Checklist - pg. 28 ~ 38

Disposable enema set Lubricant IV pole Bedpan, etc. Tissue paper Waterproof pad Basin Washcloth Soap Gloves

Administering High Volume Enema Equipment

Spirometer Pillow

Incentive Spirometer equipment

1. Open package, tubing clamped then open top of bag and fill w/warm water 2. Release clamp and allow fluid to flow to the end of tube. Reclamp tubing 3. Position into a left Sims Fold back linens, expose only rectal area Place waterproof pad under hips 4. Put on gloves 5. Elevate bag b/w 12"-18" above anus level Plan to give solution slowly 5-10 min You may use IV pole or hands 6. Lubricate end of rectal tube 2"-3" 7. Lift buttocks to expose anus, and insert 3"-4" Direct angle of tip towards umbilicus Instruct patient to take several deep breaths 8. If resistance is met, allow a small amount of fluid in, withdraw tube slightly, then continue insertion Do not force! 9. Slowly introduce warm solution for 5-10 min while holding tubing 10. Clamp tubing or lower bag if patient has the urge to go or cramping occurs Patient may be instructed to take small, fast breaths or pant 11. After solution is gone, clamp tubing and remove. Have a paper towel ready to receive tip 12. Ask patient to hold the solution as long as possible till the urge to go is strong, usually immediately. Assist patient on bedpan, etc. Offer tissue paper Don't flush! 13. Assess for color, consistency, amount and odor Perform HH 14. Put gloves on and help clean patient's anal area Offer washcloth, soap, water, towel for hand washing 15. Document

Administering High Volume Enema Steps

1. Position patient into a left side Sims. Fold back linens, only expose the rectal area. Place waterproof pad under hips 2. Apply gloves 3. Remove enema cap and lubricate 2"-3" of the tube 4. Lift buttock and expose anus. Slowly and gently insert tube 3"-4" Direct it at an angle towards umbilicus Ask patient to take several deep breaths during insertion 5. Compress container slowly and roll the end up on itself towards the rectal tip Administer all of the solution 6. If resistance is met while inserting, permit a small amount to enter, withdraw tube slightly, and then continue to insert Do not force, ask patient to take several deep breaths and relax 7. After solution is gone, remove tube, keeping the container compresses Have a paper towel ready to receive the tip 8. encourage patient to hold the solution till the urge to defecate is strong. 5-15 min 9. Implement safety exit measure Instruct patient to use call light when ready to defecate 10. When patient is ready, assist on bedpan, etc. Stay w/patient or have call light readily accessible 11. Remind patient not to flush if using toilet (inspect!) 12. Prior to flushing, assess color, consistency, amount and odor. Then HH 13. Put new gloves on if cleaning the patient. Offer washcloths, soap and water for HH. Remove gloves 14. Document

Administering a low volume or retention enema Steps

Low volume enema -oil retention -fleets Lubricant Bedpan or... -bedside commode -nearby bathroom Tissue paper Waterproof pad Basin Washcloth Soap Towels Gloves

Administering a low volume or retention enema Equipment

Warm or cold pack Washcloth Towel

Applying a Warm or Cold Compress Equipment

1. Assess patient for possible need of non-pharmacologic pain-reducing intervention or analgesic medication prior to treatment Administer appropriate analgesic, consulting HCP's orders, and allow enough time for analgesic to achieve effectiveness before beginning treatment 2. Assess treatment area for inflammation, color, or ecchymosis (broken capillaries) 3. Cover pack w/a towel if needed 4. Monitor treatment time and condition of patient's skin and response 5. After 20-30 min, remove. Or remove if the patient complains of discomfort 6. Assess treatment area and not any changes 7. Document patient's response

Applying a Warm or Cold Compress Steps

Pencil Paper Flowsheet Computerized records Suction set up Yanker - For patient on aspiration precautions

Assisting a Patient w/Eating equipment

1. Apply gloves 2. Place specimen hat on commode, etc. Assist patient to toilet, etc. Instruct patient to not urinate or place toilet paper on stool Allow patient to defecate 3. After defecation, assist patient off toilet, etc. Perform HH and apply gloves 4. With wooden applicator, collect small amount of stool from center of stool and apply onto one window of test card With the opposite end of applicator collect a sample from another area of stool and apply on second window or card 5. Close flap on card 6. If testing by bedside: -Turn card and open flap on opposite side of card and place two drops of developer over each window and control panel "Blue" means blood is present Discard the card, remove gloves and perform HH 7. If sending card to lab: -Check if the specimen label matches patient's ID bracelet -Label should contain patient's name, MR#, time, date, your initials 8. Document

Collecting Stool for Occult Blood called a Hemoccult Test Steps

Urine hat Amber bottle Bath basin Gloves Sign (24-hour urine collection) Bedpan or urinal if needed

Collecting a 24-hour Urine Specimen Equipment

1. Assess level of consciousness, physical limitations, hearing or visual acuity or swallowing impairment. If patient uses hearing aids or glasses or dentures, provide as needed. Ask patient if they have any cultural or religious preferences, food likes or dislikes, if possible 2. Assess abdomen. Ask patient of any difficulty swallowing, nausea or pain and administer meds as needed 3. Offer to assist w/any elimination needs 4. Provide patient w/HH and mouth care as needed 5. Remove any bedpans or odors 6. Assist to or position in a high Fowler's or sitting position in bed or chair. Lower the bed, if patient is in bed 7. Place a protective cover or towel over patient if desired 8. Ensure tray is the correct diet before serving. Open cover by the door of the room to prevent overwhelming smell of food 9. Place tray on overside table so patient can see food is able. Ensure hot foods are hot and cold foods are cold. Use caution w/hot beverages, allow to cool if needed. Ask patient which food item they would like to start w/first. Cut food into small pieces if needed. Observe swallowing ability throughout meal 10. If possible, sit facing the patient during feeding. If able, encourage to hold finger foods and feed self as much as possible. Converse w/patient as appropriate. If patient has dysphagia, limit questioning or conversation . Play relaxing music if desired. 11. Allow enough time for proper chew and swallowing of food May need to rest for short periods during meal 12. When meal is done or patient cannot eat anymore, remove tray from room Write down the amount food and volume of liquid consumed 13. Reposition over-bed table, remove protective covering, offer HH, and bedpan. Assist patient to a comfortable, relaxing position 14. Document

Assisting a Patient w/Eating steps

Gloves Wooden applicator Hemoccult card and developer Biohazard bag Bedpan, Specimen hat, etc.

Collecting Stool for Occult Blood called a Hemoccult Test Equipment

Need: pillow 1. Assess pain level prior to exercise and medicate if needed 2. Place in a semi-fowler's, lean forward ventilate lobes of lungs 3. Instruct to -Inhale and exhale deeply and slowly via nose 2x. (in 2-3-4; out 2,3,4) -On 3rd exhale, cough fully 2-3X in a row w/o inhaling b/w coughs 4. Repeat exercise 2-3 times 2X/day 5. Document

Effective Deep Breathing, Coughing & Splinting Procedure Steps & equipment

1. Explain to patient that you'll need to collect all urine for a 24-hour period 2. Prepare equipment: -Place urine hat on toilet -Label collection bottle w/patient name, MR#, time, and date the collection begins and ends -Fill bath basin with ice. Add ice as needed 3. Instruct patient to urinate in urine hat and then dump urine into toilet. Note the time - this is the beginning of the 24 hours 4. After first void and dump, instruct patient to collect the rest of their urine in the urine hat collector. The urine is to be poured into collection containers (by nurse or patient) Stress to the patient that every drop of urine they pass must go into the collection container 5. Place 24-hour collection signs on patient's door and in bathroom 6. Instruct patient to drink adequate amounts of water during the 24 hour period 7. Emphasize proper HH before and after each collection 8. Exactly after 24 hours ask patient to void. This will completer the collection 9. Send specimen immediately to lab 10. Document

Collecting a 24-hour Urine Specimen Steps

Tongue blade Specimen container Biohazard bag Gloves Label

Collecting a Stool Specimen for Culture Equipment

1. Place specimen hat on toilet, etc. Assist patient on bedpan, etc. Instruct patient to not urinate or discard toilet paper on top of stool Allow patient to defecate 2. After defecation, assist off of bedpan, etc. Perform HH and apply gloves 3. Use tongue blade to collect stool sample from two different sites Make sure the stool is free from blood or urine Place in container 4. Place lid on container. Remove gloves and perform HH 5. Check specimen label: Patient's name, MR#, Time, Date, and initial 6. Document

Collecting a Stool Specimen for Culture Steps

Moist cleaning towelettes or Soap Water Washcloth Gloves Sterile specimen container Biohazard bag Label

Collecting a Urine Specimen (Clean Catch, Midstream) Urinalysis & Culture & Sensitivity Equipment

1. Apply gloves 2. Assist patient on bedpan, etc. Instruct patient not to defecate or discard toilet paper on urine 3. Females: separate labia to clean and during urination 4. Males: instruct uncircumcised males to retract skin to clean and during urination 5. Have patient void 25 mL, then stop briefly, and void into a collection container Collect 10-20mL, then finish voiding the remainder Do not touch inside the container or lid 6. Place lid on container. Transfer specimen into appropriate container if necessary 7. Assist patient off bedpan, etc. 8. Remove gloves. HH 9. Check if the label matches the patient's ID bracelet Label w/patient's name, MR#, time date and your initials Place in biohazard bag and send to lab immediately 10. Document

Collecting a Urine Specimen (Clean Catch, Midstream) Urinalysis & Culture & Sensitivity Steps

Alcohol wipe Syringe Gloves Container Biohazard bag Label

Collecting a Urine Specimen from an Indwelling Catheter for a C & S Equipment

1. Clamp catheter drainage tubing or bend back on itself distal to the port If insufficient amount is present, allow tubing to remain clamped for up to 30 min unless contraindicated 2. Remove lid from container 3. Clean the aspiration port w/alcohol wipe for 15 seconds and allow to dry 4. Attach syringe to port and slowly aspirate 10 mL of urine. Remove syringe and unclamp tubing 5. Slowly inject urine into container and put on lid. Dispose the syringe 6. Remove gloves. HH 7. Check if label matches the patient's ID bracelet Label w/patient's name, MR#, time, date, and initial Place specimen in biohazard bag and send immediately to the lab 8. Document

Collecting a Urine Specimen from an Indwelling Catheter for a C & S Steps

1. Assist in an upright position 2. Administer pain meds if needed. If patient has gone through a recent abdominal or chest surgery surgery, place a pillow over incision for splinting 3. Demo how to use mouthpiece w/one hand, and steady device with the other 4. Instruct to exhale normally, place lips securely around mouthpiece, inhale slowly and as deeply as possible, hold breath, count to 3 and exhale 5. Check gauge position to determine progress. Repeat 3X 6. Document

Incentive spirometer steps

Flow meter Humidifier (sterile distilled H2O) Nasal cannula Tubing

Nasal cannula equipment

1. Connect cannula to O2 setup w/humidification if needed. -Adjust flow rate as ordered -Check flow through prongs 2. Place prongs in nostrils. Place tubing behind ears and under chin. Ensure protection pad is in place 3. Tubing should be snug but not tight. Adjust as needed 4. Encourage patient to breath through nose, w/the mouth closed 5. Reassess respiratory rate, effort, and lung sounds. Note any signs of respiratory distress, such as -tachypnea -nasal flaring -use of accessory muscles -dyspnea

Nasal cannula steps

Flow meter Humidifier Face mask Tubing

O2 mask equipment

1. Attach mask to O2 source w/humidification if needed. -Start O2 flow at specified rate -For mask w/reservoir, allow O2 to fill bag 2. Position mask over patient's nose & mouth. -Adjust straps to a snug but comfy fit -Adjust flow rate as ordered 3. Reassess respiratory rate, effort, and lung sounds. 4. Remove mask and dry skin every 2-3 hrs if O2 runs continuously. No powder around mask 5. Document

Oxygen Mask steps

1. Select site - index, middle or ring finger 2. Check proximal pulse and capillary refill. -If circulation is bad, use earlobe, forehead, bridge of nose, or toe 3. Prepare site: -Cleanse site w/wipe -Allow to dry -Remove nail polish if needed -Check manufacturer's instructions 4. Apply probe securely. Make sure light emitting and light receiving sensor are aligned opposite to each other 5. Connect sensor probe to pulse ox and turn on the oximeter, & check operation of equipment 6. Set alarms on pulse ox 7. Assess O2 saturation every 4 hrs as part of VS or as ordered 8. Remove every 4 hrs & assess skin 9. Document

Pulse Ox steps

Pulse ox Nail polish remover ETOH wipes

Pulse oximeter equipment

1. Asses pain level & medicate if needed 2. Instruct patient to practice "purse lips" (sucking a straw or whistling) 3. Inhale through nose while counting to 3 and exhale slowly and evenly while tightening abs 4. During exhalation, count to 7 5. Document

Pursed lip breathing steps

Gloves Sterile sputum specimen container Googles Biohazard bag Label

Sputum Collection Equipment

Prep: -If patient is having pain w/coughing, administer pain meds if ordered -Patient can perform task w/o assistance after instruction -Leave container at bedside and instruct to call nurse as soon as specimen is produced -"Sputum not spit" -Collect before breakfast -Confirm that patient has not recently had oral hygiene/mouthwash 1. Place patient in a semi-fowler's position 2. Instruct patient to take 4 deep breaths and at the end cough deeply mobilizing secretions If patient had had abdominal surgery ,offer a pillow for splinting 3. If patient has produced sputum, have patient expectorate specimen into a container Have patient continue until 15mL is produced 4. Apply lid, offer oral hygiene 5. Remove PPE (googles, gloves) and perform HH 6. Check if label matches patient's ID# Label should have: patient's name, MR#, time, date, your initials 7. Document

Sputum Collection Steps