NUR 311: final demo/written final

Use of PPE:

1). Check medical record and nursing care plan for type of precautions and review precautions in infection control manual. 2). Plan nursing activities before entering patient's room. 3). Provide instruction about precautions to patient, family members, and visitors. 4). Perform hand hygiene. 5). Put on gown, mask, protective eyewear, and gloves based on the type of exposure anticipated and category of isolation precautions. 6). Put on the gown, with the opening in the back. Tie gown securely at neck and waist (Figure 1). 7). Put on the mask or respirator over your nose, mouth, and chin (Figure 2). Secure ties or elastic bands at the middle of the head and neck. If respirator is used, perform a fit check. Inhale; the respirator should collapse. Exhale; air should not leak out. 8). Put on goggles (Figure 3). Place over eyes and adjust to fit. Alternately, a face shield could be used to take the place of the mask and goggles 9). Put on clean disposable gloves. Extend gloves to cover the cuffs of the gown (Figure 5). 10). Identify the patient. Explain the procedure to the patient. Continue with patient care as appropriate. 11). Remove PPE: Except for respirator, remove PPE at the doorway or in an anteroom.Remove respirator after leaving the patient's room and closing the door. 12). If impervious gown has been tied in front of the body at the waistline, untie waist strings before removing gloves. 13). Grasp the outside of one glove with the opposite gloved hand and peel off, turning the glove inside out as you pull it off (Figure 6). Hold the removed glove in the remaining gloved hand. 14). Slide fingers of ungloved hand under the remaining glove at the wrist, taking care not to touch the outer surface of the glove 15). Peel off the glove over the first glove, containing the one glove inside the other (Figure 8). Discard in appropriate container. 16). To remove the goggles or face shield: Handle by the headband or earpieces (Figure 9). Lift away from the face. Place in designated receptacle for reprocessing or in an appropriate waste container. 17). To remove gown: Unfasten ties, if at the neck and back. Allow the gown to fall away from shoulders. Touching only the inside of the gown, pull away from the torso. Keeping hands on the inner surface of the gown, pull gown from arms. Turn gown inside out. Fold or roll into a bundle and discard. 18). To remove mask or respirator: Grasp the neck ties or elastic, then top ties or elastic and remove. Take care to avoid touching front of mask or respirator (Figure 10). Discard in waste container. If using a respirator, save for future use in the designated area. 19). Perform hand hygiene immediately after removing all PPE.

administering medications via a gastric tube:

1). Gather equipment. Check each medication order against the original in the medical record, according to facility policy. Clarify any inconsistencies. Check the patient's health record for allergies. 2). Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient. 3). Perform hand hygiene. 4). Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room. 5). Unlock the medication supply system or drawer. Enter pass code into the computer and scan employee identification, if required. 6). Prepare medications for one patient at a time. 7). Read the eMAR/MAR and select the proper medication from the medication supply system or patient's medication drawer. 8). Compare the label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required. 9). Check to see if medications to be administered come in a liquid form. If pills or capsules are to be given, check with pharmacy or drug reference to verify the ability to crush tablets or open capsules 10). Prepare medication. Pills: Using a pill crusher, crush each pill one at a time. Dissolve the powder with water or other recommended liquid in a liquid medication cup, keeping each medication separate from the others. Keep the package label with the medication cup, for future comparison of information. 11). Liquid: When pouring liquid medications from a multidose bottle, hold the bottle with the label against the palm. Use the appropriate measuring device when pouring liquids, and read the amount of medication at the bottom of the meniscus at eye level (Refer to Step 9c in Skill 5-1). Wipe the lip of the bottle with a paper towel. 12). Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient. 13). Replace any multidose containers in the patient's drawer or medication supply system. 14). Lock the medication supply system before leaving it. 15). Transport medications to the patient's bedside carefully, and keep the medications in sight at all times. 16). Ensure that the patient receives the medications at the correct time. 17). Perform hand hygiene and put on PPE, if indicated. 18). Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods 19). Complete necessary assessments before administering medications. Check the patient's allergy bracelet or ask the patient about allergies. Explain what you are going to do, and the reason for doing it, to the patient. 20). Scan the patient's bar code on the identification band, if required (Figure 1). 21). Based on facility policy, the third check of the label may occur at this point. If so, recheck the labels with the eMAR/MAR before administering the medications to the patient. 22). Assist the patient to the high-Fowler's position, unless contraindicated. 23). Put on gloves. 24). If patient is receiving continuous tube feedings, pause the tube-feeding pump 25). Pour the water into the irrigation container. Measure 30 mL of water. Apply clamp on feeding tube, if present. Alternatively, pinch gastric tube below port with fingers, or position stopcock to correct direction. Open port on gastric tube delegated to medication administration (Figure 3) or disconnect tubing for feeding from gastric tube and place cap on end of feeding tubing. 26). Check tube placement, depending on type of tube and facility policy. Refer to Chapter 11. 27). Note the amount of any residual. Refer to Chapter 11. Replace residual back into stomach, based on facility policy. 28). Apply clamp on feeding tube, if present. Alternatively, pinch the gastric tube below port with fingers, or position stop-cock to correct direction. Remove 60-mL syringe from gastric tube. Remove the plunger of the syringe. Reinsert the syringe in the gastric tube without the plunger. Pour 30 mL of water into the syringe (Figure 4). Unclamp the tube and allow the water to enter the stomach via gravity infusion. 29). Administer the first dose of medication by pouring it into the syringe (Figure 5). Follow with a 5- to 10-mL water flush between medication doses. Follow the last dose of medication with 30 to 60 mL of water flush. 30). Clamp the tube, remove the syringe, and replace the feeding tubing. If a stopcock is used, position it to correct direction. If a tube medication port was used, cap the port. Unclamp the gastric tube and restart tube feeding, if appropriate for medications administered. 31). Remove gloves. Assist the patient to a comfortable position. If receiving a tube feeding, the head of the bed must remain elevated at least 30 degrees. 32). Remove additional PPE, if used. Perform hand hygiene. 33). Document the administration of the medication immediately after administration. See Documentation section below. 34). Evaluate the patient's response to the medication within the appropriate time frame.

administering oral medications

1). Gather equipment. Check each medication order against the original in the medical record, according to facility policy. Clarify any inconsistencies. Check the patient's medical record for allergies. 2). Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and potential adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient. 3). Perform hand hygiene. 4). Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room. 5). Unlock the medication supply system or drawer. Enter pass code into the computer and scan employee identification, if required. 6). Prepare medications for one patient at a time. 7). Read the eMAR/MAR and select the proper medication from the medication supply system or patient's medication drawer. 8). Compare the medication label with the eMAR/MAR (Figure 1). Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required. 9). Prepare the required medications: 10). Unit dose packages: Do not open the wrapper until at the bedside. Keep opioids and medications that require special nursing assessments separate from other medication packages. 11). Multidose containers: When removing tablets or capsules from a multidose bottle, pour the necessary number into the bottle cap and then place the tablets or capsules in a medication cup. Break only scored tablets, if necessary, to obtain the proper dosage. Do not touch tablets or capsules with hands. 12). Liquid medication in multidose bottle: When pouring liquid medications out of a multidose bottle, hold the bottle so the label is against the palm. Use the appropriate measuring device when pouring liquids, and read the amount of medication at the bottom of the meniscus at eye level (Figure 2). Wipe the lip of the bottle with a paper towel. 13). Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient. 14). Replace any multidose containers in the patient's drawer or medication supply system. Lock the medication supply system before leaving it. 15). Transport medications to the patient's bedside carefully, and keep the medications in sight at all times. 16). Ensure that the patient receives the medications at the correct time. 17). Perform hand hygiene and put on PPE, if indicated. 18). Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods 19). Check the name on the patient's identification band (Figure 3). 20). Check the identification number on the patient's identification band. 21). Check the birth date on the patient's identification band. 22). Ask the patient to state his or her name and birth date, based on facility policy. 23).Complete necessary assessments before administering medications. Check the patient's allergy bracelet or ask the patient about allergies. Explain the purpose and action of each medication to the patient. 24). scan the patient's bar code on the identification band, if required (Figure 4) 25). Based on facility policy, the third check of the medication label may occur at this point. If so, recheck the label with the eMAR/MAR before administering the medications to the patient. 26). Assist the patient to an upright or lateral (side-lying) position. 27). Administer medications: 28). Offer water or other permitted fluids with pills, capsules, tablets, and some liquid medications. 29). Ask whether the patient prefers to take the medications by hand or in a cup. 30). Remain with the patient until each medication is swallowed. Never leave medication at the patient's bedside 31). Assist the patient to a comfortable position. Remove PPE, if used. Perform hand hygiene. 32). Document the administration of the medication immediately after administration. See Documentation section below. 33). Evaluate the patient's response to the medication within the appropriate time frame.

Venipuncture

1). Gather the necessary supplies. Check product expiration dates. Identify ordered tests and select the appropriate blood collection tubes. 2). Perform hand hygiene and put on PPE, if indicated. 3). Identify the patient. 4). Explain the procedure to the patient. Allow the patient time to ask questions and verbalize concerns about the venipuncture procedure. 5). Check the specimen label with the patient's identification bracelet. Label should include the patient's name and identification number, time specimen was collected, route of collection, identification of the person obtaining the sample, and any other information required by facility policy. 6). Assemble equipment on overbed table or other surface within reach. 7). Close curtains around the bed and close the door to the room, if possible. 8). Provide for good light. Artificial light is recommended. Place a trash receptacle within easy reach. 9). Assist the patient to a comfortable position, either sitting or lying. If the patient is lying in bed, raise the bed to a comfortable working height, usually elbow height of the caregiver (VHACEOSH, 2016). 10). Determine the patient's preferred site for the procedure based on his or her previous experience. Expose the arm, supporting it in an extended position on a firm surface, such as a tabletop. Position self on the same side of the patient as the site selected. Apply a tourniquet to the upper arm on the chosen side approximately 3 to 4 in above the potential puncture site. Apply sufficient pressure to impede venous circulation but not arterial blood flow. 11). Put on gloves. Assess the veins using inspection and palpation to determine the best puncture site. Refer to the Assessment section above. 12). Release the tourniquet. Check that the vein has decompressed. 13). Attach the needle to the Vacutainer device. Place first blood collection tube into the Vacutainer, but not engaged in the puncture device in the Vacutainer. 14). Clean the patient's skin at the selected puncture site with the antimicrobial swab (Figure 2). If using chlorhexidine, use a gentle back and forth motion for at least 30 seconds or use the procedure recommended by the manufacturer (INS, 2016a). If using alcohol, wipe in a circular motion spiraling outward. Allow the skin to dry before performing the venipuncture. Do not wipe or blot. Allow to dry completely. 15). Reapply the tourniquet approximately 3 to 4 in above the identified puncture site (Figure 3). Apply sufficient pressure to impede venous circulation but not arterial blood flow. After disinfection, do not palpate the venipuncture site unless sterile gloves are worn. 16). Hold the patient's arm in a downward position with your nondominant hand. Align the needle and Vacutainer device with the chosen vein, holding the Vacutainer and needle in your dominant hand. Use the thumb or first finger of your nondominant hand to apply pressure and traction to the skin about 1 to 2 in below the identified puncture site (Van Leeuwen & Bladh, 2017). 17). Inform the patient that he or she is going to feel a pinch. With the bevel of the needle up, insert the needle into the vein at a 15 to 30 degree angle to the skin (Van Leeuwen & Bladh, 2017) (Figure 4). 18). Grasp the Vacutainer securely to stabilize it in the vein with your nondominant hand, and push the first collection tube into the puncture device in the Vacutainer, until the rubber stopper on the collection tube is punctured. You will feel the tube push into place on the puncture device. Blood will flow into the tube automatically (Figure 5). 19). Remove the tourniquet as soon as blood flows adequately into the tube. 20). Continue to hold the Vacutainer in place in the vein and continue to fill the required tubes, removing one and inserting another. Gently rotate each tube as you remove it. 21). After you have drawn all required blood samples, remove the last collection tube from the Vacutainer. Place a gauze pad over the puncture site and slowly and gently remove the needle from the vein. Engage needle guard. Do not apply pressure to the site until the needle has been fully removed. 22). Apply gentle pressure to the puncture site for 2 to 3 minutes or until bleeding stops. 23). After bleeding stops, apply an adhesive bandage. 24). Remove equipment and return the patient to a position of comfort. Raise side rail and lower bed. 25). Discard Vacutainer and needle in sharps container. 26). Remove gloves and perform hand hygiene. 27). Place label on the container per facility policy. Place container in plastic, sealable biohazard bag. 28). Check the venipuncture site to see if a hematoma has developed. 29). Remove other PPE, if used. Perform hand hygiene. 30). Transport the specimen to the laboratory immediately. If immediate transport is not possible, check with laboratory personnel or policy manual whether refrigeration is contraindicated.

Patient Identification

1). Have the patient state the name and date of birth 2). compare stated information with apparent information (what the wristband actually says) 3). If administering medications, you can compare this with the MAR

Fall prevention: potential fall risks

1). Lower extremity muscle weakness 2). Gait or balance deficit 3). Mobility impairment 4). Restraint use 5). Use of an assistive device 6). Presence of intravenous therapy 7). Impaired activities of daily living (ADLs) 8). Age older than 75 years 9). Altered elimination 10). History of falls 11). Administration of high-risk drugs, such as narcotic analgesics, antiepileptics, benzodiazepines, and drugs with anticholinergic effects 12). Use of four or more medications 13). Depression 14). Visual deficit 15). Arthritis 16). History of cerebrovascular accident 17). Cognitive impairment 18). Secondary diagnosis/chronic disease

Ambulation with a cane

1). Nurse should review the patient's chart for conditions that may influence the patient's ability to move and ambulate and for specific instruction such as distance. Nurse should assess for tubes, IV lines, incisions, or equipment that may alter the procedure for ambulation. 2). perform hand hygiene and don proper PPE 3). identify the patient, explain procedure, patient should report dizziness or shortness of breath while walking. decide how far to walk 4). place the bed in the lowest position if the patient is in bed 5). encourage the patient to make use of a stand-assist aid, either freestanding or attached to the side of the bed, if available, to move to the side of the bed 6). assist the patient to the side of the bed, if necessary. Have the patient sit on the side of the bed. Assess for dizziness or lightheadedness. Have the patient stay seated until he or she feels secure 7). Assist the patient to put on footwear and a robe, if desired 8). wrap the gait belt around the patient's waist, based on assessed need and facility policy 9). encourage the patient to make use of the stand-assist device to stand with weight evenly distributed between the feet and the cane 10). have the patient hold the cane on his or her stronger side, close to the body, while the nurse stands to the side and slightly behind the patient 11). tell the patient to advance the cane 4-12 in and then while supporting their weight on the stronger leg and the cane, advance the weaker foot forward parallel with the cane 12). while supporting his or her weight on the weaker leg and the cane, have the patient advance the stronger leg forward to finish the step 13). continue with ambulation for the planned distance and time. Return the patient to the bed or chair based on the patient's tolerance and condition. Remove gait belt 14). Perform XYZs 15). Clean transfer aid if being used by more than one patient. 16). remove PPE and perform hand hygiene.

assisting patient ambulate with a walker

1). Nurse should review the patient's chart for conditions that may influence the patient's ability to move and ambulate and for specific instruction such as distance. Nurse should assess for tubes, IV lines, incisions, or equipment that may alter the procedure for ambulation. Assess the patient's knowledge and previous experience regarding the use of a walker. Identify movement limitations. 2). perform hand hygiene, don PPE 3). identify patient, explain procedure, tell the patient to report any dizziness or shortness of breath while walking. Decide how far to walk 4). place the bed in the lowest position if the patient is in bed 5). encourage the patient to make use of a stand-assist aid, either freestanding or attached to the side of the bed, if available, to move to the side of the bed 6). assist the patient to the side of the bed, if necessary. Have the patient sit on the side of the bed. Assess for dizziness or lightheadedness. Have the patient stay seated until he or she feels secure 7). Assist the patient to put on footwear and a robe, if desired 8). wrap the gait belt around the patient's waist, based on assessed need and facility policy 9). place the walker directly in front of the patient, ask the patient to push him or herself off the bed or chair, make use of the stand-assist device or assist the patient to stand. Once the patient is standing, have him or her hold the walker's handgrips firmly and equally, stand slightly behind the patient, on one side 10). Have the patient move the walker forward 6-8 inches and set it down making sure that all four feet of the walker stay on the floor. Tell the patient to either step forward with either foot into the walker, supporting himself on his arms. Follow through with the other leg. 11). move the walker forward again, and continue the same pattern. Continue with ambulation for the planned distance and time. Return the chair based on the patient's tolerance and condition, ensuring that the patient is comfortable. Remove the gait belt 12). ensure that the patient is comfortable, side rails up, bed lowest position, call bed and personal items within reach 13). clean transfer aids if not indicated for single patient use 14). remove gloves and other PPE if used... perform hand hygiene.

Using a pulse Ox:

1). Review health record for any health problems that would affect the patient's oxygenation status. Gather equipment. 2). Perform hand hygiene and put on PPE, if indicated. 3). Identify the patient. 4). Assemble equipment to the bedside stand or overbed table or other surface within reach. 5). Close the curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. 6). Select an appropriate site for application of the sensor. 7). Use the patient's index, middle, or ring finger (Figure 1). 8). Check the proximal pulse (Figure 2) and capillary refill (Figure 3) closest to the site. 9). If circulation to the site is inadequate, consider using the earlobe, forehead, or bridge of the nose. Use the appropriate oximetry sensor for the chosen site. 10). Use a toe only if lower extremity circulation is not compromised. 11). Select proper equipment: 12). If one finger is too large for the probe, use a smaller finger. 13). Use probes appropriate for the patient's age and size. Use a pediatric probe for a small adult, if necessary. 14). Check if the patient is allergic to adhesive. A nonadhesive finger clip or reflectance sensor is available. 15). Prepare the monitoring site. Cleanse the selected area with the alcohol wipe or disposable cleansing cloth, as necessary (Figure 4). Allow the area to dry. If necessary, remove the nail polish and artificial nails after checking pulse oximeter's manufacturer's instructions. 16). Attach the probe securely to the skin (Figure 5). Make sure that the light-emitting sensor and the light-receiving sensor are aligned opposite each other (not necessary to check if placed on the forehead or bridge of the nose). 17). Connect the sensor probe to the pulse oximeter (Figure 6), turn the oximeter on, and check operation of the equipment (audible beep, fluctuation of the bar of light or waveform on the face of the oximeter). 18). Set alarms on the pulse oximeter. Check the manufacturer's alarm limits for high and low pulse rate settings (Figure 7). 19). Check oxygen saturation at regular intervals, as ordered by the primary care provider, nursing assessment, and signaled by alarms. Monitor the hemoglobin level. 20). Remove the sensor on a regular basis and check for skin irritation or signs of pressure (every 2 hours for spring-tension sensor or every 4 hours for adhesive finger or toe sensor) 21). Clean nondisposable sensors according to the manufacturer's directions. Remove PPE, if used. Perform hand hygiene.

applying and removing graduated compression stockings:

1). Review the medical record and medical orders to determine the need for graduated compression stockings. 2). Perform hand hygiene. Put on PPE, as indicated. 3). Identify the patient. Explain what you are going to do and the rationale for use of elastic stockings. 4). Close the curtains around the bed and close the door to the room, if possible. 5). Adjust the bed to a comfortable working height, usually elbow height of the caregiver (VHACEOSH, 2016). 6). Assist patient to supine position. If patient has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying stockings. 7). Expose legs one at a time. Wash and dry legs, if necessary. Powder the leg lightly unless patient has a respiratory problem, dry skin, or sensitivity to the powder. If the skin is dry, a lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications. 8). Stand at the foot of the bed. Place hand inside stocking and grasp heel area securely. Turn stocking inside-out to the heel area, leaving the foot inside the stocking leg (Figure 1). 9). With the heel pocket down, ease the stocking foot over the foot and heel (Figure 2). Check that the patient's heel is centered in heel pocket of stocking (Figure 3). 10). Using your fingers and thumbs, carefully grasp edge of stocking and pull it up smoothly over ankle and calf, toward the knee (Figure 4). Make sure it is distributed evenly. 11). Pull forward slightly on toe section. If the stocking has a toe window, make sure it is properly positioned. Adjust if necessary to ensure material is smooth. 12). If the stockings are knee-length, make sure each stocking top is 1 to 2 in below the patella. Make sure the stocking does not roll down. 13). If applying thigh-length stocking, continue the application. Flex the patient's leg. Stretch the stocking over the knee. 14). Pull the stocking over the thigh until the top is 1 to 3 in below the gluteal fold (Figure 5). Adjust the stocking, as necessary, to distribute the fabric evenly. Make sure the stocking does not roll down. 15). Remove equipment and return patient to a position of comfort. Remove gloves. Raise side rail and lower bed. Place call bell and other essential items within reach. 16). Remove any other PPE, if used. Perform hand hygiene. 17). To remove stocking, grasp top of stocking with your thumb and fingers and smoothly pull stocking off inside-out to heel. Support foot and ease stocking over it.

Teaching patient to use incentive spirometer

1). Review the patient's health record for any health problems that would affect the patient's oxygenation status. Gather equipment. 2). Perform hand hygiene and put on PPE, if indicated. 3). Identify the patient. 4). Assemble equipment on the overbed table or other surface within reach. 5). Close the curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Using the chart provided with the device by the manufacturer, note the patient's inspiration target, based on the patient's height and age. 6). Assist the patient to an upright or semi-Fowler's position, if possible. Remove dentures if they fit poorly. Assess the patient's level of pain. Administer pain medication, as prescribed, if needed. Wait the appropriate amount of time for the medication to take effect. If the patient has recently undergone abdominal or chest surgery, place a pillow or folded blanket over a chest or abdominal incision for splinting. 7). Demonstrate how to steady the device with one hand and hold the mouthpiece with the other hand (Figure 1). If the patient cannot use hands, assist the patient with the incentive spirometer. 8). Instruct the patient to exhale normally and then place lips securely around the mouthpiece. 9). Instruct the patient to inhale slowly and as deeply as possible through the mouthpiece without using nose (if desired, a nose clip may be used). Note the movement of the inhalation indicator on the spirometer. 10). When the patient cannot inhale anymore, the patient should hold his or her breath and count to three. Check position of gauge to determine progress and level attained. If patient begins to cough, splint an abdominal or chest incision. 11). Instruct the patient to remove lips from mouthpiece and exhale normally. If patient becomes lightheaded during the process, tell him or her to stop and take a few normal breaths before resuming incentive spirometry. 12). Encourage the patient to perform incentive spirometry 5 to 10 times every 1 to 2 hours, if possible. 13). Clean the mouthpiece with water and shake to dry. Remove PPE, if used. Perform hand hygiene.

AIDET

acknowledge, introduce, duration, explanation, thank you

When washing hands, use the ____ to wash underneath the nails of the opposite hand

nails

applying an extremity restraint:

1). determine the need for restraints. Assess the patient physical condition, behavior, and mental status 2). confirm facility policy for the application of restraints. Secure an order from the primary care provider, or validate that the order has been obtained within the required time frame 3). perform hand hygiene and apply PPE 4). Identify the correct patient 5). explain the reason for restraint use to the patient and family. clarify how care will be given and how needs will be met. Explain that restraint is a temporary measure 6). include that patient's loved ones in the plan of care 7). apply the restraint according to the manufacturer's directions 8). choose the least restrictive type of restraint that allows the greatest amount of possible degree of mobility 9). Pad boney prominences 10). wrap the restraint around the extremity with the soft part in contact with the skin. If the hand mitt is being used, pull over the hand with cushion to the palmar aspect of the hand 11). secure in place with the velcro straps or other mechanism, depending on specific restraint device. Depending on the characteristics of the specific restraint it may be necessary to tie a knot in the restraint ties to ensure that restraint remains secure on the extremity 12). ensure that two fingers can be inserted between the restraint and the patient's extremity 13). maintain restrained extremity in normal anatomical position. Use a quick-release knot to tie the restraint to the bed frame, not the side rail. The restraint may also be attached to a chair frame. The site should not be readily accessible to the patient 14). remove PPE and perform hand hygiene 15). assess the patient at least every hour or according to facility policy. Assessment should include the placement of the restraint, neurovascular assessment of the affect extremity and skin integrity. In addition, assess for signs and sensory deprivation such as increased sleeping, daydreaming, anxiety, panic, and hallucinations. Monitor the patient's vital signs 16). remove the restraint at least every 2 hours, or according the facility policy and patient need. Perform ROM exercises. 17). evaluate the patient for continued need of restraint. Reapply restraint only if continued need is evident and order is still valid 18). reassure that the patient at regular intervals. Provide continued explanation of rationale interventions. Reorient if necessary and plan of care. Keep the call bell within reach.

Seizure management

1). for patients with known seizures, be alert for the occurrence of an aura, if known, If the patient reports experiencing an aura, have the patient lie down 2). once a seizure begins close the curtains around the bed and close the door to the room if possible 3). if the patient is seated ease the patient to the floor 4). Remove patient's eyeglasses. Loosen any constricting clothing. Place something flat and soft, such as a folded blanket, under the head. Push aside furniture or other objects in area. 5). If the patient is in bed, remove the pillow, place bed in lowest position, and raise side rails. 6). Do not restrain patient. Guide movements, if necessary. Do not try to insert anything in the patient's mouth or open jaws. 7). If possible, place patient on the side with the head flexed forward, head of bed elevated 30 degrees. Begin administration of oxygen, based on facility policy. Clear airway using suction, as appropriate 8). Provide supervision throughout the seizure and time the length of the seizure. 9). Establish/maintain intravenous access, as necessary. Administer medications, as appropriate, based on medical order and facility policy. 10). After the seizure, place the patient in a side-lying position. Clear airway using suction, as appropriate. 11). Monitor vital signs, oxygen saturation, response to medications administered, and capillary glucose, as appropriate. 12). Place the bed in the lowest position. Make sure the call bell is in reach 13). Reassess the patient's neurologic status and comfort level. 14). Allow the patient to sleep after the seizure. On awakening, orient and reassure the patient. Reassess, as indicated 15). Remove PPE, if used. Perform hand hygiene.

Hourly rounding

1). hand hygiene 2). AIDET 3). update white board 4). 4 P's (pain, potty, position, personal) 5). give personal medications 6). say when you will be back 7). check safety

Identifying (assessing) risk for patient falls: fall prevention

1). hand hygiene 2). apply PPE 3). Identify patient 4). CAB (circulation, airway, breathing) 5). assess patients level of consciousness, orientation, and speech, assess patient's behavior and affect 6). assess the patency of an oxygen delivery device if in use 7). survey the patient's environment. assess the bed position and call bell location. Bed should be in lowest position, and call bell in reach 8). assess for clutter and hazards. Remove excess equipment, supplies, furniture, and other objects from the room and walkways. Pay particular attention to high traffic areas and the route to the bathroom 9). note the presence and location of appropriate emergency equipment, based on individual patient situation 10). note the presence and location of appropriate assistive devices and mobility aids, assure within patient's reach 11). assess for IV site, make sure infusing at right rate and right medication 12). provide bedside commode and or urinal/bedpan. Assure near bed at all times 13). ensure bedside table, telephone, and other personal items are within the patient's reach at all times 14). consider any further assessment that should be completed. Identify any further interventions and the correct person to consult. 15). Remove PPE 16). perform hand hygiene

Assist patient with oral care (unconscious or unable)

1). hand hygiene 2). identify the patient and explain the procedure 3). assemble equipment on overbed table or other surface within the patient's reach 4). Close the room door or curtains 5). place the bed at a comfortable and appropriate working height (elbow height) 6). lower the side rail and assist the patient to a side lying position 7). Place a towel across the client's chest 8). encourage the patient to brush teeth on own according to the following guidelines 9). moisten brush 10). apply paste to brush 11). place brush at 45-degree angle to gum line and brush from gum line to the crown of the tooth 12). Brush the outer and inner surfaces of the tooth 13). brush back and forth across the biting surface of each tooth 14). brush tongue gently 15). have the patient rinse and spit into an emesis basin (repeat until clear). Suction can be used 16). assist the patient to floss teeth 17). remove 18 in of floss 18). wrap floss around middle fingers leave approx. 1-1.5 in of floss to use 19). insert floss between teeth gently between teeth, move it back and forth downward towards the gums 20). need to move the floss inbetween all of the teeth and backside of the teeth until the surfaces are clean 21). patient should rinse mouth well 22). offer lip balm or petroleum jelly 23). remove equipment, gloves 24). raise rails, lower bed, call bell in reach, assist patient to comfortable position 25). remove ppe and hand hygiene

Assisting patient with oral care (able bodied)

1). hand hygiene 2). identify the patient and explain the procedure 3). assemble equipment on overbed table or other surface within the patient's reach 4). Close the room door or curtains 5). place the bed at a comfortable and appropriate working height (elbow height) 6). lower the side rail and assist the patient to a sitting position 7). Place a towel across the client's chest 8). encourage the patient to brush teeth on own according to the following guidelines 9). moisten brush 10). apply paste to brush 11). place brush at 45-degree angle to gum line and brush from gum line to the crown of the tooth 12). Brush the outer and inner surfaces of the tooth 13). brush back and forth across the biting surface of each tooth 14). brush tongue gently 15). have the patient rinse and spit into an emesis basin (repeat until clear). Suction can be used 16). assist the patient to floss teeth 17). remove 18 in of floss 18). wrap floss around middle fingers leave approx. 1-1.5 in of floss to use 19). insert floss between teeth gently between teeth, move it back and forth downward towards the gums 20). need to move the floss inbetween all of the teeth and backside of the teeth until the surfaces are clean 21). patient should rinse mouth well 22). offer lip balm or petroleum jelly 23). remove equipment, gloves 24). raise rails, lower bed, call bell in reach, assist patient to comfortable position 25). remove ppe and hand hygiene

Patient identifiers for ambulatory/LTC patients

1). patient name 2). Patient DOB 3). a visual picture of patient may be used if patient is unresponsive, confused, etc.

What identifiers can be used to identify an inpatient patient?

1). patient name (required) 2). patient medical record number/ identification number (required) 3). birth date, when possible

implementing alternatives to the use of restraints

1). perform hand hygiene and apply PPE 2). identify the patient 3). explain the rationale for interventions to the patient and family/loved ones 4). include loved ones in plan of care 5). identify behaviors that place the patient at risk for restraint use. Assess the patient's status and environment, as outline above 6). identify triggers or contributing factors to patient behaviors. EVALUATE MEDICATION USUAGE for medications that can contribute to cognitive and movement dysfunction and to increased risk for falls 7). assess the patient's functional, mental, and psychological status and the environment, as outlined above 8). provide adequate lighting. Use a nightlight during sleeping hours 9). Consult with primary care provider and other appropriate health care providers regarding the continued needs for treatments/therapies and the use of the least invasive method to deliver care 10). assess the patient for pain and discomfort. Provide appropriate pharmacological and nonpharmacological interventions 11). ask a family member or significant other to stay with the patient 12). reduce unnecessary environmental stimulation and noise 13). provide simple, clear, and direct explanations for treatments and care. Repeat to reinforce, as needed 14). distract and redirect using a calm voice 15). increase the frequency of patient observation and surveillance 1-2 hour nursing rounds, including pain assessment, toileting assistance, patient comfort, keeping personal items in reach, and meeting patient needs. 16). implement fall precaution interventions 17). camouflage tube and other treatment sites with clothing, elastic sleeves, or bandages 18). ensure the use of glasses and hearing aids if necessary 19). consider relocation to a room close to the nursing station 20). encourage daily exercise/provide exercise and activities or relaxation techniques 21). make the environment as homelike as possible; provide familiar objects 22). allow restless patient to walk after ensuring that the environment is safe. Use a large plant or a piece of furniture as a barrier to limit wandering from the designated area 23). consider the use of a patient attendant or sitter 24). remove PPE and complete hand hygiene

employing seizure precautions

1). review the health record and nursing care plan for conditions that would place the patient at risk for seizures. Review the medical orders and the nursing care plan for orders for seizure precautions 2). gather supplies 3). perform hand hygiene and apply PPE 4). identify patient 5). assemble the equipment to the bedside stand or overbed table or other surface within reach 6). close curtains around the bed and close the door to the room if possible. Explain what you are doing and why you are going to do it to the patient 7). place the bed in the lowest position with two to three side rails elevated. Apply padding to the side rails 8). attach oxygen apparatus to oxygen access in the wall at the head of the bed. Place the nasal cannula or mask equipment in a location where it can be easily reached if needed 9). attach suction apparatus to vacuum access in the wall at the head of the bed. Place suction catheter, oral airway, and resuscitation bag in a location where they are easily reached if needed 10). remove PPE and perform hand hygiene

rights of medication administration

1). right patient 2). right route 3). right reason 4). right time 5). right medication 6). right dose

What are the advantages of using an alcohol based hand rub?

1). saves time 2). more accessible 3). are to use 4). reduce bacterial count on the hands

Additional guidelines for hand hygiene

1). use of gloves does not eliminate the need for hand hygiene 2). the use of hand hygiene does not eliminate the need for gloves 3). Natural fingernails should be kept less that 1/4 inches long and artificial nails should not be worn 4). gloves should be worn when contact with blood, infectious material, mucous membranes, and non-intact skin could occur 5). hand lotions or creams (oil-free) are recommended to moisten and protect skin

Order of draw for venipuncture:

1). various colors: blood cultures 2). light blue: citrate-- coagulation studies 3). red and black stopper: gel; serum-- serum chemistry; routine blood donor studies 4). gold stopper: gel; serum-- serum chemistry; routine blood donor studies 5). red stopper: no gel, serum-- serum chemistry, routine blood donor study 6). green stopper/ green with black spots: heparin-- plasma chemistry 7). Lavender/pink stopper: EDTA-- whole blood hematology, Routine immunohematology and blood donor screening, Crossmatching (pink stopper or closure; tube has special label for required blood bank information) 8). white stopper: Potassium EDTA-- molecular diagnostic testing 9). gray stopper: sodium fluoride-- glucose testing

When should the nurse use soap and water to wash hands?

1). when hands are visibly soiled 2). when hands are soiled or in contact with blood or other bodily fluids 3). before eating and after using the restroom 4). if exposure to certain organisms, such as those causing anthrax or c. diff, is suspected

When washing the hands, wash ____ inch above the _____

1; wrist

Assessing a wound:

Assess the situation to determine the need for wound cleaning and a dressing change. Confirm any prescribed orders relevant to wound care and any wound care included in the nursing care plan. Assess the patient's level of comfort and the need for analgesics before wound care. Assess if the patient experienced any pain related to prior dressing changes and the effectiveness of interventions employed to minimize the patient's pain. Assess the current dressing to determine if it is intact. Assess for excess drainage, bleeding, or saturation of the dressing. Inspect the wound and the surrounding tissue. Assess the appearance of the wound for the approximation of wound edges, the color of the wound and surrounding area, and signs of dehiscence. Assess for the presence of sutures, staples, or adhesive closure strips. Note the stage of the healing process and characteristics of any drainage. Also assess the surrounding skin for color, temperature, and edema, ecchymosis, or maceration. measure the length, width and depth of the wound. To measure the depth of the wound use a q-tip that is soaked in normal saline

Fall preventions

Remove excess equipment/supplies/furniture from rooms and hallways. • Coil and secure excess electrical and telephone wires. • Clean all spills in patient room or in hallway immediately. Place signage to indicate wet floor danger. • Restrict window openings. Orient patient to surroundings, including bathroom location, use of bed, and location of call bell. • Keep bed in lowest position during use unless impractical (as in ICU nursing or specialty beds). • Keep top two side rails up (excludes box beds). In ICU, keep all side rails up. • Secure locks on beds, stretchers, and wheelchairs. • Keep floors clutter/obstacle free (with attention to path between bed and bathroom/commode). • Place call bell and frequently needed objects within patient reach. Answer call bell promptly. • Encourage patients/families to call for assistance when needed. • Display special instructions for vision and hearing. • Ensure adequate lighting, especially at night. • Use properly fitting nonskid footwear. • Institute flagging system: yellow card outside room and yellow sticker on medical record. Hill ROM flag (if available), assignment board/electronic board. Monitor and assist patient in following daily schedules. • Supervise and/or assist bedside sitting, personal hygiene, and toileting, as appropriate. • Reorient confused patients, as necessary. • Establish elimination schedule, including use of bedside commode, if appropriate. • PT (physical therapy) consult if patient has a history of fall and/or mobility impairment. OT (occupational therapy) consult • Slip-resistant chair mat (do not use in shower chair) • Use of seat belt, when in wheelchair Institute flagging system: red card outside room and red sticker on medical record, assignment board/electronic board: nurse call system flag, if available. Remain with patient while toileting. • Observe every 60 minutes unless patient is on activated bed/chair alarm. • If patient requires an air overlay, remove mattress (unless contraindicated by overlay type) or use side rail protectors. • When necessary, transport throughout hospital with assistance of staff or trained caregivers. Consider alternatives, for example, bedside procedure. Notify receiving area of high fall risk. • Moving patient to room with best visual access to nursing station • Bed/chair alarm • Specialty fall prevention bed • 24-hour supervision/sitter • Physical restraint/enclosed bed (only if less-restrictive alternatives have been considered and found to be ineffective)

t/f: it is not necessary to perform hand hygiene prior to performing a procedure using clean technique

false

When washing hands, wash between _____

fingers

When washing hands with soap, rub in ____ _____ motions

firm, circular

When rinsing hands, the water should flow:

toward the fingertips

How many identifiers should be used to identify the patient?

two

Performing irrigation of a wound

1). Review the patient's health record for prescribed wound care or the nursing care plan related to wound care. Gather necessary supplies. 2). Perform hand hygiene and put on PPE, if indicated. 3). Identify the patient. 4). Assemble equipment on the overbed table or other surface within reach. 5). Close the curtains around the bed and close the door to the room if possible. Explain what you are going to do and why you are going to do it to the patient. 6). Assess the patient for possible need for nonpharmacologic pain-reducing interventions or analgesic medication before wound care and/or dressing change. Administer appropriate prescribed analgesic. Allow enough time for the analgesic to achieve its effectiveness before beginning the procedure. 7). Place a waste receptacle or bag at a convenient location for use during the procedure. 8). Adjust the bed to a comfortable working height, usually elbow height of the caregiver (VHACEOSH, 2016). 9). Assist the patient to a comfortable position that provides easy access to the wound area. Position the patient so the irrigation solution will flow from the clean end of the wound toward the dirtier end or top to bottom. Use the bath blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site. 10). Put on a gown, mask, and eye protection or face shield. 11). Check the position of drains, tubes, or other adjuncts before removing the dressing. Put on clean, disposable gloves and loosen the tape on the old dressings by removing in the direction of hair growth and the use of a push-pull method (see Figure 1, Skill 8-2). Push-pull method: lift a corner of the dressing away from the skin, then gently push the skin away from the dressing/adhesive. Continue moving fingers of the opposite hand to support the skin as the product is removed (McNichol et al., 2013). Carefully lift the adhesive barrier from the surrounding skin to prevent medical adhesive-related skin injury (MARSI). Remove the sides/edges first, then the center. If there is resistance, use an adhesive remover (McNichol et al., 2013). 12). Carefully remove the soiled dressings. If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to help loosen and remove it. 13). After removing the dressing, note the presence, amount, type, color, and odor of any drainage on the dressings. Place soiled dressings in the appropriate waste receptacle. 14). Assess the wound for appearance, stage, presence of eschar, granulation tissue, epithelialization, undermining, tunneling, necrosis, sinus tract, and drainage. Assess the appearance of the surrounding tissue. Measure the wound. Refer to Fundamentals Review 8-2. 15). Remove your gloves and put them in the receptacle. Perform hand hygiene. 16). Set up a sterile field, if indicated, and wound cleaning and irrigation supplies. Pour warmed sterile irrigating solution into the sterile container. Put on the sterile gloves. Alternately, clean gloves (clean technique) may be used when cleaning a chronic wound or pressure injury. 17). Position the sterile basin below the wound to collect the irrigation fluid. 18). Fill the irrigation syringe with solution (Figure 1). Alternately, irrigation solution may be packaged in individual, single-use syringe; remove cap on syringe. Using your nondominant hand, gently apply pressure to the basin against the skin below the wound to form a seal with the skin (Figure 2). 19). Direct a stream of solution into the wound (Figure 3). Keep the tip of the syringe at least 1 in above the upper edge of the wound. Flush all wound areas. 20). Watch for the solution to flow smoothly and evenly. When the solution from the wound flows out clear, discontinue irrigation. 21). Once the wound is cleaned, dry the surrounding skin using a gauze sponge (Figure 4). 22).If a drain is in use at the wound location, clean around the drain. Refer to Skills 8-6, 8-7, 8-8, and 8-9. 23). Remove gloves and place in a waste receptacle. Perform hand hygiene. 24). Put on sterile gloves. Alternately, clean gloves (clean technique) may be used when cleaning a chronic wound or pressure injury. Apply a skin protectant or barrier to the healthy skin around the wound where the dressing adhesive or tape will be placed and where wound drainage may come in contact with skin. 25). Apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensure products stay confined to the wound and do not impact on intact surrounding tissue/skin (Figure 5). 26). Gently place a layer of dry, sterile dressing or other prescribed cover dressing at the wound center and extend it at least 1 in beyond the wound in all directions. Alternately, follow the manufacturer's directions for application. Forceps may be used to apply the dressing. 27). Apply tape, Montgomery straps, or roller gauze to secure the dressings, if needed. Alternately, many commercial wound products are self-adhesive and do not require additional tape. Remove and discard gloves. 28). After securing the dressing, label it with date and time. Remove all remaining equipment; place the patient in a comfortable position, with side rails up as indicated and bed in the lowest position. 29). Remove PPE, if used. Perform hand hygiene. 30). Check all wound dressings at least every shift. More frequent checks may be needed if the wound is more complex or dressings become saturated quickly.

Cleaning a wound and applying a dry, sterile dressing

1). Review the patient's health record for prescribed wound care or the nursing care plan related to wound care. Gather necessary supplies. 2). Perform hand hygiene and put on PPE, if indicated. 3). Identify the patient. 4). Assemble equipment on the overbed table or other surface within reach. 5). Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why you are going to do it. 6). Assess the patient for the possible need for nonpharmacologic pain-reducing interventions or analgesic medication before wound care dressing change. Administer appropriate prescribed analgesic. Allow enough time for the analgesic to achieve its effectiveness. 7). Place a waste receptacle or bag at a convenient location for use during the procedure. 8). Adjust the bed to a comfortable working height, usually elbow height of the caregiver 9). Assist the patient to a comfortable position that provides easy access to the wound area. Use the bath blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site. 10). Check the position of drains, tubes, or other adjuncts before removing the dressing. Put on clean, disposable gloves and loosen the tape or adhesive edge on the old dressings by removing in the direction of hair growth and the use of a push-pull method (Figure 11). Push-pull method: lift a corner of the dressing away from the skin, and then gently push the skin away from the dressing/adhesive. Continue moving fingers of the opposite hand to support the skin as the product is removed. Carefully lift the adhesive barrier from the surrounding skin to prevent medical adhesive-related skin injury (MARSI). Remove the sides/edges first, then the center. If there is resistance, use an adhesive remover 12). Carefully remove the soiled dressings. If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to help loosen and remove it. 13). After removing the dressing, note the presence, amount, type, color, and odor of any drainage on the dressings (Figure 2). Place soiled dressings in the appropriate waste receptacle. Remove your gloves and dispose of them in an appropriate waste receptacle. 14). Perform hand hygiene. 15). Inspect the wound site for size, appearance, and drainage (Refer to Fundamentals Review 8-2). Assess if any pain is present. Check the status of sutures, adhesive closure strips, staples, and drains or tubes, if present. Note any problems to include in your documentation. 16). Using sterile technique, prepare a sterile work area and open the needed supplies. 17). Open the sterile cleaning solution. Depending on the amount of cleaning needed, the solution might be poured directly over gauze sponges over a container for small cleaning jobs, or into a basin for more complex or larger cleaning. 18). Put on sterile gloves. Alternatively, clean gloves (clean technique) may be used when cleaning a chronic wound or pressure injury. 19). Clean the wound. Clean from top to bottom and/or from the center to the outside. Refer to Box 8-2. Use new gauze for each wipe, placing the used gauze in the waste receptacle (Figure 3). Alternatively, spray the wound from top to bottom with a commercially prepared wound cleanser; wound irrigation is often used to clean open wounds and may also be used for other types of wounds. 20). Once the wound is cleaned, dry the area using a gauze sponge in the same manner. 21). If a drain is in use at the wound location, clean around the drain 22). Remove gloves and place in the waste receptacle. Perform hand hygiene. 23). Put on sterile gloves. Alternately, clean gloves (clean technique) may be used when cleaning a chronic wound or pressure injury. Apply a skin protectant or barrier to the healthy skin around the wound where the dressing adhesive or tape will be placed and where wound drainage may come in contact with the skin 24). Apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensure products stay confined to the wound and do not impact on intact surrounding tissue/skin 25). Gently place a layer of dry, sterile dressing, or other prescribed cover dressing at the wound center and extend it at least 1 in beyond the wound in all directions. Alternately, follow the manufacturer's directions for application (Figure 6). Forceps may be used to apply the dressing. 26). As necessary, apply a surgical or abdominal pad (ABD) over the gauze at the site of the outermost layer of the dressing, with the side of the dressing with the blue line facing away from the patient. Alternately, note the side of the dressing that contains the moisture barrier and place away from the patient, based on the dressing material in use. 27). Apply tape, Montgomery straps, or roller gauze to secure the dressings. Alternately, many commercial wound products are self-adhesive and do not require additional tape. Remove and discard gloves. 28). After securing the dressing, label it with date and time. Remove all remaining equipment; place the patient in a comfortable position, with side rails up as indicated and bed in the lowest position. 29). Remove PPE, if used. Perform hand hygiene. 30). Check all wound dressings at least every shift. More frequent checks may be needed if the wound is more complex or dressings become saturated quickly.

When should the nurse used alcohol-based hand rubs

1). hands are not visibly soiled

What are the levels of assistance or dependency of hygiene

1). no assistance (self-care) 2). partial assistance 3). total or complete assistance

What are the levels of difficulty of hygiene?

1). no difficulty 2). some difficulty 3). a lot of difficulty 4). unable to perform

Three checks of medication administration:

1). checking the patient ID band with the medical order that is in the computer 2). compairing the bottle of medication from the pixis machine to the MAR 3). Comparing the drawn up medication to the MAR (at the bedside)

Monitoring an IV site and infusion

1). Verify IV solution order on the eMAR/MAR with the medical order. Consider the appropriateness of the prescribed therapy in relation to the patient. Clarify any inconsistencies. Check the patient's medical record for allergies. Check for color, leaking, and expiration date. Know the purpose of the IV administration. 2). Monitor IV infusion every hour or per facility policy. More frequent checks may be necessary if medication is being infused. 3). Perform hand hygiene and put on PPE, if indicated. 4Identify the patient. 5). Close the curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are doing it to the patient. 6). If an electronic infusion device is being used, check settings, alarm, and indicator lights. Check set infusion rate (Figure 1). Note position of fluid in IV container in relation to time tape. Teach the patient about the alarm features on the electronic infusion device. 7).If IV is infusing via gravity, check the drip chamber and time the drops (Figure 2). Refer to Box 15-1 in Skill 15-1 to review calculation of IV flow rates for gravity infusion. 8). Check the tubing for anything that might interfere with the flow (Figure 3). Be sure clamps are in the open position. 9). Observe the dressing for leakage of IV solution. 10). Inspect the site for swelling, leakage at the site, coolness, or pallor, which may indicate infiltration (Figure 4). Ask if the patient is experiencing any pain or discomfort. If any of these symptoms are present, the IV will need to be removed and restarted at another site. Check facility policy for treating infiltration. 11). Inspect the site for redness, swelling, and heat. Palpate for induration. Ask if the patient is experiencing pain. These findings may indicate phlebitis, making it necessary to discontinue and restart the IV at another site. Grade phlebitis (refer to Box 15-3 and Fundamentals Review 15-3). Check facility policy for treatment of phlebitis. Notify the primary health care provider for severe (Grade 3 or 4) phlebitis (INS, 2016a). 12). Check for local manifestations (redness, pus, warmth, induration, and pain) that may indicate an infection is present at the site. Also check for systemic manifestations (chills, fever, tachycardia, hypotension) that may accompany local infection at the site. If signs of infection are present, discontinue the IV and notify the primary care provider. Be careful not to disconnect the IV tubing when putting on the patient's hospital gown or assisting the patient with movement. 13). Be alert for additional complications of IV therapy, such as fluid overload or bleeding. Refer to Fundamentals Review 15-3. 14). Fluid overload can result in signs of cardiac and/or respiratory failure. Monitor intake and output and vital signs. Assess for edema and auscultate lung sounds. Ask if the patient is experiencing any shortness of breath. 15). Check for bleeding at the site. 16). If appropriate, instruct the patient to call for assistance if any discomfort is noted at the site, solution container is nearly empty, flow has changed in any way, or if the electronic pump alarm sounds. 17). Remove PPE, if used. Perform hand hygiene.

Collecting a stool specimen for culture

1). Verify the order for a stool specimen collection in the patient's health record. Gather equipment. 2). Perform hand hygiene and put on PPE, if indicated. 3). Identify the patient. 4). Discuss with the patient the need for a stool sample. Explain to the patient the process by which the stool will be collected, either from a bedpan, commode, or plastic receptacle in the toilet (Figure 1) to catch stool without urine. Instruct the patient to void first and not to discard toilet paper with stool. Tell the patient to call you as soon as a bowel movement is completed. 5). Check specimen label with the patient's identification bracelet. Label should include the patient's name and identification number, time specimen was collected, route of collection, identification of the person obtaining the sample, and any other information required by facility policy. 6). Assemble equipment on overbed table or other surface within reach. 7). After the patient has passed a stool, put on gloves. Use the tongue blades to obtain a sample, free of blood or urine, and place it in the designated clean specimen container 8). Collect as much of the stool as possible to send to the laboratory. 9). Place lid on container. Dispose of used equipment per facility policy. Remove gloves and perform hand hygiene. 10). Place label on the container per facility policy. Place container in plastic, sealable biohazard bag 11). Remove other PPE, if used. Perform hand hygiene. 12). Transport the specimen to the laboratory while stool is still warm. If immediate transport is impossible, check with laboratory personnel or policy manual whether refrigeration is contraindicated.

Testing stool for occult blood:

1). Verify the order for a stool specimen collection in the patient's health record. Gather equipment. 2). Perform hand hygiene and put on PPE, if indicated. 3). Identify the patient. 4). Discuss with the patient the need for a stool sample. Explain to the patient the process by which the stool will be collected, either from a bedpan, commode, or plastic receptacle in the toilet. 5). If sending the specimen to the laboratory, check specimen label with patient identification bracelet. Label should include the patient's name and identification number, time specimen was collected, route of collection, identification of the person obtaining the sample, and any other information required by facility policy. 6). Assemble equipment on overbed table or other surface within reach. 7). Close curtains around the bed or close the door to the room, if possible. 8). Place the plastic collection receptacle in the toilet, if applicable. Assist the patient to the bathroom or onto the bedside commode, or onto the bedpan. Instruct the patient not to urinate or discard toilet paper with the stool. 9). After the patient defecates, assist the patient out of the bathroom, off the commode, or remove the bedpan. Perform hand hygiene and put on disposable gloves. 10). If using gFOBT: Open flap on sample side of card. With wooden applicator, apply a small amount of stool from the center of the bowel movement onto one window of the testing card. With the opposite end of the wooden applicator, obtain another sample of stool from another area and apply a small amount of stool onto second window of testing card 11). Close flap over stool samples. 12). If sending stool to the laboratory, label the specimen card per facility policy. Place in a sealable plastic biohazard bag and send to the laboratory immediately. 13). If testing at the point of care, wait 3 to 5 minutes before developing. Open flap on opposite side of card and place two drops of developer over each window and wait the time stated in the manufacturer's instructions (Figure 2). 14). Observe card for any blue areas 15). If using FIT: Open flap on sample side of card. With applicator, brush, or sampling probe, apply a small amount of stool from the center of the bowel movement onto the top half of window of the testing card. With the opposite end of the device, obtain another sample of stool from another area and apply a small amount of stool onto the bottom half of window of testing card. 16). Use the applicator to mix the samples and spread samples over entire window. Close flap over sample. Allow card to dry. 17). If sending to the laboratory, label the specimen card per facility policy. Place in a sealable plastic biohazard bag and send to the laboratory immediately. 18). If testing at the point of care, open collection card according to manufacturer's instructions. Add three drops of developer to center of sample on Sample Pad. Developer should flow through the test (T) line and through the control (C) line. Snap Test Device closed. 19). Wait 5 minutes, or time specified by manufacturer. Observe card for pink color on the test (T) line. The control (C) line must also turn pink within 5 minutes (Figure 4). If the control (C) line turns pink, read and report the result. 20). After reading results, discard testing slide appropriately, according to facility policy. Remove gloves and any other PPE, if used. Perform hand hygiene.

Obtaining a urine specimen from an indwelling urinary catheter

1). Verify the order for a urine specimen collection in the patient's health record. Gather equipment. 2). Perform hand hygiene and put on PPE, if indicated. 3). Identify the patient. 4). Explain the procedure to the patient. 5). Check the specimen label with the patient's identification bracelet. Label should include the patient's name and identification number, time specimen was collected, route of collection, identification of person obtaining the sample, and any other information required by facility policy. 6). Assemble equipment on overbed table or other surface within reach. 7). Close curtains around the bed and close the door to the room, if possible. 8). Put on nonsterile gloves. 9). Clamp the catheter drainage tubing or bend it back on itself distal to the port. If an insufficient amount of urine is present in the tubing, allow the tubing to remain clamped up to 30 minutes, to collect a sufficient amount of urine, unless contraindicated. Remove lid from specimen container, keeping the inside of the container and lid free from contamination. 10). Scrub aspiration port vigorously with alcohol or other disinfectant wipe and allow port to air dry. 11). Attach the syringe to the needleless port. Alternately, insert the blunt-tipped cannula into the port. Slowly aspirate enough urine for specimen (usually 3 to 5 mL is adequate; check facility requirements) (Figure 1). Remove the syringe from the port. Engage the needle guard, if needle was used. Unclamp the drainage tubing. 12). If a needle or blunt-tipped cannula was used on the syringe, remove from the syringe before emptying the urine from the syringe into the specimen cup. Place the needle into a sharps collection container. Slowly inject urine into the specimen container. Take care to avoid touching the syringe tip to any surface. Do not touch the edge or inside of the collection container. 13). Replace lid on container. If necessary, transfer the specimen to appropriate containers/tubes for specific test ordered, according to facility policy. Dispose of syringe in a sharps collection container. 14). Remove gloves and perform hand hygiene. 15). Place label on the container per facility policy. Note specimen collection method, according to facility policy. Place container in plastic sealable biohazard bag. 16). Remove other PPE, if used. Perform hand hygiene. 17).Transport the specimen to the laboratory as soon as possible. If unable to take the specimen to the laboratory immediately, refrigerate it

What are criteria for performing hand hygiene?

1). before and after contact with each patient 2). before putting on gloves 3). before performing invasive procedures 4). after accidental contact with body fluids, mucous membranes, non-intact skin, and wound dressing, even if hands are not visibly soiled 5). when moving from a contaminated body site to a clean one during patient care 6). after contact with inanimate objects near the patient 7). after removal of gloves

What five moments should the nurse use hand hygiene?

1). before touching a patient 2). before a clean or aseptic procedure 3). after body fluid exposure risk 4). after touching a patient 5). after touching the patient surroundings