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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.
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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
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.
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
Total of 40 ______
Sterile Dressing Change: Student Name ____________________________ Start Time: __________ Finish Time: Step By Step Appropriate Actions Dressing Change Category Pts Point Deductions & Notes
Step By Step Appropriate Actions Dressing Change Category Pts Point Deductions & Notes
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
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---------------
bedside, is considered finished when balloon is filled)
Naso-gastric (NG) Pass-off Rubric Student Name______________________________________ Date ____________________ Section______________
Total Points 25
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