart feeding pump

11 If residual is >500 ml or >250 ml in 2 consecutive feedings do not replace residual and

notify HCP

12 Document

Administering Medications through a Feeding Tube

1 Hand Hygiene

2 Prepare medications by crushing pills, mixing with water and drawing each into a 10 ml

syringe.

3 Explain procedure to pt.

4 Make sure bed is in semi-fowlers position

5 Pause pump if applicable

6 If not currently receiving a feeding check tube for placement by checking pH

7 Flush tubing with 30 ml sterile water

8 Administer prepared medication

9 Flush with 20 ml sterile water

10 Repeat procedure for each remaining medication

11 Restart pump if applicable

Irrigating an NG Decompression tube

1 Hand Hygiene

2 Explain procedure to pt

3 Disconnect tubing from suction source if applicable

4 Check tube placement by pH method

5 Irrigate with 30 ml sterile water

6 Immediately pull back to aspirate 30 ml

7 Reconnect to suction if applicable

8 Document